Perforation of the Esophagus:

A Complication of Vagotomy or Hiatal Hernia Repair

ROBERT P. MCBURNEY, M.D.

From the Departnment of Surgery, Baptist Memorial Hospital atd theUniversity of Tennessee Medical School, Memphis, Tennessee

THE KNOWLEDGE that perforation of theesophagus is most commonly secondary toinstrumental procedures is appreciated bythe medical profession and those experi-enced in esophagoscopy or dilatation takedue caution to prevent this complication.Perforations which occur in the course ofother surgical procedures are not so widelyappreciated.On the basis of the following five cases

it appears that during vagotomy or hiatalhernia repair there is not full awareness orrecognition or proper treatment of this dan-gerous and often fatal complication.

Case ReportsCase 1. R. H. A 42-year-old obese man had an

esophageal hiatal hernia with esophagitis for overa year prior to operation in January 1962. Priormedical treatment failed to relieve his symptoms.

At operation, through an abdominal incision,inflammatory reaction and edema were marked inthe area of the terminal esophagus. The esophaguswas drawn down by traction to expose the cruraand at this time a posterior perforation occurredin the terminal esophagus. Because of inflamma-tion the terminal portion was removed and theesophagus was re-implanted into the fundus ofthe stomach.

A complicated course followed, marked by sub-phrenic abscess, wound disruption, esophageal ob-struction, gastrointestinal bleeding and finallydeath 23 days subsequent to operation. Postmortem examination was not done.

Case 2. B. J. A 42-year-old obese man under-went operation on November 27, 1965, for repair

Presented at the Annual Meeting of the South-ern Surgical Association, December 9-11, 1968,Boca Raton, Florida.

of an esophageal hiatal hernia. Symptoms had notbeen previously controlled by medical measures.The esophagus was retracted without event andsutures were placed in the crura both anterior andposterior to the esophagus. Sutures were alsoplaced from fundus to esophagus to "reconstructthe angle."

The following day he was febrile with de-creased breath sounds at the right lung base. Onthe fourth postoperative day a right sided hydro-pneumothorax was identified (Fig. 1) and closedthoracotomy drainage done. Open rib resectiondrainage of an empyema was done on the 9tlpostoperative day. A low esophageal fistula hadbeen identified two days previously (Fig. 2).

The patient's subsequent course was markedby infection, respiratory complications and gastro-intestinal bleeding. Death from infection andbleeding occurred 17 days postoperative. Autopsywas not done.

Case 3. A. C. A 44-year-old man was seen onSeptember 16, 1966 with a history of long stand-ing chronic duodenal ulcer. He had nearly totalduodenal obstruction (Fig. 3) and gastrointestinalbleeding.

Laparotomy was done on September 2, 1966and a large indurated mass was found in the duo-denal area. It was intended to perform vagotomybut considerable induration in the area of the ter-minal esophagus made the vagus nerves difficult toidentify. When slight traction was applied to theesophagogastric area a tear in the esophagus oc-curred exposing a severe ulcerative esophagitis inthe lumen of the esophagus. The tear was repairedwith interrupted silk sutures and a subtotal gas-trectomy was then performed. The subphrenic andduodenal areas were drained.

The patient recovered without complicationsbut returned 2 weeks after dismissal with nearlycomplete dysphagia (Fig. 4). Gastrostomy was per-formed and gentle dilatation through an esophago-scope was done a week later. During the ensuing

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McBURNEY Annals of SurgeryJune 1969

FIG. 1. Case 2. Right sided hydropneumothoraxafter insertion of thoracotomy tube for drainage.

2 months dilatation was carried out twice andswallowing slowly improved.

On December 19, 1966 he was found to havesevere anemia and hospitalization was advised butrefused at that time. He was transfused as an out-patient and returned home.

He entered his home hospital 10 days laterand expired after massive gastrointestinal hemor-rhage.

FIG. 2. Case 2. Contrast media in the mediastinumfollowing "Gastrografin" swallow.

Case 4. L. W. A 46-year-old woman was ad-mitted to the Baptist Hospital on August 1, 1967.She had been operated upon at another city 10days previously and a right subcostal incision hadbeen made to remove the gallbladder. At lapa-rotomy a duodenal ulcer was found and in addi-tion to cholecystectomy, a pyloroplasty and va-

gotomy were performed. Exposure of the esopha-gogastric area was difficult and a perforation ofthe esophagus was accidentally made with scissors.The perforation was sutured with chromic catgutand the operation terminated.

On the third postoperative day she was takingfluids by mouth but developed fever, dyspnea anda hydro-pneumothorax in the left pleural space.A chest tube was inserted and the patient im-proved (Fig. 5). A week later because of failureto continue improvement and because of increas-ing dysphagia she was referred for further treat-ment. An esophageal fistula was demonstrated(Fig. 6).

Thoracotomy and closure of a low esophagealperforation were performed August 3, 1967. Clo-sure was with interrupted silk sutures reinforcedby omentum pulled up through an enlarged hiatusand sewn against the perforated area. The lungwas decorticated and tube drainage instituted.

She did well but developed an esophagocu-taneous fistula which closed after 3 weeks.

When last seen in January, 1968 she had re-

gained her weight, had no dysphagia and had re-

turned to work (Fig. 7).

Case 5. G. B. A 50-year-old woman had a

cholecystectomy, appendectomy and hiatal herniarepair on March 12, 1966. The findings were

chronic cholecystitis with stones and esophagealhiatal hernia of the sliding type.

A right sub-costal incision was used and thecholecystectomy and appendectomy were unevent-ful. During mobilization of the esophagus for hiatalhernia a small longitudinal tear in the right ante-rior aspect of the esophagus occurred. This was

closed with a continuous chromic catgut suture inthe mucosa and interrupted 3-0 silk in the muscu-

lar layer. The crura of the hiatus were then ap-

proximated behind the esophagus and the woundclosed without drainage.

The patient was febrile the day following op-

eration and was given vasopressors because of hy-potension.. Chest x-ray on March 15, 1966 showeda shift of the mediastinum to the right with col-lapse of the left lung and a fluido-pneumothorax(Fig. 8). Thoracentesis on March 17, 1966 yielded900 cc. of air and 50 cc. of bloody fluid.

At reoperation a 3 cm. tear in the terminalesophagus with extensive empyema were found.

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PERFORATION OF THE ESOPHAGUS 853

FIG. 3. Case 3 (left). Duodenal obstruction secondary to duodenal ulcer. FIG. 4. Case 3 (right).Partial esophageal stricture at gastroesophageal junction.

The esophagus was closed with 3-0 silk in twolayers. Decortication of the lung was carried outand the tube drainage of the chest instituted.

After improvement for several days, however,on resumption of oral intake fever recurred andchest x-ray of March 24, 1966 showed inadequatedrainage of the pleural space (Fig. 9). On March26, 1966 rib resection drainage of the left pleuralspace was performed and about 300 cc. of gastricsecretions and pus were removed at that time.

On March 28, 1966 a tube jejunostomy was

created for feeding purposes. The patient's nutri-tion continued to be poor, however, she seemed tobe improving when sudden death occurred on

April 4, 1966.Autopsy showed the esophageal tear unhealed

and a small portion unrepaired. The jejunostomytube had penetrated the wall of the jejunum and2,000 cc. of formula and gastric fluid were free inthe abdominal cavity. Gastric and duodenal ulcerswere present as well as a residual empyema.

Discussion

Esophageal perforation is not uncommonduring endoscopic procedures and about75% of those reported are related toesophagoscopy, gastroscopy, dilatation or

various other esophageal manipulations.Some other causes of perforation are pene-

trating or blunt trauma, spontaneous per-

foration, foreign body perforation, perfora-tion of esophageal ulcer and perforationsecondary to the use of balloon tamponade.Only two references to perforation at the

time of vagotomy or hiatal hernia repair

FIG. 5. Case 4. Left hydropneumothorax afterinsertion of thoracotomy tube and 5 days of tubedrainage.

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Annals of SurgeryJune 1969

FIG. 6. Case 4 (left).Contrast media in themediastinum. X-ray done10 days subsequent tothe original operation.FIG. 7. Case 4 (right).Slight narrowing of ter-minal esophagus. X-raydone 4 month subse-quent to recovery.

are in the American literature as far as can

be determined.* One report by Foster andassociates 1 indicated that such perforationsare not rare since their seven cases madeup 16% of 42 perforations from all causes.

Five of their perforations occurred at thetime of vagotomy and two at the time ofhiatal hernia repairs.

* See Addendum p. 855.

Four of the seven were recognized im-mediately and sutured. Three patients re-

covered, one died. In the other three recog-

nition of the complication was 2 to 10 dayslater. Apparently these patients died al-though it is not so stated in their report.

Patterson 4 reported three instances ofesophageal perforation in 199 operationsfor duodenal ulcer. All three were recog-

s.i............M~-

FIG. 8. Case 5 (left). Left hydropneumothorax demonstrated 3 days subsequent to theoriginal operation.

FIG. 9. Case 5 (right). Continued presence of empyema space after attempted closure ofesophageal laceration and decortication.

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Volume 169 PERFORATION OF THE ESOPHAGUS 855Number 6

nized at the time, were closed and the pa-tients recovered.

Obviously, technic is faulty when perfo-ration occurs at operation. There are, how-ever, predisposing factors in some instances.When esophagitis is severe and of longstanding tissues in the area of the terminalesophagus are friable and traction on theesophago-gastric area may tear the esopha-gus (Cases 1 and 3).Poor exposure is the next most likely pre-

disposing cause of perforation (Case 4)and excessive obesity, poor lighting, andother such factors must be evaluated andcontrolled.A third cause may be sutures inadvert-

ently placed through the entire wall of theesophagus (a possibility in Case 2).

Foster, Jolly, Sawyers and Daniel1 sug-gest that ischemic necrosis of the esopha-geal wall may account for some instances.

Treatment

If perforation is recognized at operationcareful closure plus drainage of the area isthe best therapy. When esophagitis is se-vere and perforation of an esophageal ulceroccurs at operation, esophago-gastrectomyor simple closure with omental reinforce-ment and drainage may be carried out.Subphrenic drainage may be inadequateand if mediastinal effusion or pleural effu-sion occurs then pleural and mediastinaldrainage are required.Only highly selected instances of perfo-

ration can be safely treated by nonopera-tive means. Paulson, Shaw and Kee 5 re-ported a mortality of 70% for perforationswhich were untreated; 40 to 70%o for thosetreated by nonoperative measures and 14to 20% for cases treated by operation.They reported a case of successful surgi-cal closure 28 days after perforation withplural drainage as the only prior treatment.

In massive esophageal tears or in tissuesso friable that closure is impossible or hasfailed exclusion of the esophagus should be

considered with later reconstruction by useof a segment of colon. This has been suc-cessfully carried out in one patient2 andhas been used in seven others by Maillard 3with six survivals.

Summary1. Perforation of the esophagus is a po-

tential complication associated with va-gotomy or hiatal hernia repair.

2. This complication probably occursmore frequently than is indicated by re-ports in the surgical literature.

3. Severe esophagitis predisposes theesophagus to perforation. Most perfora-tions, however, are due to technical errors.

4. Five cases are reported in which per-foration occurred. Three patients died sec-ondary to mediastinitis or peritonitis. Oneis living and well and one died later dueto gastrointestinal hemorrhage.

5. Recognition and immediate surgicalclosure is the optimal treatment. Closurewith appropriate surgical drainage, how-ever, offers the best change for survival re-gardless of the time elapsing between per-foration and diagnosis.

AddendumSubsequent to preparation of this paper, Postle-

thwait and associates 6 have reported one case andtate that 24 cases were to be found in the litera-ture.

References1. Foster, J. H., Jolly, P. C., Sawyers,, J. L. and

Daniel, R. A.: Esophageal Perforation: Diag-nosis and Treatment. Ann. Surg., 161:701,1965.

2. Jimenez-Martinez, M., McBurney, R. P., Pat-terson, R. and Robbins, S. G.: Esophagoplastyby Use of Isolated Segments of Colon: Surg.Gynec. Obstet., 114:749, 1962.

3. Maillard, J. N.: Perforation of the Esophagus.Acta Chir. Belg. 1967, 66:725. In: Intl Abst.Surg., 127:63, 1968.

4. Patterson, H. C.: Morbidity Following GastricResection for Duodenal Ulcer With and With-out Vagotomy. Amer. Surg., 31:175, 1965.

5. Paulson, D. L., Shaw, R. R. and Kee, J. L.:Recognition and Treatment of EsophagealPerforations. Ann. Surg., 152:13, 1960.

6. Postlethwait, R. W., Kim, S. K. and Dillon,M. L.: Esophageal Complications of Vagot-omy. Surg. Gynec. Obstet., 128:481, 1969.