Modified Urschel Maneuver for the Surgical Management of Subacute and Chronic Traumatic Esophageal Ruptures

Objective: Traumatic esophageal ruptures are a rare but life-threatening entity. They are mostly caused iatrogenically (>50%) [1]. Fast management of these patients is essential but often difficult because the diagnostic process may be prolonged. The Urschel maneuver (a lateral esophagostomy with preservation of the esophagus in its mediastinal bedding) has been suggested as treatment for such cases. However, it may not be sufficient in cases of secondary mediastinitis and/or active bleeding. We illustrate here a modified Urschel maneuver to treat subacute and chronic thoracic esophageal ruptures by completely resecting the injured part of the esophagus and achieving the esophagostomy by externalizing the remaining trunk.

Presentation of Case: A 77-year-old woman presented with iatrogenic esophageal rupture caused by the placement of a Sengstaken-Blakemore (SB)-tube. The rupture had been occult and there were signs of mediastinitis. The SB tube was placed when acute bleeding occurred and all endoscopic efforts had failed. We performed a left-sided thoracotomy in the 5^th intercostal space and identified the ruptured part of the esophagus. We ligated it distally, resected the injured part and then irrigated and drained the infected area. The remaining proximal trunk of the esophagus was mobilized and deposited in a sub- subclavian pocket that was created from the inside of the thorax. Later, a subclavicular incision developed the trunk and it was then tunneled under the skin for the esophagostomy. The patient tolerated the procedure well and was extubated the day of surgery.

Conclusion: Our modification to the Urschel maneuver presents a complex but useful operation for patients where esophageal ruptures require acute resection for uncontrollable bleeding or drainage for significant infections.