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