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M.A. Cuesta and D.L. van der Peet
References
1. Broeders JA, Mauritz FA, Ahmed Ali U, et al. Systematic review and meta-analysis of
laparoscopic Nissen versus Toupet fundoplication for gastro-esophageal refl ux disease. Br
J Surg. 2010;97:1318–30.
2. Awais O, Luketich JD, Schuchert MJ, et al. Reoperative antirefl ux surgery for failed fundopli-
cation: an analysis of outcomes in 275 patients. Ann Thorac Surg. 2011;92:1083–9.
3. Booth MI, Stratford J, Jones L, et al. Randomized clinical trial of laparoscopic total (Nissen)
versus posterior partial (Toupet) fundoplication for gastro-oesophageal refl ux disease based on
preoperative oesophageal manometry. Br J Surg. 2009;95:57–63.
4. Pizza F, Rossetti G, Del Genio G, et al. Infl uence of esophageal motility on the outcome of
laparoscopic Total fundoplication. Dis Esophagus. 2008;21:78–85.
5. Chrysos E, Tsiaoussis J, Zoras OJ, et al. Laparoscopic surgery for gastroesophageal refl ux
disease patients with impaired esophageal peristalsis: total or partial fundoplication? J Am Coll
Surg. 2003;197:8–15.
6. Makris KI, Lee T, Mittal SK. Roux-en-Y reconstruction for failed fundoplication. J Gastrointest
Surg. 2009;13:2226–32.
Chapter 10
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Case on Iatrogenic Esophageal Perforation
Miguel A. Cuesta and Donald L. van der Peet
Keywords Esophageal perforation • Iatrogenic perforation • Empyema •
Mediastinitis • Stent
Diagnosis and Indication for Surgery: Identifi cation
and Treatment of the Complication
A 62-year-old male patient had been operated on by a cardiac surgeon because of a
mitral stenosis. The valve had been replaced through a sternotomy. Postoperatively,
the patient was admitted to the intensive care department, and there he developed a
respiratory infection with respiratory insuffi ciency. The patient was treated by
mechanical ventilation and antibiotics. After a period of 4 weeks, he still could not be
disconnected from the mechanical ventilator and in order to rule out an insuffi ciency
of the new implanted valve, a cardiac trans-esophageal ultrasound was performed.
The valve was found to work correctly, but the patient’s low-grade sepsis persisted,
which impeded weaning him from mechanical ventilation. Moreover, he developed
an acute renal insuffi ciency requiring hemodialysis. The CT scan showed mediastinitis with free air in the mediastinum and a suspicion of a right thoracic empyema
(Figs. 10.1 and 10.2 ). To rule out an esophageal perforation, an esophagoscopy was
performed showing an esophageal perforation at 30 cm of incisors line. The clinical
condition of the patient was considered too unstable for surgery and he was treated
primarily by a stent and thoracic drainage (Fig.
and 5 days later, a mediastinal abscess, located in the right superior and mid
10.3 ). The septic condition persisted
M. A. Cuesta , M.D. () • D.L. van der Peet
Department of Surgery , VU University Medical Center ,
Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_10,
© Springer International Publishing Switzerland 2014
55
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Fig. 10.1 Mediastinitis by
esophageal perforation
M.A. Cuesta and D.L. van der Peet
Fig. 10.2 Mediastinitis and empyema
10 Case on Iatrogenic Esophageal Perforation
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Fig 10.3 Stent placed in the
esophagus
Fig. 10.4 Defect of the
esophagus showing the stent
57
mediastinum, was drained through a right cervical incision. The patient’s clinical
condition did not improve and after much deliberation a decision was taken to perform a right explorative thoracotomy to drain the empyema and fi x the perforation.
Operation
A large esophageal perforation was seen at operation including destruction of at
least fi ve cm of the mid-esophagus (Fig. 10.4 ). An esophageal resection was per-
formed, a gastric conduit created, and anastomosed at cervical level. In addition,
decortication of the right lung was performed and the thorax drained.
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M.A. Cuesta and D.L. van der Peet
Postoperative Course
After 3 weeks of mechanical ventilation via a tracheotomy, the patient’s condition
fi nally improved so he could be retired from mechanical ventilation. Also the renal
function recovered. His clinical situation was restored after a long period of
rehabilitation.
Discussion
Following a trans-esophageal ultrasound, this patient’s iatrogenic esophageal perforation was fi rst treated with a stent (Illustration 10.1a ). Even with a critically ill
patient, stent treatment for a longer existing perforation combined with mediastinitis and thoracic empyema is not an optimal treatment option. It should be preserved
for acute perforations with intact mediastinal pleura without contamination of the
mediastinum and pleural cavity [ 1 – 3 ]. A direct perforation of the esophagus through
the mediastinal pleura or a delay in diagnosis will contribute to disruption of the
mediastinal abscess into the pleural cavity involving the formation of an empyema.
The empyema and mediastinitis should be promptly and adequately drained. The
only option for this patient was an explorative thoracotomy on the right side with
treatment of the perforation.
a
Illustration 10.1 ( a ) Iatrogenic esophageal perforation. ( b ) Two possibilities, (a) esophageal per-
foration with intact mediastinal pleura may be treated by stent placement and (b) patient with
esophageal perforation with empyema treated by a right thoracotomy, lung decortication, closure
of the perforation, and muscular fl a p
10 Case on Iatrogenic Esophageal Perforation
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59
Contained
perforation
mediastinitis
Perforation
Empyema
Preparation of
intercostal muscle
b
Illustration 10.1 (continued)
Closure of
perforation
Intercostal muscle.
Stent
Decortication
plasty
Yet, the question may be: How to manage an iatrogenic esophageal perforation?
In case of a small perforation with intact pleura and no empyema (contained rupture), a stent could be suffi cient with eventually a drainage of the medistinitis, but
close observation remains important. In case of an “open” perforation with empyema, the perforation should be closed primarily, in two layers, with some kind of
muscular fl ap or fundoplication if the perforation is distal. The empyema should be
treated by decortication of the lung and drainage (Illustration 10.1b ). Important fac-
tor here is adequately draining the place of the closed perforation. There is also an
option for thoracoscopic exploration with adequate debridement and drainage [ 4 ]. If
the leakage reappears, the drain should be maintained for a long period of time in
order to have a controlled fi stula. The option to drain the empyema percutaneously
and to cover the perforation by means of a stent is not optimal. In the patient here
presented, having a large perforation and necrosis of the esophagus around the stent,
the only treatment option should have been an esophageal resection with the formation of a gastric conduit anastomosis in the neck.
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M.A. Cuesta and D.L. van der Peet
References
1. Pla V, Cuesta MA, van den Broek WT. Treatment of thoracic esophageal perforations. Cir Esp.
2005;77:327–31.
2. Freeman RK, Ascioti AJ. Esophageal stent placement for the treatment of perforation, fi stula
or anastomotic leak. Semin Thorac Cardiovasc Surg. 2011;23:154–8.
3. Ryom P, Ravn JB, Schmidt S, et al. Aetiology, treatment and mortality after oesophageal per-
foration in Denmark. Dan Med Bull. 2011;58:A4267.
4. Haveman JW, Nieuwenhuijs VB, Kobold JP, et al. Adequate debridement and drainage of the
mediastinum using open thoracotomy or video assisted thoracoscopic surgery for Boerhaave’s
syndrome. Surg Endosc. 2011;25:2492–7.
Chapter 11
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Case on Peritonitis After Unrecognized
Perforation Following Heller Myotomy
and Dor Fundoplication for Achalasia
Miguel A. Cuesta and Donald L. van der Peet
Keywords Peritonitis • Perforation • Heller myotomy • Dor fundoplication •
Achalasia
Diagnosis and Indication for Surgery
A 16-year-old boy presented with dysphagia for solid food and weight loss of 5 kg
during the fi nal year of his secondary education.
Diagnosis revealed achalasia, as based on the manometry fi ndings involving
hypoactivity of the contractions and no relaxation of the lower esophageal sphincter
(LES). In another hospital, the patient had been dilated twice without improvement
and now he was referred to our center for a laparoscopic Heller myotomy.
Operation
During the laparoscopic intervention, it was diffi cult to develop the plane between
the muscular layer of the esophagus and the mucosa. It seemed that two different
planes were developing. Two small iatrogenic perforations were made and were
closed with 4-0 stitches. Myotomy was performed adequately, on 6 cm of the
distal esophagus and on 2 cm of the proximal stomach. Across the defect an
M. A. Cuesta , M.D. () • D.L. van der Peet
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl; dl.vdpeet@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_11,
© Springer International Publishing Switzerland 2014
61
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anterior Dor fundoplication (180°) was created without mobilizing the short gastric vessels.
M.A. Cuesta and D.L. van der Peet
Postoperative Course: Identifi cation and Treatment
of the Complication
The second day after operation the patient could ingest some bland liquids; on the
third day he developed fever and upper abdominal pain. A CT scan with oral contrast was performed, and leakage of contrast was found at the distal esophagus
(Fig. 11.1a, b ) A laparoscopic exploration was performed. Leakage of gastric con-
tent was seen in the upper abdomen, and after removal of the stitches of the Dor
plasty, a 3-cm long perforation was seen at the distal part of the mucosa (Illustration
11.1 ). This extended perforation was possibly caused by necrosis of the mucosa.
The perforation was carefully closed again with a 5.0 PDS continuous suture, and a
Dor plasty was created to cover the defect. The abdomen was drained and patient
received a central line for feeding. He recovered in a week time. A new control by
swallow X-ray showed a normal passage and no leakage.
Discussion
This patient possessed an unusual complication. Boeckstaens et al. have published
recently a randomized study of a “total of 201 patients randomly assigned to pneumatic dilation (95 patients) or laparoscopic Heller myotomy (LHM) (106)” [ 1 ]. The
a b
Fig. 11.1 ( a ) CT scan showing leakage of contrast at the myotomy site. ( b ) CT scan with leakage
of contrast
11 Case on Peritonitis After Unrecognized Perforation Following Heller Myotomy
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63
Illustration 11.1 Heller’s myotomy with Dor fundoplication as treatment of idiopathic achalasia.
Postoperative leakage with peritonitis. Laparoscopically approached: Dor fundoplication was dismantled, mucosa perforation seen, and closed by running suture. Dor fundoplication was added
therapeutic success with pneumatic dilation with the random group was 90 % after
1 year of follow-up and 86 % after 2 years as compared with a rate of the group with
LHM of 93 % after 1 year and 90 % after 2 years. Perforation of the esophagus
occurred in 4 % of the patients during pneumatic dilation, whereas mucosal tears
occurred in 12 % during LHM. There were no postoperative perforations in this
series. Zaninotto et al. published the outcome of a study of 400 patients treated for
achalasia by means of Heller myotomy and Dor fundoplication, and they determined conversion and morbidity rates of 1.5 % and 1.9 %, respectively, whereas the
mortality was 0 % [ 2 ]. Moreover, Lan Wang and You Ming Li reviewed 16 papers
on the outcomes of surgical treatment of recurrent achalasia and complications
involved. “The most common intraoperative complication was gastrointestinal perforation, including gastric and esophageal perforation in 1.5–20 % of patients.
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