Esophageal varices

A 51-year-old woman, a known alcohol abuser, had sclerotherapy for esophageal varices from portal hypertension. A perforation of the distal esophagus, diagnosed several days later, could not be closed primarily at thoracotomy due to extensive bleeding. The method of "exclusion and diversion in continuity" was modified by ligation of the esophagogastric junction with absorbable suture over a tube stent. The perforation healed and patency of the esophageal lumen was demonstrated 2 weeks later. This alternative life-saving procedure may be useful in chronic esophageal perforation, especially in cirrhotic or otherwise debilitated patients.

(Chest 1994; 105:1896-98)

Controversy surrounds the treatment of esophageal perforations. This condition is best managed surgically, with some exceptions dictated by the size and location of the perforation, the time elapsed, and the patient's condition. Procedures include drainage, with primary repair if possible, and buttressing the repair.[1,2] Celestin tubes, stents, or T-tubes are advocated without wide acceptance.[3,4] Resection with gastroesophageal replacement in patients with underlying esophageal disease has also been proposed.[5,6]

In 1974, Urschel and coworkers[7] introduced "exclusion and diversion in continuity, "which involved ligation of the gastroesophageal junction to prevent reflux and a cervical esophagostomy to control oral secretions. The perforation was closed primarily, the mediastinum was drained, and a gastrostomy was constructed. This requires a second operation to reconstruct the distal esophagus later. Popovsky[8] modified this procedure by ligating the distal esophagus with a nonabsorbable suture and thus avoided the need for a second operation. We present a further modification of this procedure.

Case Report

A 51-year-old woman with a history of alcohol abuse was admitted to the hospital emergently with crampy upper abdominal pain, coffee ground emesis, loose tarry stools, generalized weakness, and recent weight loss. Physical examination revealed epigastric tenderness without rebound, normal bowel sounds, hepatomegaly, and spider angiomata. On panendoscopy, varices in the distal esophagus were identified as the source of bleeding and were sclerosed, Two days later, panendoscopy and sclerotherapy were repeated. Two days after the last sclerotherapy treatment, the patient complained of acute right-sided chest pain and shortness of breath. Her temperature was 38.3[degrees]C and her WBC count was 13,40O/[mm.sup.3]. A chest radiograph revealed bilateral pleural effusions that had increased. A right thoracentesis yielded 600 ml of culture-negative and amylase-negative fluid. A ventilation perfusion scan was interpreted as low probability for a pulmonary embolism. The right pleural effusion returned 2 days later, greater than before, and showed signs of loculation on ultrasound.

An esophagogram revealed a posterior esophageal perforation with extravasation along the right side of the esophagus, 2 to 3 cm above the right hemidiaphragm (Fig 1). Bilateral chest tubes were placed. Cultures of the pleural fluid were positive for polymicrobial growth. She received triple antibiotics and was taken to the operating room for emergent repair and drainage. A computed tomographic scan was not obtained.

Operative Procedure

Through a lower left lateral thoracotomy, intense bleeding was encountered with attempted dissection of the thickened and inflamed mediastinum. Approximately 500 ml of blood were lost in 20 min without reaching the esophagus. Therefore, the diaphragm was radially incised and the esophagogastric junction was freed. With a nasogastric tube in place, two strands of No. 1 chromic catgut suture were placed around the gastroesophageal junction and tied securely. A Stamm gastrostomy was constructed followed by a pants over vest repair of the diaphragm; the chest was closed after placement of a No. 36F chest tube. A left lateral esophagostomy was constructed; a Levine tube drain was placed via the esophagostomy into the distal esophagus.

Clinical Course

The antimicrobial and nutritional support were maximized. One week postoperation, 15 ml of diatrizoate meglumine (Gastrografin) was injected into the distal esophagus via the Levine tube within the esophagostomy site. There was no evidence on radiograph of contrast extravasation (Fig 2). On the 13th postoperative day, edema and scarring in the distal esophagus were noted during endoscopy performed via the esophagostomy. The drain tubes were removed and the endoscope was advanced comfortably through the gastroesophageal junction into the stomach. The site of the esophageal perforation was well healed. The patient's condition improved clinically. and she was tolerating an oral diet.

Discussion

The operative procedure for the esophageal perforation was effective, the lumen of the esophagus remained patent, and a second procedure was not required. Patency had been maintained by the nasogastric tube. Maintaining esophageal patency, while avoiding gastric reflux in the esophagus, is very desirable in such high-risk patients.

Popovsky[8] ligated the gastroesophageal junction with nonabsorbable suture and later successfully used a mercury dilator to open the lower esophagus after the perforation healed. However, his patients were gunshot victims, in good health prior to the incident, and without abnormalities of the esophagus. Dilatation of the distal esophagus in this setting is much different than with a patient with esophageal varices such as our patient. Attempts to dilate the distal esophagus with varices may provoke a lifethreatening bleed.

Hantke et al[9] proposed the physiologic exclusion of the esophagus recently. In this procedure, the distal esophagus is not excluded; a cervical esophagostomy, gastrostomy, and primary repair of the perforation are performed. There is no need for a second operation to reconstruct the distal esophagus with this method, but gastric reflux may not be completely controlled. If the gastrostomy fails, the ensuing gastric distention may lead to forceful regurgitation and damage to the esophageal repair. Furthermore, the refluxed bile and gastric secretions can interfere with healing and aggravate the mediastinitis. The chance of any reflux with its complications is avoided by functionally excluding the distal esophagus in such patients.

Gastroesophageal reconstruction or forceful dilatation in the presence of esophageal varices is an intimidating procedure. With the modification presented, there is no need for a second operation and the patient can begin to take oral sustenance early. Morbidity and mortality are reduced. At most, controlled and gentle dilatation of the GE junction may be required, done in our patient with the endoscope itself. The cirrhotic, debilitated, and/or nursing home patients who can survive the initial major operation are ideal candidates for this modification.

References

[1] Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg 1986; 42:235-39 [2] Schwartz ML, McQuarrie DG. Surgical management of esophageal perforation. Surg Gynecol Obstet 1980; 151:669-70 [3] Asplund CM, Hill LD. Delayed lower esophageal perforation: management with Celestin tube. Ann Otol Rhinol Laryngol 1985; 94:114-16 [4] Burnett CM, Rosemurgy AS, Pfeiffer EA. Life threatening acute osterior mediastinitis due to esophageal perforation. Ann Thorac Surg 1990; 49:979-83 [5] Attar S, Hankins JR, Suter CM, Coughlin TR, Sequeira A, McLaughlin JS. Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 1990; 50:45-51 [6] Orringer MB, Stirling MC. Esophagectomy for esophageal disruption. Ann Thorac Surg 1990; 49:35-43 [7] Urschel HC, Rassuk MA, Wood RE, Galbraith N, Pockey M, Paulson DL. Improved management of esophageal perforation: exclusion and diversion incontinuity. Ann surg 1974;179:587-91 [8] Popovsky. J. Perforations of the esophagus from gunshot wounds. J Trauma 1984; 24:337-39 [9] Hantke DR, Hoover LA, Zuckerbraun L. Physiologic exclusion of the injured esophagus. Arch Otolaryngol Head Neck Surg 1988; 114:457-59

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