Delayed primary repair of intrathoracic esophageal perforation: is it safe?

The management of intrathoracic esophageal perforation with delayed diagnosis is a subject of controversy. Because of the obvious advantages of primary repair as a simple single-stage operation, this technique was preferentially used to treat 18 of 22 consecutive patients with esophageal perforation. These patients were stratified into three groups according to the time interval between perforation and repair: group A, less than 6 hours, five patients (28%); group B, 6 to 24 hours, six patients (33%); and group C, more than 24 hours, seven patients (39%). Group A patients were older (p < 0.05) and group B had fewer iatrogenic perforations (B, 17%; A, 80%; C, 57%, p < 0.1). Additional tissue was used to buttress the repair site in all three groups (A, 3/5 patients, 60%; B, 4/6 patients, 67%; C, 6/7 patients, 86%; p = not significant). In seven patients (39%), a fundic wrap was used to reinforce the site of primary repair. The outcomes of the three groups were analyzed. Group A had the lowest proportion of postoperative leaks (A, 0/4 patients, 0%; B, 4/6 patients, 67%; C, 5/6 patients, 83%; p < 0.05) and postoperative morbidity (A, 2/5 patients, 40%; B, 6/6 patients, 100%; C, 6/7 patients, 86%; p < 0.1). However the increased incidence of leak and morbidity did not lead to an increase in mortality. One death occurred in each group, with an overall mortality of 17% (A, 1/5 patients, 20%; B, 1/6 patients, 17%; C, 1/7 patients, 14%; p = not significant). We conclude that in the era of advanced intensive care capabilities, primary repair of intrathoracic esophageal perforation can be safely accomplished in most patients regardless of the time interval between perforation and operation. Leakage at the suture site is common unless primary repair is carried out without delay. Postoperative leakage, however, is usually inconsequential and does not necessarily result in an adverse outcome.

One-stage primary repair of distal esophageal perforation using fundic wrap.

Esophageal leak following primary repair of esophageal perforation is a serious complication that can lead to severe mediastinitis and sepsis. Complete diversion with esophageal exclusion or resection is designed to minimize further mediastinal contamination. However, this approach is not necessarily associated with less morbidity or mortality. Furthermore, a second stage operation is required to restore esophageal continuity. From 1986 to 1994, we performed a one-stage primary repair of the distal esophagus in seven patients with either iatrogenic (n = 5) or spontaneous (n = 2) perforations and reinforced the repair by a fundic wrap. One patient underwent an additional modified Heller myotomy for achalasia. Delay between perforation and operation was less than 6 hours in 3 patients, 6 to 24 hours in 2 patients, and greater than 24 hours in 2 patients. Only one patient (14%) developed a small esophageal leak that spontaneously resolved with adequate mediastinal drainage, intravenous antibiotics, and aggressive nutritional support. One patient (14%), whose repair was delayed by 12 hours, died postoperatively of profound sepsis. This patient was moribund from sepsis preoperatively, and postmortem examination of the esophagus revealed no evidence of esophageal leak. Esophageal continuity was maintained in all patients. The median length of stay was 21 days (range, 15-58 days). We conclude that primary reinforced repair of esophageal perforation using a fundic wrap is an effective method of treatment for distal esophageal perforation, even when the repair is delayed by more than 24 hours.

Percutaneous transluminal coronary angioplasty failures in patients with multivessel disease. Is there an increased risk?

In recent years, there has been a nationwide trend toward performing percutaneous transluminal coronary angioplasty in patients with multivessel coronary artery disease. The clinical course of 57 consecutive patients who required emergency first-time coronary artery bypass grafting operations were reviewed to assess for difference in outcome between the 28 patients (49%) with single-vessel disease and the 29 patients (51%) with multivessel disease. The two groups were similar in preoperative characteristics except for a higher proportion of chronic obstructive pulmonary disease in the patients with multivessel disease (p = 0.03). Twice as many patients with multivessel disease were in shock (single-vessel disease = 4 [14%], multivessel disease = 8 [28%], p = not significant) en route to the operating room and significantly more patients with multivessel disease required on-going cardiopulmonary resuscitation (single-vessel disease = 0 [0%], multivessel disease = 5 [17%], p = 0.03). Significantly more coronary artery bypass grafts were placed in the patients with multivessel disease (single-vessel disease = 1.5 +/- 0.6, multivessel disease = 2.9 +/- 0.7, p < 0.01), which required longer aortic clamping time (p = 0.02) and cardiopulmonary bypass time (p < 0.01). There were seven postoperative deaths; all but one occurred in patients with multivessel disease (single-vessel disease = 1 [4%], multivessel disease = 6 [21%], p = 0.05). According to multivariate analysis, incremental risk factors of mortality were preoperative shock (p < 0.01), urgent or emergency percutaneous transluminal coronary angioplasty (p = 0.06), and multivessel disease (p = 0.12). Despite a similar incidence of myocardial infarction (single-vessel disease = 8 [29%], multivessel disease = 12 [41%], p = not significant), patients with multivessel disease had a higher incidence of cardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 11 [38%], p = 0.04) and noncardiac morbidity (single-vessel disease = 4 [14%], multivessel disease = 12 [41%], p = 0.02). By multivariate analysis, incremental risk factors of morbidity were preoperative shock (p < 0.01), multivessel disease (p = 0.02), and ejection fraction < 50% (p = 0.07). In the subset of patients with multivessel disease, preoperative shock, ejection fraction < 50, and an age of 60 years or greater were associated with higher morbidity and mortality. In conclusion, the risk of percutaneous transluminal coronary angioplasty failure is considerably higher in patients with multivessel disease. In certain subsets of patients with multivessel disease, coronary artery bypass grafting would be a safer procedure when compared with percutaneous transluminal coronary angioplasty for initial myocardial revascularization.

Simple approach for extrapericardial placement of defibrillator patches via median sternotomy.

The intrapericardial placement of implantable cardioverter defibrillator patches has been associated with a variety of complications due to the patch-epicardial interface. Extrapericardial placement of defibrillator patches minimizes these problems. We describe a simple and reproducible technique to achieve this goal whenever a median sternotomy approach is used.

Pericardioperitoneal shunt: an alternative treatment for malignant pericardial effusion.

The treatment of 37 consecutive cases of symptomatic malignant pericardial effusion over a period of 13 years was retrospectively analyzed. The most common diagnoses were lung cancer (59%) and breast cancer (11%). In the most recent 4 patients, the Denver pleuroperitoneal shunt was used to drain the pericardial effusion into the peritoneal cavity. In each case, the procedure was performed under local anesthesia, and the patient was discharged 2 to 4 days later without complications. Three of the patients subsequently died of the disease process without evidence of cardiac failure or tamponade during 6-month follow-up. The more traditional means of pericardial drainage, the subxiphoid approach (14 patients) and the anterior thoracotomy approach (19 patients), were associated with higher postoperative morbidity (21% and 53%, respectively) and mortality (7% and 42%, respectively). Because of the small number of patients treated by pericardioperitoneal shunting, a significant difference was demonstrated only in the length of hospital stay (shunt, 2.8 +/- 0.5 days; subxiphoid, 11.2 +/- 4.6 days; thoracotomy, 14.9 +/- 6.1 days). Median survivals were essentially the same (shunt, 3.5 months; subxiphoid, 2.7 months; thoracotomy, 1.2 months). It is apparent that the pericardioperitoneal shunt, although a much simpler procedure, can accomplish similar palliation effectively in the treatment of malignant pericardial effusion.

Pseudoaneurysms of the aorta after cardiac surgery or chest trauma.

Between March 1982 and June 1992, 17 patients (age: 21-76 years) were diagnosed with pseudoaneurysm of the thoracic aorta (PTA). Four PTAs developed post-trauma while 13 developed after aortic or cardiac surgery. Unusual presentations included: dyspnea, hoarseness, dysphagia, massive hemoptysis (2 degrees to aortobronchial fistula), massive hematemesis (2 degrees to aorto-esophageal fistula), superior vena cava syndrome, paralyzed right hemidiaphragm, and herald bleeding from the sternotomy. The interval between initial operation and recognition of PTA varied from three months to eight years while the four posttraumatic PTAs presented 5 to 26 years postinjury. The sites of postoperative PTA were: the aortotomy (3), proximal vein graft anastomosis (4), aortic cannulation site (2), and distal anastomosis of ascending aortic graft replacement (4). Aortography was very sensitive, outlining the false aneurysm in 13/13. Five patients had transesophageal echo-cardiography with one false negative. Seven patients died (41%), three from postoperative PTAs from massive hemorrhage intraoperatively and four from sepsis and multiorgan failure following repair. We conclude that patients who have previously had aortic or cardiac surgery or a history of blunt chest trauma presenting with unusual cardiorespiratory symptoms should be aggressively evaluated for PTA. Due to the magnitude of the operative problems encountered, repair of PTA is associated with a significantly high rate of mortality.

Pericardioplasty.

When so desired, a simple technique can be performed to close the pericardium after a cardiac operation. The only requirement is to think about it during the opening of the pericardium and make the appropriate cuts.

Embryonal carcinoma of the testis presenting as a left heart mass.

A 31-year-old man with a history of intravenous drug abuse and tooth abscess was admitted for evaluation of possible infective endocarditis. Echocardiography showed that he had a left atrial mass. The mass removed from the left atrium had the same histology as the primary embryonal carcinoma discovered in the right testicle during hospitalization. The patient made a smooth recovery after surgical intervention and chemotherapy. This is believed to be the first reported case of metastasis from embryonal carcinoma of the testis to the left side of the heart that was successfully removed at surgery.

Coaxial needle biopsy of lesions of the lung guided by computed tomography.

Thirty patients underwent coaxial needle aspiration biopsies of lesions of the lung under CTG. Tissue obtained was adequate for diagnosis in 90 per cent of the patients. The incidence of pneumothorax was low using the coaxial needle technique. The limitations of the fine needle are diminished, and the risk of tumor implant during the procedure is greatly minimized. Additional studies should be conducted to further evaluate this technique and confirm its safety.

Impalement injuries to the thorax as a result of motor vehicle accidents.

We report three cases of thoracic impalement by large-diameter steel pipes as a result of motor vehicle accidents. The steel pipes were removed in all patients in the operating room under general anesthesia and controlled circumstances. Despite the dramatic nature and presentation of these injuries, all 3 patients had nonlethal injuries and have recuperated without sequelae. Orderly care with standard surgical procedures is required and will give good results.

Interrupted aortic arch complex: successful total correction in the neonate.

Two neonates subjected to definitive repair of interrupted aortic arch complex during the first week of life are presented. Results correlated well with preoperative status. Our definition of complete correction, including direct aortic anastomosis, is discussed along with the surgical strategy employed for successful repair of this otherwise dismal anomaly.