Perforation of the thoracic esophagus may be fatal unless diagnosed promptly and treated with an effective operation. The wide mortality range in different reports reflects the importance of these two factors. This range spans from as low as 11%, if operation is within 24 hours, to greater than 50% after two to three days. The high mortality with delayed treatment is principally due to inability to surgically close the perforation. Eighteen patients (aged from 31 to 78 years) were treated four hours to 14 days after thoracic esophageal perforation (less than 24 hours: 7 patients; 24 to 72 hours: 7 patients; greater than 72 hours: 4 patients). In 14 patients the perforation was sutured, after which the suture line was buttressed with a circumferential wrap of parietal pleura, originally described by Grillo. Underlying esophageal pathology was corrected and wide mediastinal drainage was instituted. All 14 patients recovered and were discharged from the hospital after a median stay of 20 days. Two patients had minor leaks at the suture line that soon closed. Four patients had perforations too extensive to close. Of these, one was resected, the Urschel procedure was used in two, and the Abbott T-tube drainage was used in one. Three of the four patients died. It was quite significant that the pleural wrap was equally effective with both early (6 patients) and delayed perforations (8 patients). These data indicate that the pleural wrap should be used routinely. Extensive perforations that cannot be closed should probably be treated by resection and drainage, followed by esophageal reconstruction at a later time.

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Primary neuroendocrine neoplasms of the mediastinum are extremely rare. We report the case of a 54-year-old woman who presented with dyspnea and was found to have a 6.8-cm tumor completely obliterating the right main pulmonary artery. Analysis of an endobronchial ultrasound fine-needle aspiration revealed a neuroendocrine tumor. A positron emission tomography scan showed no evidence of distant disease. The patient underwent surgical resection with reconstruction of the right main pulmonary artery with a Dacron (DuPont, Wilmington, DE) graft, followed by chemoradiotherapy. We discuss the presentation and management of this patient and review the current treatment options of primary neuroendocrine carcinomas of the mediastinum.

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