Esophageal leaks repaired by a muscle onlay approach in the presence of mediastinal sepsis.
BACKGROUND
Nineteen patients were evaluated after closure of intrathoracic esophageal leaks by a pediculated muscle flap onlay repair in the presence of mediastinal and systemic sepsis.


METHODS
Intrathoracic esophageal leaks with mediastinitis and systemic sepsis occurred after delayed spontaneous perforations (n = 7) or surgical and endoscopic interventions (n = 12). Six patients presented with fulminant anastomotic leaks. Seven patients had previous attempts to close the leak by surgery (n = 4) or stenting (2) or both (n = 1). The debrided defects measured up to 2 x 12 cm or involved three quarters of the anastomotic circumference and were closed either by a full thickness diaphragmatic flap (n = 13) or a pediculated intrathoracically transposed extrathoracic muscle flap (n = 6). All patients had postoperative contrast esophagography between days 7 and 10 and an endoscopic evaluation 4 to 6 months after surgery.


RESULTS
There was no 30-day mortality. During follow-up (4 to 42 months), 16 patients (84%) revealed functional and morphological restoration of the esophagointestinal integrity without further interventions. One patient required serial dilatations for a stricture, and 1 underwent temporary stenting for a persistent fistula; both patients had normal control endoscopy during follow-up. A third patient requiring permanent stenting for stenosis died from gastrointestinal bleeding due to stent erosion during follow-up.


CONCLUSIONS
Intrathoracic esophageal leaks may be closed efficiently by a muscle flap onlay approach in the presence of mediastinitis and where a primary repair seems risky. The same holds true for fulminant intrathoracic anastomotic leaks after esophagectomy or other surgical interventions at the gastroesophageal junction.
Kotzampassakis
Nikos
N
Division of Thoracic and Vascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
Christodoulou
Michel
M
Krueger
Thorsten
T
Demartines
Nicolas
N
Vuillemier
Henri
H
Cheng
Cai
C
Dorta
Gian
G
Ris
Hans-Beat
HB
D000328:Adult; D000368:Aged; D004937:Esophageal Fistula / Q000401:mortality / Q000601:surgery*; D004939:Esophageal Perforation / Q000150:complications; D004940:Esophageal Stenosis / Q000209:etiology / Q000628:therapy; D016629:Esophagectomy; D004945:Esophagoscopy / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000628:therapy; D018805:Sepsis / Q000150:complications / Q000601:surgery*; D013524:Surgical Flaps; D013529:Surgical Wound Dehiscence / Q000150:complications