1. Esophageal perforation
Presented by ;
v.ramya,
Tutor.

2. Esophageal perforation

3. INTRODUCTION
*Esophageal perforation is rare but life
threatening emergency.
*Most lethal alimentary tract perforation.
* Incidence is too low
* Mortality is too high

4. • DELAY IN DIAGNOSIS
• Presentation similar to other various medical and
surgical illnesses - one of most lethal gastrointestinal
perforation
• incidence is too low
• Mortality is too high.

5. etiology
• Increased intraluminal pressure at the anatomical sites
of narrowing, as well as sites narrowed by a
malignancy, foreign body, or physiologic dysfunction.
• ETIOLOGY • More than one half of all esophageal
perforations are iatrogenic and most of these occur
during endoscopy.

6. etiology
• trauma
• spontaneous
• Other surgical foreign body
• malignancy
• peptic ulcer
• Operative injury
• Hsv/Hiv/Tb

7. Risk factors
• Malignant stricture
• Severe esophagitis
• Prior radiation therapy
• History of caustic ingestion

8. Risk factors
• Pill esophagitis
• NSAID
• KCL
• ALENDRONATE (osteoporosis)
• DOXYCYCLIN

9. Common anatomical location
•COMMON ANATOMICAL LOCATION
Instrumentation Dilatation Foreign body
Caustic Cricopharynx At / Proximal to
lesion Cricopharynx Near LES

10. Boerhaave syndrome
• It is thought to occur due to a forceful ejection of gastric contents in an
unrelaxed oesophagus against a closed glottis.
• Boerhaave syndrome
• It is named after Hermann Boerhaave (1668-1738),a Dutch professor of
clinical medicine.
• The syndrome was described after the case of Dutch Admiral Baron Jan
von Wassenaer, who died of the condition in 1723.

11. Boerhaave syndrome
• The first successful repair of post- emetic esophageal rupture was
performed by Barrett in 1946.
• Boerhaave syndrome
• The tears are vertically oriented,1-4 cm in length.
• Approximately 90% occur along the left posterolateral wall of the distal
esophagus,3-6 cm above the esophageal hiatus of the diaphragm
• Complete disruption of wall in the absence of preexisting pathology
• Male and alcoholic are more prone.

12. Boerhaave syndrome

13. Delay in diagnosis
• Due to close similarity between other medical and surgical conditions.
• MEDICAL
• MI
• Pericarditis
• Spontaneous pneumotharx
• Pneumonia

14. Delay in diagnosis
• SURGICAL
• Peritonitis
• Acute Pancreatitis
• Perforated PUD
• Aortic aneurysm (leak or rupture)
• Biliary/ Renal colic
• Mesenteric ischaemia….

15. Diagnostic test
• Radiological study X- Ray .
• CT
• Gastrograffin
• Thin barium
• Endoscopy

16. INITIAL MANAGEMENT
• NPO
• Fluid resuscitation
• Broad spectrum I/V antibiotics
• Opiate based analgesics
• Proton pump inhibitor
• Monitors Vitals
• Tube thoracostomy

17. SURGICAL MANAGEMENT
• Primary repair of the perforation site is the optimal procedure .
• Exceptions to performing a primary repair
• Cervical perforation that cannot be accessed but can be drained
• Diffuse mediastinal necrosis

18. SURGICAL MANAGEMENT
• 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

19. 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 perforation is closed in two layers (mucosa/sub mucosa and
muscularis) with interrupted absorbable sutures

20. CERVICAL PERFORATION
• More easily treated
• Primary repair performed if the perforation site clearly visualized and if
there is no distal obstruction
• Otherwise drainage of the perforation is adequate to control leak since the
anatomical structure of the neck typically confine extraluminal
contamination to a limited space and thereby enhance spontaneous
healing.

21. THORACIC ESOPHAGEAL PERFORATION
• SURGERY
• 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 .

22. Abdominal esophageal perforation
• Laparotomy is the preferred approach.
• General principles for the management of
an intra- abdominal esophageal perforation
are the same.

23. 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.
• 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.

24. PRIMARY SURGICAL REPAIR
•
• ALTERNATIVES TO PRIMARY SURGICAL REPAIR
• Drainage
• Diversion
• Endoscopic stent placement
• Esophagectomy

25. 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.
• Colon interposition for esophageal replacement: an alternative technique
based on the use of the right colon.

26. ENDOSCOPIC STENT PLACEMENT
*May be appropriate for patients
*Extensive comorbidities
*Advanced mediastinal sepsis
*Large esophageal defects
*Inability to tolerate more extensive surgery.

27. ESOPHAGECTOMY
*A primary repair alone of an esophageal perforation
should not be performed
*Proximal to untreated achalasia,
*An undilatable stricture, or
*In malignancy

28. OPERATIVE MANAGEMENT
• The principal variables associated with mortality
• Delay in diagnosis
• Type of repair
• Location of perforation
• Etiology of the perforation

29. NON-OPERATIVE MANAGEMENT
• NON-OPERATIVE MANAGEMENT
• • Diagnosed quickly
• • Less extraluminal contamination
• • Cervical perforation is most commonly considered for nonoperative
management

30. NON-OPERATIVE MANAGEMENT
• NON-OPERATIVE MANAGEMENT
• NPO
• I/V fluids
• Broad spectrum antibiotics
• Monitor the Patients
• Surgical intervention if patient deteriorates