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126 Thomas Anthony Horan
may need to add a Collis gastroplasty to lengthen the esophagus or to close the perforation using the gastric fundus as a serosal patch, combined with a floppy, nonconstricting antireflux procedure. This is the one time I do not insist on the wrap being
in the abdomen; it is most important not to put any tension on the repair of the per-
foration. If it does not easily go back into the abdomen, then leave it in the chest.
Isolated external penetrating and blunt injuries to the esophagus are rare.
Thoracic gunshot injury will hit the esophagus about 1 in 20 cases. Associated injuries to heart, lung, blood vessels, spine, and airway always take precedence. Signs
of esophageal injury such as hemothorax or mediastinal emphysema are similarly
attributable to concomitant injuries. Therefore, always examine the esophagus
prior to closure after all the other more dramatic injuries to lung, heart, and blood
vessels have been controlled. Complete exploration of the hematoma and tracts of
penetrating objects usually prevents missing the esophageal defect. There is nothing worse than operating for trauma and 2 days later finding the patient moribund
from mediastinitis from overlooked esophageal perforation. Blunt disruption of
the esophagus implies violent deceleration, difficult diagnosis, and a terrible
prognosis. However, blunt trauma may occasionally cause rupture of the esophagus from intrusion of osteophytes at a lower degree of violence.
The Kind Nobody Wants
The kind nobody wants is the killer. The patient presents late, is septic, and
has mediastinitis and empyema, whether from spontaneous vomiting-induced
rupture, FB, neglect, or missed iatrogenic perforation—it doesn’t matter; the patient is in big trouble, and you know it. Perforations occurring in cancer, manipulation of extensive caustic strictures, third-degree caustic burns, congenital connective
tissue disorders, and congenital epidermolysis bullosa are all in the same category.
Rapid concerted effort from a dedicated group is critical. You have to stabilize and
then operate. You have to control the source of the infection - often this requires an
esophagectomy—and provide wide drainage. You can restore continuity at a time
of your choice; after all, you can always reoperate on an alive patient.
The toughest decision to make in perforation of the esophagus is what to do
when the diagnosis has been delayed in a previously well esophagus. The inclina-
tion is to preserve the esophagus if possible. The mediastinal tissues and the
state of the esophagus will tell you. If the patient is lucky, the perforation has
passed directly into the pleural cavity, and the mediastinum and esophagus are
relatively intact. The basis of surgical treatment is surgical closure as described
above, but you must debride any necrotic tissue prior to any attempt at closure.
Even so, the sutures you place will be at a high risk of leakage. Thus, along with
wide mediastinal drainage, large-bore chest tubes, antibiotics, and nutrition you
15 Esophageal Emergencies 12 7
must consider proximal diversion and gastrostomy to protect the closure, especially if the mucosa is edematous, stiff, and friable.
When the perforation is mostly contained within the mediastinum, severe
mediastinitis is invariable. None of t he c hoic es is good but do not g ive up; remem-
ber, the patient survived with no treatment until now. With good treatment, the
patient can still pull through. The inflamed esophagus will not hold sutures, so it
is useless to think of primary closure. Wide drainage alone will lead to a long,
debilitating, and perilous course; therefore, isolation-exclusion of the esophagus
by cervical diversion proximally and gastrostomy distally is a safer option.
Emergency resection is my preferred option, especially when the esophagus is
partially necrotic, and wide debridement will make stricture a near certainty. The
benefits of this approach are rapid effective control of the mediastinum contamination and avoidance of complications such as vascular or tracheal fistula.
Perforations from dilatation of strictures secondary to accidental caustic ingestion outnumber acute perforations from liquefaction of the esophagus secondary to suicide attempts. Both need emergency resection. I have never
understood the reticence in resection of severe caustic injuries. Should patients
survive without resection, they are condemned to a life of stricture dilatation, with
one in five suffering instrumental perforations. Anyway, if not resected at the
acute stage many of these patients will come to resection and replacement at a
later date because of difficulties with nutrition and the high risk of malignancy
developing in the burned esophagus—perhaps as high as 1,000 times the general
risk.
Perforations That Cannot Be Fixed
“Doctor, the lymphoma patient you “mediastinoscoped” yesterday wants to go
home.”
“Sure, but how is he?”
“Just fine, but he feels a little cold coming on and would feel better at home. Oh! By
the way, his neck is kind of sore and crinkly. Do you think he needs a prescription for
antibiotics before he goes?”
Inaudible response.
Never underestimate the risk in this type of patient. They need a little operation for diagnostic biopsy or palliative therapy, but their disease cannot be
cured surgically. Do not give up too easily. Thoracostomy, drainage, antibiotics,
nutrition, and proximal diversion and gastrostomy may salvage the inoperable
or unfixable patient. This is worth the effort, especially if there is other effective
ancillary therapy for the underlying disease, like for my patient involved in the
lymphoma disaster.
128 Thomas Anthony Horan
Palliative attempts to dilate, stent, or laser ablate inoperable or nonresectable carcinomas should have been discussed with the patient and family prior to
the procedure. The instrumental perforation rate is in the region of 10%, and it
will not be long before the surgeon is confronted with this problem. If you have
already dilated it and accessed the distal esophagus, put in a stent and count
yourself lucky. The patient still has a chance for palliation if the antibiotics, nasogastric suction, and nothing-by-mouth regimen is successful. Otherwise, morphine may be your only choice.
Summary
Always suspect perforation, especially following instrumentation
Investigate and manage aggressively
Be aware of esophageal comorbidity
Preserve the normal esophagus
Close and patch perforations
Drain widely
Resect if the gullet is very diseased (cancer, long strictures, burns)
When it [occurs] it can be recognized but it cannot be remedied by the medical
profession. (Herman Boerhaave, 1668–1738)
Invited Commentary
Philip T. Peverada
As Dr. Horan so ably discusses, the two most common surgical esophageal
emergencies are foreign body (FB) obstruction and perforation. The former outnumbers the latter by a significant amount.
Foreign body obstruction. In the modern hospital, the obstructed patient
frequently presents first to the medical gastroenterologist, who will pursue the
obstructing agent with the flexible gastroscope. The surgeon will be called when
that attempt is unsuccessful in clearing the obstruction or when it has cleared the
obstruction but caused the graver problem of esophageal perforation. In the case
of the retained FB, facility with the rigid Jackson esophagoscope is required. The
esophagus is by now raw, inflamed, and prone to perforation. It is folly to attempt
removal with the rigid scope in this situation if one’s skills are rudimentary or long
unused. If transfer to another facility with skilled endoscopy is not an option,
15 Esophageal Emergencies 12 9
thoracotomy and esophagotomy are preferable and less morbid than a perforation
with subsequent need for drainage and repair. If a trip to the operating room is
deemed necessary, it is always prudent to repeat the endoscopy just after induction
as general anesthesia and relaxation can result in FB migration and militate the
need for thoracotomy.
Esophageal perforation and postoperative anastomotic leaks. Although
many new minimally invasive and endoscopic techniques are now available for
managing esophageal pathology, the disaster of esophageal perforation requires
adherence to basic surgical principles and judicious use of the newer technologies. Since many perforations are iatrogenic, the tendency of the clinician is to
push for the less-invasive approach, perhaps as a way of lessening the self-guilt
surrounding the complication. The key is prompt recognition and treatment. No
matter how stable and comfortable the patient may seem, oral flora in the mediastinum are not tolerated for long, and untreated the problem is uniformly fatal.
Whatever approach is used in treating an esophageal perforation, one must
adhere to the time-honored principles of dealing with this problem:
Elimination of the septic process
Provision of adequate drainage
Augmentation of host defenses by antibiotics
Maintenance of adequate nutrition
How this is accomplished is less important than that it is accomplished
expeditiously.
Dr. Horan discussed the criteria for nonoperative management, namely, a
contained perforation, “self-drainage” back into the esophagus, and minimal
signs of sepsis. This selective approach can be used with up to 80% success in
avoiding surgery.
Endoscopic Treatment
Although thoracotomy with debridement, drainage, and repair remains the
gold standard for the perforated esophagus, the introduction of video-assisted
thoracic surgery (VATS) and endoscopic approaches has provided alternative
methods of achieving the same goal. Initially, there were case reports of success in
managing selected patients without a thoracotomy. With time, larger experience is
beginning to emerge reporting VATS and stenting with varying degrees of success.
However, I believe that meanwhile the “gold standard” remains thoracotomy.
Drainage and debridement are easily accomplished via the thoracoscope,
but the closure of the defect with a secure buttress is problematic. It appears that
small defects with minimal contamination can be primarily repaired with a degree of success. Larger defects have been repaired over a T tube with reported
130 Thomas Anthony Horan
good results. Endoscopic stenting of the disruption combined with VATS debridement and drainage have also been described. Sealing in around 70% of patients
with ultimate stent extraction in two-thirds of the long-term survivors has been
reported (Tuebergen et al. 2008). However, others reported high reoperation rates
and leak rates in the perforation groups (Pennathur et al. 2008; Zisis et al. 2008;),
so the absolute utility of these techniques is not currently established. Further
technological improvements may result in fewer leaks and less stent migration.
In approaching esophageal perforation, attention to long-established surgical principles is required. As techniques evolve, a VATS/endoscopic approach
will probably become the norm. This will be delivered best in specialty centers
with expertise in VATS procedures and surgical endoscopy. The question then
becomes how to best serve the patient.
I would concur with Dr. Horan that time matters in these patients, and that
operative intervention should not be delayed in the hopes of avoiding a thoracotomy. Perform the operation needed using the techniques available and best
fitting the surgeon’s training and experience. In the end, it is the outcome and not
the size of the scar that is the indicator of success.
References
Pennathur A, Chang AC, McGrath KM, et al. Polyflex expandable stents in the treatment of
esophageal disease: initial experience. Ann Thorac Surg 2008;85:1968–1973.
Tuebergen D, Rijcken E, Mennigen R, Hopkins AM, Senninger N, Bruewer M. Treatment of
thoracic esophageal anastomotic leaks and esophageal perforations with endoluminal
stents: efficacy and current limitations. J Gastrointest Surg 2008;12:1168–1176.
Zisis C, Guillin A, Heyries L, et al. Stent placement in the management of oesophageal leaks.
Eur J Cardiothorac Surg 2008;33:541–556.
Editorial Comment
Some authorities believe that the time factor is unimportant. This is not
necessarily to disagree with Dr. Horan since he observed that the important issue
is to tailor the procedure to the state of the gullet at the time of surgery. The time
interval may obviously have some indirect bearing on this. We wish to quote
another expert in this field: Dr. David J. Richardson of Louisville as published in
the book Source Control (2002).
I really do not think that the time of perforation should enter into treat-
ment decisions to any significant extent. Generally, we try to treat the patients
15 Esophageal Emergencies 131
in a similar fashion regardless of the time that they are seen after esophageal
perforation.
If the esophagus is presumably normal prior to the insult (such as with
Boerhaave’s syndrome), preservation of the esophagus should be the primary
goal with attempted closure of the perforation.
If the underlying disease is cancer and an iatrogenic perforation has occurred
during its diagnosis or treatment, then the patient is best treated by esophagectomy and immediate reconstruction in my experience.
I b elie ve n onoper ativ e tre atment must b e re served for rel ativ ely few pat ients
and should only be done in a very narrow set of circumstances. If contrast goes
beyond the wall of the esophagus, it is my opinion that the patient should have
operation and treatment of that problem—even if the contrast drains back into
the esophagus from a cavity. Granted, some patients may be able to heal such
a perforation nonoperatively, but I am aware of several disasters with patient
deaths where this strategy was tried and subsequently failed. I have also observed
significant scarring at the area of the healed perforation. Therefore, I reserve non-
operative treatment only for “micro-perforations” in which there may be some
small tear observed in the muscle itself, but the contrast does not actually escape
the confines of the esophagus.
I believe that an attempt should be made to close every perforation.
In my opinion, esophageal diversion should be reserved only for those pa-
tients who are almost certainly going to die unless diversion is done.
Reference
Richardson JD. In: Schein M, Marshall J (eds), Source Control: A Guide to the Management
of Surgical Infections. Springer, Berlin, 2002, Chap 20, p 197.
Diaphragmatic Emergencies
Ulrich Schoeffel · Moshe Schein
The only diaphragmatic pathology of interest to the emergency abdominal
surgeon is the diaphragmatic hernia through which one or more abdominal
structures may migrate into the thorax and become incarcerated or strangulated. This may occur in different settings, each of which however shares many
clinical features.
Diaphragmatic Hernia
Congenital Diaphragmatic Hernia
Congenital diaphragmatic hernias are very rare entities that include the
Bochdalek hernia (posterolateral defect in the trigonum lumbocostale) or
Morgagni hernia (just posterior to the xyphoid at the foramen Morgagni or the
trigonum sternocostale), a defect of the tendinous center of the left diaphragm,
or the paraesophageal hernia. Left-sided defects more commonly become symptomatic because the liver seals those of the right side. Most congenital hernias are
symptomatic and require operative treatment during the first hours of life due to
compression of the lungs and mediastinal structures. This can easily be accomplished from an abdominal incision by manual reposition (there are no adhesions between thoracic structures and abdominal viscera in these cases) and
direct closure of the defect. If several organs are transposed intrathoracically,
the reposition should follow the order stomach first, small bowel next, then large
bowel, and finally parenchymal organs such as the spleen.
If there is no overt herniation during the fetal development, the newborn
may appear normal but may develop herniation anytime later in life. It then
would present like any acquired diaphragmatic hernia, with the final diagnosis
established at operation when the exact localization of the defect is revealed.
1
16
Ulrich Schoeffel
University Freiburg, Rotkreuzklini k, Jägerstrasse 41, 88161 Lindenberg, Germany
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_16, © Springer-Verlag Berlin Heidelberg 2010
133
134 Ulrich Schoeffel · Moshe Schein
Rupture of the Diaphragm Due to Blunt or Penetrating Trauma
When the diaphragm is ruptured due to blunt or penetrating trauma, the
hernia may become symptomatic acutely, immediately after the injury, or may
present many years later—in a patient who has almost forgotten the trivial car
accident 14 years ago. Read about the diagnosis and treatment of acute traumatic
hernia in > Chaps. 38 and 39. Late complications are diagnosed and managed
along the lines described next for nontraumatic diaphragmatic hernia.
Acquired Diaphragmatic Hernia
In clinical practice, only two entities have to be considered in the context of
acquired diaphragmatic hernia: the herniation through a traumatic or congenital
defect of the tendinous part of the left diaphragm and paraesophageal hernia.
Left diaphragmatic hernia. It has been stated commonly that older posttrau-
matic hernia should be approached via a thoracotomy and nontraumatic hernia by
laparotomy. Indeed, the presence of a peritoneal envelope in a nontraumatic hernia
generally simplifies repositioning by gentle traction from below, whereas perforation or rupture of the diaphragm often includes a tear in the peritoneal lining, thus
leading to dense adhesions between the thoracic and herniated abdominal structures. However, in the individual case, the etiology is often not clear, and the presence
or absence of a peritoneal hernia sac is difficult to predict preoperatively. Therefore,
the operative strategy is influenced by probability and personal experience. It has
to be stressed, however, that a posterolateral thoracotomy in the seventh intracostal
space always permits careful dissection of herniated organs and exploration of the
subdiaphragmatic space, whereas an abdominal approach may prove more difficult and hazardous. If, irrespective of the approach, a small hernia ring has to be
enlarged, the radial ramifications of the phrenic nerve have to be respected.
Paraesophageal hernia. Here, the gastroesophageal junction lies inside the
abdomen, anchored by the phrenoesophageal membrane (nonsliding hernia) and
the herniation—most commonly of the stomach—develops through the enlarged
esophageal hiatus and a defect in the phrenoesophageal membrane alongside the
esophagus. The fundus of the stomach may roll up and down intermittently, producing no or only “subacute” symptoms but occasionally a larger portion or even
the whole of the stomach may herniate into the chest, producing the so-called
intrathoracic gastric volvulus (the “upside-down stomach,” or giant type II hiatal
hernia). Common complications include gastric strangulation with infarction, necrosis, and perforation, mucosal bleeding, or acute intrathoracic dilatation causing
compression of other intrathoracic structures.
16 Diaphragmatic Emergencies 13 5
Gastric Volvulus
Gastric volvulus is defined as an abnormal rotation of the stomach of at least
180°, creating a closed-loop obstruction. According to the axis around which the
stomach rotates, volvulus of the stomach may be organoaxial, mesenteroaxial, or
a combination of both.
In organoaxial volvulus, which is the more common variant, the stomach
rotates around an axis that connects the gastroesophageal junction and the
pylorus. In this situation, the stomach flips up into the chest with the greater
curvature—dragging the omentum with it—coming to lie at the top; this kinks
the esophagogastric junction as well as the distal stomach, producing a closedloop gastric obstruction. The less-common variant, mesenteroaxial volvulus,
occurs around the axis that runs from the center of the greater curvature of the
stomach to the gastric angulus. Gastric volvulus can occur at any age and with
equal frequency in both men and women and has been reported in neonates
and infants.
Clinical Features
Acute gastric volvulus may develop against a background of intermittent
nonspecific dyspepsia attributed to the known presence of a paraesophageal hernia, but usually it presents acutely “out of the blue.” Precipitating events may be
a heavy meal or any event that increases intra-abdominal pressure, such as postoperative ileus, pregnancy, or parturition.
The abdomen is relatively innocent, with little epigastric pain and no
abdominal findings on examination. There is more pain substernally or in the
chest, and the compression of the left lung by the herniated stomach (or other
viscera) may result in acute respiratory distress. A shift of mediastinal structures
to the right may result in cardiovascular instability, while kinking of the
gastroesophageal junction may produce retching. Th e d ia gn ost ic t ri ad desc ri be d
by Moritz Borchardt (1868–1948) includes epigastric/substernal pain, retching
without vomiting, and the inability to pass a nasogastric tube.
Traditionally, acute gastric volvulus was diagnosed on a chest X-ray showing a retrocardiac air bubble or a large fluid level in the chest (> Fig. 16.1). An oral
contrast study, showing obstruction of the stomach at the site of the volvulus,
would have then confirmed the diagnosis. Currently, however, a computed tomographic (CT) scan can offer an immediate diagnosis with all the anatomical
details (see > Figs. 16.2 and 16.3).
136 Ulrich Schoeffel · Moshe Schein
Fig. 16.1. “What is your stomach doing in the chest?”
Fig. 16.2. Scout film of the CT scan showing a distended stomach occupying the
left hemithorax with gross shift of mediastinum to the right
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