Thoracoscopic management of postoperative esophageal leak

Abstract

Esophageal perforation is an uncommon problem, but one that is associated with high mortality (9%-36%). 1-3 Treatment consists of aggressive surgical management and broadspectrum antibiotics. Surgical approaches to management of esophageal perforation include primary closure, esophagectomy, use of esophageal T-tube, exclusion-diversion, and mediastinal drainage. Selection of treatment depends on factors such as the cause and duration of perforation, clinical condition of the patient, and the degree of surrounding tissue injury. During the past decade, advances in minimally invasive surgical technology have allowed surgeons to apply thoracoscopic methods to the management of esophageal disease. Thoracoscopic operations have been applied to esophageal myotomy, resection of esophageal diverticulum, excision of esophageal leiomyoma, antireflux operations, and esophagectomy. 4 In this report we used our experience in video-assisted thoracoscopic operations for the management of 2 patients in whom an esophageal perforation developed as a result of a thoracoscopic esophageal operation. Clinical summary. The first patient was a 60-year-old woman who was referred with a 2-year history of severe chest pain and intermittent dysphagia. Upper esophageal endoscopy showed no obstructive lesions. Esophageal manometry revealed high-amplitude contraction in the body of the esophagus consistent with a diagnosis of diffuse esophageal spasm. The patient was treated nonoperatively with calcium-channel blockers and nitrates without success. She was offered surgical treatment consisting of a long esophagomyotomy. The operation was performed through the right side of the chest with 4 thoracoscopic trocars. Intraoperative endoscopy after the myotomy revealed no air leaks (Fig 1). The patient was discharged on postoperative day 4 on a clear liquid diet. On postoperative day 7, the patient returned with shortness of breath and acute chest pain. Gastrograffin contrast study revealed extravasation of contrast material at the midesophageal region. Endoscopy showed a small 3-mm perforation at the middle esophagus. The patient was reexplored thoracoscopically. Intraoperative endoscopy identified the