“Spontaneous” perforation of the oesophagus treated by utilization of a pericardial flap

Abstract

SUMMARYA case of 'recurrent' spontaneous perforation of the oesophagus treated by the utilization of a pericardial flap is reported. It is suggested that this manaeuvre, which does not appear to have been described previously, may be life-saving when there has been delay in operating or major secondary leakage has occurred. THE purpose of this report is to record the successful management of a case of spontaneous perforation of the oesophagus using a flap of pericardium to reinforce the repair after there had been further gross leakage following a conventional closure of the tear.This does not appear to have been attempted previously.FlG. I.-Radiograph of chest and abdomen revealing elevation of the left diaphragm hut no free gas. CASE REPORTH. J., a man of 37, was admitted at 1.30 a.m. on 28 Sept., 1969, having collapsed with severe upper abdominal pain whilst vomiting after a big meal with much alcohol.On examination he was found to be hypotensive, cold, and cyanosed with marked upper abdominal tenderness and rigidity; radiographs of the chest and abdomen revealed a little elevation of the left diaphragm but no free gas (Fig. I). The white blood-count was 17,000; serum amylase, 29 I.U.; and E.C.G., normal. A provisional diagnosis of a perforated peptic ulcer was made and at 3.30 a.m. a laparotomy was performed but no abnormality found. By 6.0 p.m. signs of fluid and air had appeared in the left chest associated with respiratory distress (Fig. z), thus revealing the diagnosis of a perforated oesophagus. As the general condition of the patient precluded further immediate operation, an intercostal drain was inserted and supportive treatment given. By 10 a.m. the following day (29 September) sufficient improvement had occurred to permit a left thoracotomy (A. H. M.), when a longitudinal tear of approximately 7 cm. was found on the left lateral aspect of the lower oesophagus associated with a gross contamination of the pleural cavity with food debris and beer. Although oedematous, the tear was easily repaired with a series of interrupted 'all-layer' silk sutures and, after pleural toilet, the chest was closed with apical and basal valved drains. Improvement was immediate and maintained until 4 October, when fluid again began to appear in the left chest, culminating, on 6 October, in a frank aeropleural fistula, indicating that a major oesophageal leakage had recurred. The chest was reopened and a gross empyema secondary to complete disruption of the repair found, all the sutures having 'cut through'.The oesophagus was now so oedematous and friable that any attempt at resuture appeared foredoomed to failure and further leakage inevitable. The loosely sutured oesophagus was therefore reinforced by turning down a large flap from the adjacent pericardium and carefully suturing it to the mediastinal pleura along its posterior, superior, and inferior margins (Fig. 3); pleural toilet was again carried out and the chest closed with valved drainage as before but, in addition, a gastrostomy was established. Further progress w...

Esophageal perforation: the importance of early diagnosis and primary repair

“…Reinforcement of the primary repair has been advocated by many surgeons. [15][16][17] We favor use of a pleural flap for middle third injuries and the omental flap for lower third ruptures. Primary repair is not advisable in some situations, such as: underlying malignant disease, scleroderma, grade IV reflux esophagitis and stage III achalasia.…”

Spontaneous esophageal rupture responding to simple suture closure, drainage, and percutaneous endoscopic gastrostomy (PEG): case report

“…Also, because of the high incidence of anastomotic insufficiency, tissues such as the omentum, base of the stomach, pericardium, or pleura have been used to cover the perforation site in recent years [14][15][16], although some studies have found that T-tube insertion is effective for severe contamination in the ruptured area [11,17].…”

Gastropericardial fistula-a complication of hiatus hernia

“…The oesophagus can also perforate into the pericardium (Shackelford, 1931), though more commonly it perforates into the chest. Spontaneous perforation of the oesophagus into the pleural cavity was first successfully treated by operation by Barrett (I 948), and a recent suggestion to help in the technique of repair is the use of a flap of pericardium (Millard, 1971). However, the development of a fistula into the pericardium is much rarer and more sinister.…”