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Esophageal perforation Management
- 2. PRESENTATION • XYZ • 40 Y • Female dr.basit@live.com
- 3. PRESENTATION • Retrosternal chest pain • Dysphagia dr.basit@live.com
- 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 dr.basit@live.com
- 6. EXAMINATION • Abdomen • NAD • Chest • NAD • CVS • NADdr.basit@live.com
- 7. INVESTIGATIONS • Baseline labs • Normal • C-XR • Normal • ECG • Normal dr.basit@live.com
- 8. RIGID ESOPHAGOSCOPY • Impacted meat bolus • Patient developed dyspnea and central chest pain • Suspicion of iatrogenic perforation • Shifted to ICU dr.basit@live.com
- 9. • ECG • Normal • C-XR • Right pleural effusion dr.basit@live.com
- 10. TUBE THORACOSTOMY • Pleural fluid with food debris • Shortness of breath improved but tachycardia worsened (Pulse 110/min) • Low grade fever dr.basit@live.com
- 11. ICU CARE • NPO • I/V fluid resuscitation • Broad spectrum antibiotics • Vital monitoring • Blood group dr.basit@live.com
- 12. • 2 days history of food impaction • Patient was not NPO • Rigid esophagoscopy (Emergency) • Strong suspicion of perforation during esophagoscopy dr.basit@live.com
- 13. • High load perforation • Patient developed pleural effusion • Food debris and slough in chest drain • Worsening tachycardia • Low grade fever dr.basit@live.com
- 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 dr.basit@live.com
- 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 dr.basit@live.com
- 17. POST OP MANAGEMENT • Managed in ICU • Recovery uneventful • NPO • I/V fluids dr.basit@live.com
- 18. POST OP MANAGEMENT • I/V antibiotics • Parenteral nutrition • Vitals and I/O record • Chest tube care dr.basit@live.com
- 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 dr.basit@live.com
- 22. ANATOMY • Three anatomical points of narrowing • The cricopharyngeus muscle • The broncho-aortic constriction • The esophagogastric junction dr.basit@live.com
- 24. ETIOLOGY • Increased intraluminal pressure at the anatomic sites of narrowing, as well as sites narrowed by a malignancy, foreign body, or physiologic dysfunction dr.basit@live.com
- 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. dr.basit@live.com
- 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. dr.basit@live.com
- 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. dr.basit@live.com
- 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. dr.basit@live.com
- 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. dr.basit@live.com
- 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. dr.basit@live.com
- 31. PRESENTATION • The clinical features of esophageal perforation depend upon the location of the perforation, degree of leakage, and the duration since the injury. dr.basit@live.com
- 32. PRESENTATION • Cervical perforation • Neck pain • Tenderness over sternocleidomastoid • Dysphonia • Hoarseness • Cervical subcutaneous emphysema dr.basit@live.com
- 33. PRESENTATION • Intra-thoracic perforation • Chest, back, or epigastric pain • Dysphagia • Odynophagia • Dyspnea • Hematemesis • Cyanosisdr.basit@live.com
- 34. • Intra-abdominal perforation • Epigastric, chest pain • Hematemesis • Epigastric tenderness • Pneumoperitonium PRESENTATION dr.basit@live.com
- 35. DIAGNOSIS • Clinical features • Diagnostic tests • Thoracic and cervical radiographs • Contrast esophagography • Computerized tomography dr.basit@live.com
- 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. dr.basit@live.com
- 38. NATURAL HISTORY • Perforation Mediastinitis Sepsis Multiorgan Failure Death dr.basit@live.com
- 39. INITIAL MANAGEMENT • NPO • Fluid resuscitation • Broad spectrum I/V antibiotics • Antifungal coverage ( in selected cases) • ICU care • Preparation for operative management dr.basit@live.com
- 40. PRINCIPLES OF SURGICAL MANAGEMENT • Primary repair of the perforation site is the optimal procedure. dr.basit@live.com
- 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. dr.basit@live.com
- 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. dr.basit@live.com
- 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 dr.basit@live.com
- 52. ABDOMINAL ESOPHAGEAL PERFORATION • Laparotomy is the preferred approach. • General principles for the management of an intra- abdominal esophageal perforation are the same. dr.basit@live.com
- 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. dr.basit@live.com
- 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 dr.basit@live.com
- 55. ALTERNATIVES TO PRIMARY SURGICAL REPAIR • Drainage • Diversion • Endoscopic stent placement • Esophagectomy dr.basit@live.com
- 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. dr.basit@live.com
- 57. DIVERSION • The patient is unstable • The defect is large due to tissue destruction from contamination • Pre-existing esophageal disease is present dr.basit@live.com
- 58. DIVERSION • The goals • Control and drain extraluminal contamination • Divert the esophagus proximally with a cervical esophagostomy • Resection of the remaining esophagus dr.basit@live.com
- 59. • The goals • Obtain gastric diversion with a gastrostomy tube and feeding tube access with a jejunostomy • Close the diaphragmatic hiatus DIVERSION dr.basit@live.com
- 63. ENDOSCOPIC STENT PLACEMENT • May be appropriate for patients • Extensive comorbidities • Advanced mediastinal sepsis • Large esophageal defects • Inability to tolerate more extensive surgery. dr.basit@live.com
- 64. ESOPHAGECTOMY • A primary repair alone of an esophageal perforation proximal to untreated achalasia, an undilatable stricture, or a malignancy should not be performed. dr.basit@live.com
- 65. OUTCOMES FOLLOWING OPERATIVE MANAGEMENT • The principal variables associated with mortality • Delay in diagnosis • Type of repair • Location of perforation • Etiology of the perforation dr.basit@live.com
- 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. dr.basit@live.com
- 67. NON-OPERATIVE MANAGEMENT • Diagnosed quickly • Less extraluminal contamination • Cervical perforation is most commonly considered for nonoperative management dr.basit@live.com
- 68. NON-OPERATIVE MANAGEMENT • NPO • I/V fluids • Broad spectrum antibiotics • Surgical intervention if patient deteriorates dr.basit@live.com
- 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. dr.basit@live.com
- 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. dr.basit@live.com
- 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. dr.basit@live.com
- 72. SUMMARY • Esophagectomy should be performed when the patient presents with malignancy, extensive esophageal damage that precludes repair, or end-stage benign esophageal disease. dr.basit@live.com
- 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 dr.basit@live.com