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Esophageal perforation

for medical students and residents.
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Esophageal perforation

  1. 1. Esophageal Perforation Facebook: Happy Friday Knight February, 2nd, 2018 General Surgical Residency Program Thailand
  2. 2. • Can be from iatrogenic (most common - during diagnostic or therapeutic endoscopic procedures), spontaneous, foreign body, trauma, operative injury, and tumor. • Regardless of etiology, it is surgical emergency • Surgical therapy is mainstay treatment
  3. 3. Basic Anatomy of Esophagus
  4. 4. • A muscular tube • From pharynx to cardia of stomach • 3 narrowing points: tend to hold up objects and injured when ingesting corrosive agent – Uppermost: entrance of esophagus caused by cricopharyngeal muscle (1.5 cm) – Middle: caused by crossing of Lt main stem bronchus and aortic arch (1.6 cm) – Lowermost: hiatus caused by sphincter (1.6-1.9 cm)
  5. 5. • In normal anatomic position, transition from oropharynx to esophagus is lower border of 6th cervical vertebra • Attach to cricoid cartilage • It lies in the midline, with a deviation to the left in the lower portion of the neck and upper portion of the thorax, and returns to the midline in the midportion of the thorax near the bifurcation of the trachea In the lower portion of the thorax, the esophagus again deviates to the left and anteriorly to pass through the diaphragmatic hiatus
  6. 6. Netter’s Atlas of anatomy
  7. 7. Netter’s Atlas of anatomy
  8. 8. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015
  9. 9. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw- Hill Education, 2015
  10. 10. • Cervical portion: 5 cm • Thoracic portion: 20 cm • Abdominal portion: 2 cm • Musculature: – Outer longitudinal and inner circular layer – 2 – 6 cm uppermost contains only striated muscle, then smooth muscle gradually becomes more abundant
  11. 11. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.
  12. 12. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.
  13. 13. • Primary function of esophagus is to transport materials from pharynx to stomach • Swallowing – three phases: oral, pharyngeal, esophageal
  14. 14. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.
  15. 15. Clinical Presentation • Depends on – the mechanism of injury – time elapsed from injury – location of the perforation – associated comorbid conditions • Pain • Fever • Dyspnea • crepitus
  16. 16. Clinical Presentation • Cervical perforation: – Pain – Dysphagia – Odynophagia worsening when swallowing and neck flexion – Crepitus – Fever – Right-sided pleural effusion
  17. 17. Clinical Presentation • Midthoracic perforation: – Fever – Right-sided pleural effusion – Substernal and epigastric pain – Mediastinal air
  18. 18. Clinical Presentation • In spontaneous perforation of distal thoracic esophagus (Boerhaave syndrome) : Mackler triad: – Thoracic pain – Vomiting – Subcutaneous emphysema • Perforation of abdominal portion: – severe epigastric pain radiate to back and left shoulder – Generalized peritonitis suggests diffuse contamination
  19. 19. Diagnosis • Critical period of 24 hours is essential • Wide range of diagnostic option can guide the clinician: – CXR – Oral contrast studies – CT – Direct endoscope • Which to choose depends on clinical screnario
  20. 20. Diagnosis • In stable and cooperative patient  CXR PA upright with lateral CXR – Mediastinal emphysema – Mediastinal widening – In cervical perforation  subcutaneous emphysema
  21. 21. http://www.anmjournal.com/article.asp?issn=0331- 3131;year=2015;volume=9;issue=1;spage=30;epage=32;aulast=Nair
  22. 22. Diagnosis • Stable patient suspected endoscopic injury: contrast esophagogram – Standard confirmatory study – maybe non-operative management – Most protocols initially utilize water-soluble iodinated radiopaque medium (Gastrograffin) followed by dilute barium
  23. 23. https://thoracickey.com/esophageal-perforation/
  24. 24. Diagnosis • More urgent presentations often come with CT scan – Used in atypical presentation, unable to tolerate oral study, critically ill, intubated – Good for identify extraluminal air and fluid
  25. 25. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.
  26. 26. Diagnosis • Next is to do endoscopic assessment – direct visualization of the esophageal mucosa for tears, perforations, and pathologic lesions – useful in assessing the extent of injury and its location, thus guiding surgical decision making and operative approach – Therapeutic benefit in removing foreign body and placement of stent – Air insufflation may exacerbate pneumothorax – Best perform in OR – ICD before performing
  27. 27. Management • Principles – Accurate diagnosis – Resuscitation – Control of extraluminal contamination – Broad spectrum antibiotic coverage – both aerobe and anaerobe – NPO and nutritional support – Restoration of GI tract continuity
  28. 28. Management • Choices – Nonoperative management – Placement of a covered stent – Primary surgical repair – Drainage – Esophageal resection and exclusion or proximal diversion
  29. 29. Management • Factors that guide the choice – location of perforation – degree of contamination – sepsis – Tissue destruction – preexisting esophageal disease – comorbidities – time from the diagnosis
  30. 30. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.
  31. 31. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.
  32. 32. Nonoperative and Endoscopic Managemtn • Cameron and Altorjay proposed criteria for nonoperative management: – Perforation within neck or mediastinum with free drainage back into the esophagus on esophagogram – Minimal symptom without evidence of sepsis – Early diagnosis of intramural perforation – Absence of benign or malignant obstructive disease
  33. 33. Nonoperative and Endoscopic Managemtn • Observe the patient for 3 – 5 days then repeat esophagogram and step diet • Stent can be used to seal perforation and control a leak but debridement and drainage must be ensured
  34. 34. Operative Management • Gold standard • Best outcomes when early identification (<24h) • Surgical exploration allows – direct visualization of the perforation – drainage of contaminated spaces – debridement of devitalized tissue – followed by a primary repair, resection, or diversion if necessary.
  35. 35. Operative Management • Cervical esophagus – Left neck incision – Anterior to SCM – Drainage – 2-layer primary repair – containment of the cervical esophageal perforation by the surrounding cervical structures limits contamination
  36. 36. https://www.ctsnet.org/article/exposure-cervical-esophagus 2 FB below cricoid cartilage, horizontally from anterior to posterior SCM
  37. 37. https://www.ctsnet.org/article/exposure-cervical-esophagus - Short subplastymal flaps are elevated - Fascial incised
  38. 38. https://www.ctsnet.org/article/exposure-cervical-esophagus
  39. 39. https://www.ctsnet.org/article/exp osure-cervical-esophagus
  40. 40. Operative Management • In contrast, perforation of the thoracic or abdominal esophagus is associated with contamination of larger, free spaces (i.e., pleura or peritoneum) and therefore requires a more aggressive surgical approach in order to obtain source control of the underlying infection and prevent continued soilage
  41. 41. Operative Management • Abdominal esophagus: explore laparotomy • Thoracic esophagus – Right thoracotomy through 6th ICS for proximal and middle esophagus – Left thoracotomy through 8th ICS for distal esophagus
  42. 42. Operative Management • Principles: debridement devitalized tissue and primary closure • Mucosal repair by interrupted absorbable suture • Minimize esophageal stricture • Muscular layer is reapproximated with interrupted or running suture • Subsequent coverage with a vascular pedicle, such as an intercostal muscle flap, and pleural, pericardial, or omental pedicle allows further buttressing of a repair and is recommended whenever feasible
  43. 43. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.
  44. 44. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013.
  45. 45. Operative Management • Any of the antireflux procedures (Belsey Mark IV, Nissen, Dor, Toupet) may be used to buttress the repair • Alternative choices when extensive tissue necrosis: – T-tube placement – stent placement with muscle flap coverage – esophageal resection with proximal esophageal diversion and distal feeding access
  46. 46. • In setting of underlying esophageal diseases may complicate the choice  absolute contraindications to primary esophageal repair unless distal obstruction can be relieved : – Achalasia – Chronic stricture – eosinophilic esophagitis – severe reflux disease – malignancy Operative Management
  47. 47. • Achalasia, repaired primarily in two layers, and esophageal myotomy performed on the contralateral side of the LES • end-stage achalasia with sigmoid esophagus, malignancy, retractory esophageal stricture, esophagectomy with gastric pull-up Operative Management
  48. 48. • Esophagectomy with reconstruction VS proximal diversion and distal enteral access: – Remain challenging – judging from the degree of contamination – the patient’s physiologic status – suitability of a conduit for esophageal replacement Operative Management
  49. 49. References Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. Yeo CJ et al. Shackelford’s surgery of alimentary tract. 7th ed. Philadelphia: Elsevier Saunders, 2013. Netter’s Atlas of anatomy https://www.ctsnet.org/article/exposure-cervical-esophagus

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