Due to the special anatomy of esophagus, it is easy to burst and perforate under pressure and trauma. The incidence of esophageal perforation is much higher than other parts of digestive tract. The common causes usually include the foreign body, iatrogenic and accidental injuries, spontaneous ruptures and others. The disease of esophageal perforation is already difficult to deal with in thoracic surgery, the situation is even more complicated when combined with the vascular dysplasia and other complications.
Early diagnosis of esophageal perforation is the key to timely treatment and lower mortality. The main reason of misdiagnosis of the disease is that it is rarely considered due to the low incidence of esophageal perforation. The principle of treatment for esophageal perforation are adequate drainage, prevention of further spread of infection, anti-inflammation and nutritional support. Therefore, extra attention should be paid to the damage of surrounding tissue before treatment in addition to evaluating the severity of esophageal lesions. The following is our treatment experience based on this patient.
1. The diagnosis of esophageal perforation.
The main reason for the delayed diagnosis in this patient’s was that her neck injury and infection were not obvious, since the perforation area was located in the first stenosis of the esophagus near the entrance of thorax. The physical examination on the neck did not reveal any positive sign. Mediastinal infection has developed by the time the patient presents with febrile symptoms. Barium is not recommended for esophageal radiography, because barium can infiltrate the mediastinum and lead to mediastinitis. Chest CT examination revealed barium residues around the esophagus. In this setting, Gastrografin was recommended to use for esophageal radiography examination, but we should keep in mind that small esophageal perforation may be negative with this method. Therefore, the injured area needs to be observed from multiple angles and positions, otherwise gastroscopy is required.
2. The choice for surgical approach.
The selection of appropriate surgical methods is the key to treatment of esophageal perforation. We didn't use traditional neck incision and esophageal repair since this patient’s esophageal injury had lasted for a long time, although the neck infection was not severe and the anatomy of vessels in neck and chest had been changed by the right aortic arch. Our analysis was as follows: (1) the neck incision can increase the area of operation and increase the opportunity of iatrogenic infection; (2) the damage of the patient’s esophageal mucosal has lasted for a long time, the surrounding tissue may have edema, so the chance of first-stage suturing of the esophageal tissue is low; (3) even if we used the neck incision, mediastinal drainage must be placed, it is still uncertain whether the reverse drainage can solve the problems of the mediastinal infection; (4) the abnormal anatomy of vessels with this patient will make it complicated to extend the surgery to mediastinum from the neck. Based on the above analysis, we adopted the method of thoracoscopic mediastinal abscess incision and drainage, and put two tubes for drainage in the thoracic cavity and mediastinum. The efficacy of this surgical method is satisfactory.
3. The instructions for use of surgical instruments.
The patient used permanent pacemaker due to the pathological sinus syndrome. The pacing rhythm was set at 60 times/min in operation. Considering the impact of surgical electrotome energy on pacemaker, the electric knife was not allowed to use during the surgery. Ultrasonic knife was used instead during the intrathoracic operation because it will not affect the pacemaker. The surgery is successful along with the normal heart rhythm、heart function and intraoperative arterial blood oxygen saturation .
4. The impact of right aortic arch on surgery.
After opening the chest, the superior border of the arcus aortae was found to be close to the cupula pleurae, the three main branches of the aortic arch were not seen. The superior vena cava and azygos vein contorts showed to be normal. Based on above vascular abnormality of the patient, the patient’s condition belongs to type II right aortic arch. The medial mediastinal abscess at the descending aorta azygos vein level showed the abscess parcel and aortic tissue edema. We opened the mediastinal pleura and abscess with the ultrasonic knife, removed pus, and then gradually expanded the area of clearing. During the operation, The superior vena cava presented as an abscess-like mass due to inflammation and must be protected.
5. The nutritional support during perioperative period.
It is necessary for patient to fast before the operation. In this case, we placed a naso-jejunum three-lumen feeding tube (one is the stomach decompression tube and another two are duodenal nutrition tubes). The enteral nutritional support must be offered as soon as possible, which ensures the nutritional status of patients, as well as reduces patient’s cost in hospital. The time of removing the nutrition tube is 5 days after starting oral food intake.
6. The indication for removing the chest drainage tube.
Effective and favorable chest drainage is critical to successful surgery. After the operation, double-tube drainage was used, one for mediastinal drainage and one for ordinary thoracic drainage. The mediastinal drainage tube should be placed in the 7th intercostal space of the posterior axillary line with a depth of around 25 cm. The drainage tube should be placed on the top of the mediastinum(see figure 5). The ordinary chest drainage should be located in the 7th intercostal space in midaxillary line. After operation, doctors should observe the quantity, color, intermittent bacterial culture of the chest drainage, and regularly arrange chest CT examinations to understand the conditions of chest and mediastinum. The ordinary chest drainage tube can be removed if the quantity and quality of drainage are stable. The mediastinal drainage tube can be removed when the patient starts to eat normal food.