Post on 11-Jul-2015
CASE PRESENTATION
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PRESENTATION
• XYZ• 40 Y• Female
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PRESENTATION
• Retrosternal chest pain• Dysphagia
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PAST HISTORY
• APD
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EXAMINATION• Middle aged lady sitting in bed, well oriented in time,
place and person• Vitals
• Pulse = 90/min• B.P = 120/70 mmHg• R.R = 18/min• Temp = AF
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EXAMINATION
• Abdomen• NAD
• Chest• NAD
• CVS• NADdr.basit@live.com
INVESTIGATIONS• Baseline labs
• Normal
• C-XR• Normal
• ECG• Normal
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RIGID ESOPHAGOSCOPY
• Impacted meat bolus• Patient developed dyspnea and central chest pain• Suspicion of iatrogenic perforation• Shifted to ICU
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• ECG• Normal
• C-XR• Right pleural effusion
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TUBE THORACOSTOMY
• Pleural fluid with food debris• Shortness of breath improved but tachycardia worsened
(Pulse 110/min)• Low grade fever
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ICU CARE
• NPO• I/V fluid resuscitation• Broad spectrum antibiotics• Vital monitoring• Blood groupdr.basit@live.com
• 2 days history of food impaction• Patient was not NPO• Rigid esophagoscopy (Emergency)• Strong suspicion of perforation during esophagoscopy
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• High load perforation• Patient developed pleural effusion• Food debris and slough in chest drain• Worsening tachycardia• Low grade fever
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RIGHT THORACOTOMY AND ESOPHAGEAL REPAIR
• Left lateral position• Chest opened through 6th ICS• Lung retracted forward• Right Pleural cavity full of dirty fluid, food debris and
slough• All material aspirated and cavity thoroughly lavageddr.basit@live.com
RIGHT THORACOTOMY AND ESOPHAGEAL REPAIR• 2 cm longitudinal perforation was found at junction of
middle and lower 3rd of esophagus• Margins refreshed• Nasogastric tube passed and advanced beyond
perforation under vision
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RIGHT THORACOTOMY AND ESOPHAGEAL REPAIR
• Mucosa closed with interrupted sutures• Muscularis closed with interrupted sutures• Cavity washed with N. Saline• Chest drain placed and attached to underwater seal
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POST OP MANAGEMENT
• Managed in ICU• Recovery uneventful• NPO• I/V fluids
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POST OP MANAGEMENT
• I/V antibiotics• Parenteral nutrition• Vitals and I/O record• Chest tube care
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POST OP MANAGEMENT
• Gastrografin esophagogram performed on 11th POD• Oral sips started on 12th POD• Patient developed SSI (MRSA)• Chest drain removed on 20th POD
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ESOPHAGEAL PERFORATION
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ANATOMY
• Three anatomical points of narrowing• The cricopharyngeus muscle• The broncho-aortic constriction• The esophagogastric junction
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ETIOLOGY
• Increased intraluminal pressure at the anatomic sites of narrowing, as well as sites narrowed by a malignancy, foreign body, or physiologic dysfunction
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ETIOLOGY
• More than one half of all esophageal perforations are iatrogenic and most of these occur during endoscopy
Merchea A, Cullinane DC, Sawyer MD, et al. Esophagogastroduodenoscopy-associated gastrointestinal perforations: a single-center experience. Surgery 2010; 148:876.
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ETIOLOGYPercentage
Spontaneous perforation (Boerhaave’sSyndrome)
15 %
Foreign body ingestion 12 %
Trauma 09 %
Intra-operative injury 02 %
Malignancy 01 %
Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal perforation. Ann Thorac Surg2004; 77:1475.
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The estimated risk of esophageal perforationDiagnostic endoscopy with a flexible endoscope
0.03 %
Diagnostic endoscopy with a rigid endoscope
0.11 %
Stricture dilation 0.09 – 2.2 %Sclerotherapy 1 -5 %Pneumatic dilation for achalasia 2 – 6 %
Chirica M, Champault A, Dray X, et al. Esophageal perforations. J Visc Surg 2010; 147:e117.
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RISK FACTORS
• Malignant stricture• Severe esophagitis• Prior radiation therapy• History of caustic ingestion
Hernandez LV, Jacobson JW, Harris MS, Hernandez LJ. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc 2000; 51:460.
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RISK FACTORS
• Eosinophilic esophagitis• Complex (tortuous) or long strictures• Presence of esophageal diverticula• Inexperienced operator• A large hiatal hernia
Hernandez LV, Jacobson JW, Harris MS, Hernandez LJ. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc 2000; 51:460.
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• Use of high inflation pressures with balloon dilation• A history of previous esophageal perforation• A history of prior esophageal surgery (such as for trauma
or a congenital abnormality)
RISK FACTORS
Hernandez LV, Jacobson JW, Harris MS, Hernandez LJ. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc 2000; 51:460.
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PRESENTATION
• The clinical features of esophageal perforation depend upon the location of the perforation, degree of leakage, and the duration since the injury.
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PRESENTATION• Cervical perforation
• Neck pain• Tenderness over sternocleidomastoid• Dysphonia• Hoarseness• Cervical subcutaneous emphysema
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PRESENTATION• Intra-thoracic perforation
• Chest, back, or epigastric pain• Dysphagia• Odynophagia• Dyspnea• Hematemesis• Cyanosisdr.basit@live.com
• Intra-abdominal perforation• Epigastric, chest pain• Hematemesis• Epigastric tenderness• Pneumoperitonium
PRESENTATION
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DIAGNOSIS
• Clinical features• Diagnostic tests
• Thoracic and cervical radiographs• Contrast esophagography• Computerized tomography
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MANAGEMENT
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•Surgical emergency
de Schipper JP, Pull ter Gunne AF, Oostvogel HJ, van Laarhoven CJ. Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm. Dig Surg 2009; 26:1.dr.basit@live.com
NATURAL HISTORY
• Perforation Mediastinitis Sepsis MultiorganFailure Death
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INITIAL MANAGEMENT• NPO• Fluid resuscitation• Broad spectrum I/V antibiotics• Antifungal coverage ( in selected cases)• ICU care• Preparation for operative managementdr.basit@live.com
PRINCIPLES OF SURGICAL MANAGEMENT
• Primary repair of the perforation site is the optimal procedure.
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PRINCIPLES OF SURGICAL MANAGEMENT• Exceptions to performing a primary repair
• Cervical perforation that cannot be accessed but can be drained
• Diffuse mediastinal necrosis
• Perforation too large for the esophagus to be re-approximated
• Esophageal malignancy
• Pre-existing end-stage benign esophageal disease (eg, achalasia)
• The patient is clinically unstable
Wright CD, Mathisen DJ, Wain JC, et al. Reinforced primary repair of thoracic esophageal perforation. Ann Thorac Surg 1995; 60:245.
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GENERAL PRINCIPLES FOR ESOPHAGEAL REPAIR
• Devitalized tissue is debrided from the perforation site.• The muscular layer is incised longitudinally along the
muscle fibers superior and inferior to the perforation to expose the entire extent of the mucosal injury.
• The mucosa is closed in two layers ( mucosa/sub mucosa and muscularis) with interrupted absorbable sutures
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CERVICAL PERFORATION• More easily treated• Primary repair is performed if the perforation can be
clearly visualized and there is no distal obstruction.• Otherwise, drainage of the perforation is adequate to
control the leak since the anatomic structures of the neck typically confine extraluminal contamination to a limited space and thereby enhance spontaneous healing.
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THORACIC ESOPHAGEAL PERFORATION
• Mid-esophageal perforation is approached through a right thoracotomy at the sixth or seventh intercostal space.
• Distal esophageal perforation is approached through a left thoracotomy at the seventh or eighth intercostal space
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ABDOMINAL ESOPHAGEAL PERFORATION
• Laparotomy is the preferred approach.• General principles for the management of an intra-
abdominal esophageal perforation are the same.
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POSTOPERATIVE MANAGEMENT
• Nutritional support is necessary until oral feedings can be initiated and effectively sustained.
• The patient is maintained on intravenous broad spectrum antibiotics typically for 7 to 10 days.
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• Contrast esophagogram is obtained on 7th POD if the patient is clinically stable.
• Drains remain in place until patient is tolerating oral feedings and without clinical evidence of a leak.
POSTOPERATIVE MANAGEMENT
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ALTERNATIVES TO PRIMARY SURGICAL REPAIR
• Drainage• Diversion• Endoscopic stent placement• Esophagectomy
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DRAINAGE• Surgical drainage as the sole operative management is
reserved for perforations of the cervical esophagus when the perforation site cannot be completely visualized and when there is no distal obstruction.
• T-tube may be inserted into the perforation to create a controlled fistula when a patient cannot tolerate more extensive surgery.
Fürst H, Hartl WH, Löhe F, Schildberg FW. Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon. Ann Surg 2000; 231:173.
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DIVERSION
• The patient is unstable• The defect is large due to tissue destruction from
contamination• Pre-existing esophageal disease is present
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DIVERSION
• The goals• Control and drain extraluminal contamination• Divert the esophagus proximally with a cervical
esophagostomy• Resection of the remaining esophagus
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• The goals• Obtain gastric diversion with a gastrostomy tube and
feeding tube access with a jejunostomy• Close the diaphragmatic hiatus
DIVERSION
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ENDOSCOPIC STENT PLACEMENT• May be appropriate for patients
• Extensive comorbidities• Advanced mediastinal sepsis• Large esophageal defects• Inability to tolerate more extensive surgery.
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ESOPHAGECTOMY
• A primary repair alone of an esophageal perforation proximal to untreated achalasia, an undilatable stricture, or a malignancy should not be performed.
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OUTCOMES FOLLOWING OPERATIVE MANAGEMENT
• The principal variables associated with mortality• Delay in diagnosis• Type of repair• Location of perforation• Etiology of the perforation
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PROGNOSTIC VARIABLES FOR MORTALITY PERCENTAGE
Etiology (n = 431)Spontaneous 36Iatrogenic 19Traumatic 7Location (n = 397)Cervical 6Thoracic 27Abdominal 21Time to diagnosis (n = 396)<24 hrs 14>24 hrs 27
Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004; 77:1475.
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NON-OPERATIVE MANAGEMENT
• Diagnosed quickly• Less extraluminal contamination• Cervical perforation is most commonly considered for
nonoperative management
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NON-OPERATIVE MANAGEMENT
• NPO• I/V fluids• Broad spectrum antibiotics• Surgical intervention if patient deteriorates
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SUMMARY
• Prompt diagnosis and management is critical to minimizing mortality.
• The mortality rate following operative management of an esophageal perforation is dependent on location of the perforation.
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SUMMARY
• A primary repair is the gold standard of care
• Drainage alone should only be performed for perforation of the cervical esophagus when the perforation cannot be visualized and when there is no distal obstruction.
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SUMMARY• Diversion is reserved for patients who present with clinical
instability and more extensive operative procedure is not possible or when extensive esophageal damage precludes a primary repair.
• Esophageal stents may be appropriate for patients with extensive comorbidities, advanced mediastinal sepsis, or large esophageal defects and the patient’s inability to tolerate more extensive surgery.
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SUMMARY
• Esophagectomy should be performed when the patient presents with malignancy, extensive esophageal damage that precludes repair, or end-stage benign esophageal disease.
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• Non-operative management should be reserved for clinically stable patients with no evidence of systemic inflammation, expediently diagnosed perforations, and no spillage of mediastinum, pleura or peritoneum.
SUMMARY
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