F. Griffith Pearson

The Management of Nonmalignant Intrathoracic Esophageal Perforations

Eight patients with nonmalignant intrathoracic esophageal perforations recognized more than 48 hours (48 hours to 14 days) after rupture were treated at Toronto General Hospital between 1973 and 1978. Perforation was due to postemetic rupture in 7 patients and to instrumentation in 1. The patients were seen with pain (8), vomiting (7), fever (7), shock (4), respiratory insufficiency (5), pleural effusion (7), pulmonary infiltrates (7), and leukocytosis (6). All patients were managed with thoracotomy. Direct suture closure of the perforation was carried out in 4 patients with midesophageal perforations. Postoperative localized leaks developed in 2 of these patients but healed with conservative management. Cervical esophagostomy and esophageal diversion were used in 1 patient in whom a severe empyema developed in the postoperative period. Direct suture closure, reinforced with a gastric patch, was used to close three lower esophageal perforations. None of these patients had a postoperative leak but all developed subsequent reflux esophagitis. All 8 patients survived. In patients with delayed recognition of a nonmalignant intrathoracic esophageal perforation, elimination of continued chemical and bacterial contamination can be achieved by a clear definition and closure of the esophageal mucosal margins. The obliteration of potential pleural spaces by good tube drainage, lung decortication, and the elective use of mechanical ventilation with positive end-expiratory pressure decreases the incidence of uncontrolled intrapleural sepsis.

Pulmonary Arteriography for the Assessment of Technical Feasibility of Sleeve Resection in Lung Cancer

BACKGROUNDnPulmonary arteriography has been reported to be useful in the preoperative assessment of patients with lung cancer to determine the technical resectability and feasibility of pneumonectomy by imaging the main right and left pulmonary arteries. In this report, we describe the use of selective pulmonary arteriography in the assessment of lobar resectability.nnnMETHODSnSelective pulmonary arteriography provides a detailed anatomic view of the lobar branches and has been used at our institution for the past 30 years to preoperatively investigate patients who are candidates for a sleeve lobectomy.nnnRESULTSnThree cases are described that demonstrate the usefulness of selective pulmonary arteriography in the assessment of the technical feasibility of sleeve resection in patients with lung cancer.nnnCONCLUSIONSnArteriographic findings may accurately show whether a sleeve lobectomy is technically possible, that only a pneumonectomy is possible, or that the only safe way to ensure clearance of the pulmonary artery is to perform arterioplasty. This information may obviate an unnecessary thoracotomy in patients who are judged on the basis of a physiologic assessment to be unable to tolerate a pneumonectomy.

The Collis-Belsey Procedure

We reported initial experience with this operation in 1971 [1]. Collis’ technique of gastroplasty was somewhat modified, and a long partial fundoplication was added rather than a Collis’ repair. Our modification uses a transthoracic approach through the left sixth intercostal space. Several technical features warrant emphasis: n n1. n nExposure and mobilization of the esophagus, cardia and proximal stomach is identical to that used for a Belsey Mark 4 repair. n n n n n2. n nThe addition of gastroplasty requires a more extensive removal of the esophagogastric fat pad than the Mark 4 repair. n n n n n3. n nThe length and luminal diameter of the gastric tube are considered important features of the anti-reflux mechanism. The tube is fashioned snugly over a No. 48 French bougie, is of uniform diameter from top to bottom, and is usually about 5 cms. in length. n n n n n4. n nA 270 degree partial fundoplication is created over a length of 4 to 5 cms. The length of fundoplication is longer than that used for a standard Belsey repair, — and is created using three rather than two tiers of fundoplicating sutures.