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OESOPHAGEAL PERFORATION BREAKTHROUGH.ppt
- 1. OESOPHAGEAL PERFORATION Presented by Olumuyiwa BreakthroughDolapo for cardiothoracic surgery unit UITH
- 2. Outline • Introduction • Esophagealanatomy • Definition • Etiology • Risk factors • Boerhaave syndrome • Clinical presentation • Diagnosis • Management
- 3. Introduction • Esophageal perforationis rare but life threatening emergency. • Most lethal alimentary tract perforation. • INCIDENCE IS TOO LOW • MORTALITY IS TOO HIGH
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- 5. ESOPHAGEAL ANATOMY Distance from Incisiors 40-45 cm Cricopharyngeal junction Distancefrom Incisiors 15 cm Cervical part C6-T1 (3-5 cm) Thoracic part T1-T10 (18-22 cm) Abdominal part T11-T12 (3-6 cm)
- 6. ESOPHAGEAL ANATOMY Incisiors 0 cm Cricopharyngus muscle/UES 10-15 cm Esophagogastric Junction/LES 40-45 cm Bronchoaortic constriction 22-24 cm Distance from Incisiors 40-45 cm
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- 10. Definition • Esophageal perforation(rupture)is a tear or hole in the esophageal wall. • It is usually an acute injury, but slow progessing conditions can also cause it. • If a rupture occurs no matter how small it is an emergency. This is because contents from the esophagus can escape through the hole into the chest and bloodstream, causing life threatening complications.
- 11. ETIOLOGY • Increased intraluminalpressure at the anatomical sites of narrowing, as well as sites narrowed by a malignancy, foreign body, or physiologic dysfunction. • More than one half of all esophageal perforations are iatrogenic and most of these occur during endoscopy.
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- 13. ETIOLOGY • The estimatedrisk of esophageal perforation by endoscopic procedure :- 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 %
- 14. RISK FACTORS • Chronicacid reflux (GERD) • Severe esophagitis • Prior radiation therapy • History of caustic ingestion • Chronic alcohol use • Esophageal cancer • Previous medical procedures on esophagus • Pill Esophagitis NSAID KCl ALENDRONATE (Bisphosphonates) : Px should remain upright for >30min after ingestion DOXYCYCLIN
- 15. RISK FACTORS • Eosinophilicesophagitis • Complex (tortuous) or long strictures • Presence of esophageal diverticula • Inexperienced operator • Use of high inflation pressures with balloon dilation 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.
- 16. RISK FACTORS • Alarge hiatal hernia • A history of previous esophageal perforation • A history of prior esophageal surgery (such as for trauma or a congenital abnormality)
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- 18. Boerhaave syndrome • Itis thought to occur due to a forceful ejection of gastric contents in an unrelaxed oesophagus against a closed glottis. • Also due to sudden rise in intra-esophageal pressure with negative intrathoracic pressure e.g. after forceful vomiting, retching,seizures,childbirth,heavy lifting • Typically affects distal left posterolateral esophagus.
- 19. Boerhaave syndrome • Itis 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.
- 20. Boerhaave syndrome • Thefirst successful repair of post- emetic esophageal rupture was performed by Barrett in 1946.
- 21. Boerhaave syndrome • Thetears 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.
- 22. BOERHAAVE’S SYNDROME TRIAD • Incase of Boerhaave’s Syndrome patient may presented with the clinical triad Mackler's triad Vomiting Subcutaneous emphysema Chest pain
- 23. CLINICAL PRESENTATION • Theclinical features of esophageal perforation depend upon the location of the perforation, degree of leakage, and the duration since the injury.
- 24. CLINICAL PRESENTATION <24hrs Cervical perforation •Neck pain • Tenderness over sternocleidomastoid • Movement of the thyroid cartilage often elicit significant pain • Dysphonia • Hoarseness • Cervical subcutaneous emphysema
- 25. CLINICAL PRESENTATION Intra-thoracic perforation •Chest, back, or epigastric pain • Dysphagia • Odynophagia • Dyspnea • Hematemesis • Cyanosis
- 26. CLINICAL PRESENTATION Intra-abdominal perforation •Epigastric, chest pain • Hematemesis • Epigastric tenderness • Pneumoperitonium
- 27. • Unexplained pyrexia •Systemic shock • Metabolic acidosis CLINICAL PRESENTATION >24hrs
- 28. DIAGNOSIS • Diagnostic tests •Radiological study X-RAY GASTROGRAFFIN THIN BARIUM CT ENDOSCOPY
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- 34. NATURAL HISTORY Pathophysiology Perforation MediastinitisSepsis MOF Death
- 35. MANAGEMENT • Initial Management •Surgical emergency
- 36. INITIAL MANAGEMENT •ICU carewith close monitoring •NPO + enteral feeding distal to perforation (jejunal) or parenteral •Fluid resuscitation •Broad spectrum I/V antibiotics •Opiate based analgesics •Proton pump inhibitor •Monitors Vitals •Tube thoracostomy •Preparation for operative management
- 37. PRINCIPLES OF SURGICAL MANAGEMENT •Primary repair of the perforation site is the optimal procedure • Best if diagnosis is within 24 hours and tissue is healthy .
- 38. 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
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- 40. CERVICAL PERFORATION- SURGERY • Moreeasily 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
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- 43. 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
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- 45. ABDOMINAL ESOPHAGEAL PERFORATION • Laparotomyis the preferred approach. • General principles for the management of an intra- abdominal esophageal perforation are the same.
- 46. POSTOPERATIVE MANAGEMENT • Nutritional supportis 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.
- 47. POSTOPERATIVE MANAGEMENT • Contrast esophagogramis 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.
- 48. ALTERNATIVES TO PRIMARY SURGICALREPAIR • Drainage • Diversion • Endoscopic stent placement • Esophagectomy
- 49. DRAINAGE • Surgical drainageas 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.
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- 51. DIVERSION • The patientis unstable • The defect is large due to tissue destruction from contamination • Pre-existing esophageal disease is present
- 52. DIVERSION • The goals Controland drain extraluminal contamination Divert the esophagus proximally with a cervical esophagostomy Resection of the remaining esophagus
- 53. DIVERSION • The goals Obtaingastric diversion with a gastrostomy tube and feeding tube access with a jejunostomy Close the diaphragmatic hiatus
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- 57. ENDOSCOPIC STENT PLACEMENT • Maybe appropriate for patients Extensive comorbidities Advanced mediastinal sepsis Large esophageal defects Inability to tolerate more extensive surgery.
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- 59. INDICATIONS IN SURGICAL MANAGEMENTS •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.
- 60. CONTD, • Diversion isreserved for patients who present with clinical instability and where 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.
- 61. ESOPHAGECTOMY • A primaryrepair alone of an esophageal perforation should not be performed… Proximal to untreated achalasia, An undilatable stricture, or In malignancy
- 62. CONTD • Esophagectomy shouldbe performed when the patient presents with malignancy, extensive esophageal damage that precludes repair, or end- stage benign esophageal disease. • 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.
- 63. OUTCOMES FOLLOWING OPERATIVE MANAGEMENT •The principal variables associated with mortality Delay in diagnosis Type of repair Location of perforation Etiology of the perforation
- 64. SUMMARY • Prompt diagnosisand 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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