Eur J Cardiothorac Surg 2004;26:870-871
© 2004 Elsevier Science NL
Reply to Foroulis and Desimonas
Jacques Jougon*,
Jean-François Velly
Department of Thoracic Surgery, Haut-Lévêque Hospital, and Université Victor Segalen de Bordeaux II, Bordeaux University Hospital, avenue de Magellan, 33604 Pessac, France
Received 5 July 2004;
accepted 7 July 2004.
* Corresponding author. Tel.: +33-557-656-009; fax: +33-557-656-021. (E-mail: jacques.jougon{at}chu-bordeaux.fr).
Thank you for giving us the opportunity to discuss again the management of esophageal perforation in Boerhaave's syndrome. Dr Foroulis reported one case of a 42-year-old man who suffered from Boerhaave's syndrome with 48h of free interval before treatment. Primary repair was attempted but failed. In the case reported, presentation was very serious mimicking descending mediastinitis rather than Boerhaave's syndrome in which unilateral pleural empyema is more often associated with other side inflammatory pleural effusion than bilateral empyema. Dr Foroulis did not detail medical history of the patient. One may suppose alcohol abuse or debilited condition or other immunosuppressive condition, which explain the severity of septic shock in this young patient.
Removing of any esophageal stenosis is one of the major point to allow healing of the tear after primary repair. In that way, we always perform just before operating on a rigid esophagoscopy to rule out any underlying esophageal disease and esophageal stenosis [1]. One may suspect that an underneath esophageal stenosis should be present to explain the delayed leak. Primary repair should be performed in most cases but esophageal diversion may be an alternative, in case of mediastinal necrosis precluding esophageal suture. In our recent series, we never had to perform esophageal diversion. After performing a primary repair, we always put a silastic aspirated drain against the esophageal suture. The drain is withdrawn after a water-soluble contrast swallow and 2 days of resuming oral eating to rule out an esophageal leak. In case of leak, the drain is progressively withdrawn which seal the leak as a Abbott drainage [2]. At last, the concept of primary esophageal suture is advised by many centers who use it to manage esophageal disease [3,4].
References
- Jougon J, Mc Bride T, Delcambre F, Minniti A, Velly JF. Primary esophageal repair for Boerhaave's syndrome whatever the free interval between perforation and treatment. Eur J Cardiothorac Surg 2004;25:475-479.[Abstract/Free Full Text]
- Abbott OA, Mansour KA, Logan XD, Hatcher CR, Symbas PN. Atraumatic so called ‘spontaneous’ rupture of the oesophagus. A review of 47 personal cases with comments on a new method of surgical therapy. J Thorac Cardiovasc Surg 1970;59:67-83.[Medline]
- Lawrence DR, Ohri SK, Moxon RE, Tonsend ER, Fountain SW. Primary esophageal repair for Boerhaave's syndrome. Ann Thorac Surg 1999;67:818-820.[Abstract/Free Full Text]
- Yena S, Doddoli C, Thomas P, Lienne P, Pietri P, Sabiani F, Giudicelli R, Fuentes P. Le syndrome de Boerhaave. Place de la suture directe et ses résultats à propos de 12 observations. J Chir Thorac Cardio-Vasc 2000;4:13-20.
