Esophageal Repair after Late Diagnosis of Perforation

esophagus in continuity, with care being taken to preserve the blood supply and avoid injury to the recurrent laryngeal nerve. A longitudinal or oblique incision approximately 1.5 cm in length is made in the esophageal wall, and the muscularis and mucosa are sutured to the subcutaneous fascia and skin with interrupted 4-0 silk.

At an elected time after improvement in nutrition and healing of the perforation a left thoracotomy is performed. The esophageal ligature is removed and a transverse gas- trotomy made in the stomach approximately 1 cm below the cardia. The esophageal lumen is examined, and if a stricture is present it is dilated in retrograde fashion or perorally using a Maloney bougie. If necessary, esophageal lengthening can be achieved by a Collis gastroplasty combined with a Belsey type reconstruction of the new cardia to prevent gastroesophageal reflux. The cervical esophagotomy is closed concomitantly. We have employed this technique in 6 patients, and all did well except 1 who died as a result of complications due to a massive course of steroids.

DR. C. FREDERICK KITTLE (Chicago, Ill.): I enjoyed Dr. Grillo’s presentation very much and agree with his emphasis on use of a pedicled pleural flap as an important adjunct for many situations in thoracic surgery. I would like to call your attention to the value of a pedicled pleural flap in pulmonary sleeve resections.

In reviewing 108 sleeve resections done at the Presbyterian-St. Luke’s Hospital in Chicago, 80 of which were lobectomies and 28 tracheal, we have found them to be divided into two main groups: In the first 20, before any pleural flap was used, there were 3 leaks at the suture line postoperatively. Subsequently, in an attempt to reduce the incidence of this complication, a pedicled pleural flap was used. In both the tracheal sleeves and the sleeve lobectomies the incidence of bronchopleural leak decreased; there were only 5, a reduction from 15 to 6%. We believe covering the suture line with a pleural flap is quite important in sleeve resections.

NOTICE FROM T H E AMERICAN BOARD O F THORACIC SURGERY

A limited number of copies of the 1974 Self-Assessment Examination for Thoracic Surgery (SATSE), together with an answer sheet, are available for $25 per copy from the office of the American Board of Thoracic Surgery, 14624 E. Seven Mile Rd., Detroit, Mich. 48205.

VOL. 20, NO. 4, OCTOBER, 1975 399