5. 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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8. RIGID ESOPHAGOSCOPY
• Impacted meat bolus
• Patient developed dyspnea and central chest pain
• Suspicion of iatrogenic perforation
• Shifted to ICU
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10. TUBE THORACOSTOMY
• Pleural fluid with food debris
• Shortness of breath improved but tachycardia worsened
(Pulse 110/min)
• Low grade fever
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11. ICU CARE
• NPO
• I/V fluid resuscitation
• Broad spectrum antibiotics
• Vital monitoring
• Blood group
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12. • 2 days history of food impaction
• Patient was not NPO
• Rigid esophagoscopy (Emergency)
• Strong suspicion of perforation during esophagoscopy
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13. • High load perforation
• Patient developed pleural effusion
• Food debris and slough in chest drain
• Worsening tachycardia
• Low grade fever
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14. 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
15. 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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16. 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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17. POST OP MANAGEMENT
• Managed in ICU
• Recovery uneventful
• NPO
• I/V fluids
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18. POST OP MANAGEMENT
• I/V antibiotics
• Parenteral nutrition
• Vitals and I/O record
• Chest tube care
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19. 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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22. ANATOMY
• Three anatomical points of narrowing
• The cricopharyngeus muscle
• The broncho-aortic constriction
• The esophagogastric junction
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24. 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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25. 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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26. ETIOLOGY
Percentage
Spontaneous perforation (Boerhaave’s
Syndrome)
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 Surg
2004; 77:1475.
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27. The estimated risk of esophageal perforation
Diagnostic 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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28. 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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29. 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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30. • 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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31. 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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37. •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.
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41. 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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42. 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 suturesdr.basit@live.com
44. 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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47. 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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52. 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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53. 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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54. • 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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56. 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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57. 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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58. 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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59. • 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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63. 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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64. 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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65. 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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66. PROGNOSTIC VARIABLES FOR MORTALITY PERCENTAGE
Etiology (n = 431)
Spontaneous 36
Iatrogenic 19
Traumatic 7
Location (n = 397)
Cervical 6
Thoracic 27
Abdominal 21
Time 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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67. NON-OPERATIVE MANAGEMENT
• Diagnosed quickly
• Less extraluminal contamination
• Cervical perforation is most commonly considered for
nonoperative management
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69. 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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70. 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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71. 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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72. 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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73. • 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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