Trans-abdominal-mediastinal approach with median phrenotomy for esophageal disruption

The prognosis for esophageal disruption is still poor. The aim of this study is to clarify the usefulness and safety of the transabdominal-mediastinal approach for spontaneous esophageal disruption.

The surgical procedure is as follows: upper median laparotomy with resection of the xyphoid process, folding up of the lateral segment of the left liver, median phrenotomy from the root of the xyphoid process to the esophageal hiatus, trans-mediastinal left thoracotomy by blunt dissection, blind lavage of the thoracic cavity, and simple interrupted suture and fundic patch of this suture line, if necessary.

We managed 3 cases using this technique. Two cases had severe prior chronic diseases (poorly controlled diabetes and liver cirrhosis, and hemodialysis). In all cases, the lesions were completely exposed in the abdomen by and the ruptured sites were safely and completely sutured under a good field of view. The left thoracic cavity was adequately washed. All cases were saved without lethal complication. One case showed minor leakage, which was easily managed by continuous high pressure aspiration using double luminal drainage system (CHPA-DLD).

We concluded that our technique is useful for esophageal disruption long after the onset, with severe prior chronic diseases, or with pleuritis.