Case presentation_esophageal perforation (final).pptx

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1. Case presentation Supervised by: Prof. Yasser Obadiel Done by: Dr. Aymen Al Syaghi

2. 70 years old male patient, Unknown case of any chronic illnesses Complain of chest pain not preceded by retching and vomiting , Aggravated by eating & relieved/subsided by fasting Associated with recurrent vomiting for food intolerance

3. Patient sought medical advice for 7 days and misdiagnosed as MI and peptic ulcer where has done for him all investigation with normal results.

4. On physical Examination : Patient looked ill, conscious, oriented to Time, Place and Persons, no pallor, jaundice nor cyanosis. Vital signs: T=37.5 c, BP=110/70 mmHg, PR= 76 b/m, RR= 16 c/m

5. H&N exam: Chest exam: Cardiovascular exam: Abdominal exam: All were un-remarkable

6. Investigations: WBC: 6.8 , Hb= 14.1, PLT= 297 CRP= 24 PT= 15, PTT= 42.1, INR= 1.1

7. Radiological investigations:

8. CT scan report

9. Patient is prepared for upper GI endoscopy which determined that foreign body located at distal esophagus 37 cm from upper incisors and was not successful because of its large size and possibility of bleeding. So the decision was for surgery through abdominal approach

10. Post-operative Patient was under cover of i.v fluids Broad spectrum antibiotics Analgesics Anti-acids

11. Patient’s condition passed smoothly passed flatus on 2 nd day post operative Started liquid diet on the 3 rd day through NGT Passed stool 5 th day

12. Drains: Are two in the Sub-hepatic close to GE junction Lt. sub-splenic. Discharging around 50cc to 100cc serousanguinous during last week. Lt. chest tube is working discharging nothing

13. Esophagogram Was done on the 10 th day post operative, show: Mild irregular lower esophageal stricture toward GE junction with mild dilated dilatation of esophagus proximally. No evidence of extravasation

14. Esophageal perforation

15. Esophageal perforation is a rare and potentially life-threatening condition. It poses a significant  interprofessional challenge to the entire therapeutic team. The frequency is 3 in 100,000 in the United States, Intrathoracic perforations being most common (54%) followed by Cervical esophagus perforations (27%), then Intra-abdominal perforations (19%)

16. The esophagus is a 25-cm long fibromuscular tube that connects the pharynx to the stomach. Starts at the level of C6 vertebra, End at the level T10 vertebra via a separate opening in the right crus of the diaphragm. Esophageal perforation can occur in three different anatomical sites .

17. The esophagus has three constrictions : The first constriction is approximately  15 cm from the upper incisor teeth, where the esophagus begins at the cricopharyngeal sphincter at the level of the C6 vertebra. The second constriction is approximately  23 cm from the upper incisor, which is the landmark of the crossing of the aortic arch and the left main bronchus. The third constriction is approximately 40 cm from the upper incisor, where it pierces the diaphragm and forms the physiologic lower esophageal sphincter ( LES) at the T10 vertebra.

18. Esophageal parts Supplied by Extend Parts To From inferior thyroid artery suprasternal notch cricopharyngeus muscle The cervical esophagus bronchial and esophageal branches of the descending thoracic aorta. diaphragm suprasternal notch The thoracic esophagus branches of the left phrenic and left gastric arteries cardia of the stomach diaphragm  The abdominal esophagus

19. Etiology Iatrogenic, mostly during endoscopy >50% Spontaneous perforation ( Boerhaave's Syndrome): 15% Foreign body ingestion: 12% Trauma: 9% Malignancy: 1% Others as: Caustic Injury, Infectious Injury

20. Clinical manifestations Distal Esophageal Mid- Esophagea Cervical Esophageal Perforated Esophageal parts pleuritic chest pain, mostly on the left side, chills, malaise, SOB, and abdominal pain Centralized chest or back pain, malaise, chills, SOB, pleuritic chest pain, dysphagia and odynophagia Pain, chills, drooling, dysphagia, and odynophagia History Clinical manifestations similar as Mid-esophagus with peritonitis including guarding and diffuse abdominal tenderness fever, tachycardia, hypotension, auscultatory rales, and muffled heart tones. + ve Hamman sign fever or tachycardia. S.C cervical emphysema, tenderness, fullness, or tracheoesophageal deviation Examination

21. Radiological manifestations endoscopic evaluation Oral contrast radiographic images CT scan Chest x-ray Is now a vital component of the workup by well expert endoscopist in suspected esophageal perforation. Are the true definitive diagnostic study. Show: Free extravasation of contrast into the chest or peritoneal cavity or merely a contained leak Show: Extraluminal air or fluid in the periesophageal tissues. Extravasation of contrast Identify any inflammatory processes with resultant abscess or fluid collections Show: S.C emphysema in the neck pneumomediastinum left or right pleural effusions Pneumothoraxes Pneumoperitoneum

22. PRIMARY MANAGEMENT The major principles of the primary and immediate management of an esophageal perforation include: Prompt diagnosis. Stabilization of the patient. Assessment for operative or nonoperative management. 

23. PRIMARY MANAGEMENT Initial management  — Once the diagnosis is suspected , treatment is started immediately : NPO . I.V fluids with N/S or R/L solutions. I.V antibiotics that provide coverage for aerobes and anaerobes , such as  Ampicillin/sulbactam (3 grams every six hours),  Piperacillin/tazobactam (3.375 grams every six hours), or a carbapenem.

24. In the setting of beta lactam hypersensitivity , use Clindamycin (900 mg every eight hours) plus a fluoroquinolone, such as ciprofloxacin (400 mg every 12 hours), is acceptable.

25. Antifungal coverage ( eg , fluconazole 400 mg once a day) is warranted in selected cases. These include Patients who have been hospitalized or received broad-spectrum antimicrobial agents prior to perforation. Patients on long-term antacid therapy. Patients who have received steroids or other immunosuppressive therapy prior to perforation. Patients with HIV infection. Patients with known esophageal candidiasis. Patients with chronic obstructive motility pathology with stasis in the esophagus. Patients who fail to improve after several days of appropriate antibacterial therapy.

26. Management of esophageal perforation Conservative management. Endoscopic stenting and closure. Surgical management.

27. Guidelines for such conservative therapy Clinically stable patients with minimal signs of sepsis on presentation (and do not develop them during therapy ). Instrumentation type (generally iatrogenic) perforations in which the patient had been on a regime of (NPO) in the period surrounding the perforation. Perforation is detected early (or the patient presents late but has developed “ tolerance ” to the perforation Perforation is contained within the neck, mediastinum, or abdomen with no free extravasation of contrast ( perforation drains back into the esophagus ) and no signs of crepitus, pneumothorax, or pneumoperitoneum.

28. Surgical management Indicated for: Patients not meeting conservative management criteria. Patients fail conservative management.

29. General principles for esophageal repair First, devitalized tissue is debrided from the perforation site. Second, the muscular layer is incised longitudinally superior and inferior to the perforation to expose the entire extent of the mucosal injury. Third, the mucosa is closed with absorbable interrupted sutures and the muscularis layer is closed with interrupted non absorbable sutures. N.B: Narrowing of the esophageal lumen should be avoided using precise re-approximation .

30. When can we use pedicled flap to support primary repair?

31. Generally pedicled flap is used: If there has been a delay in diagnosis greater than 24 hours and/or Substantial extraluminal contamination from the leakage of fluid and debris has occurred. The muscle layer cannot be identified or cannot be closed The purpose is To enhance the integrity of the repair with the use of a vascularized pedicle flap.

32. Primary surgical repair- Cervical perforations Cervical perforations are more easily treated than perforations of the thoracic or intra-abdominal esophagus . A primary repair of a cervical perforation 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.

33. Using pedicle flap for cervical perforation Sternocleidomastoid muscle flap is created by: Detaching the medial head of the muscle from the manubrium. Dividing the lower portion of the muscle Finally, Securing it to the repair site with suture.

34. Primary surgical repair-Thoracic perforation Level of the perforation determines the surgical approach for controlling the leak and repairing the perforation. Mid-esophageal perforation is approached through a right thoracotomy at the 6 th or 7 th intercostal space. Distal esophageal perforation is approached through a left thoracotomy at the 7 th or 8 th intercostal space.

35. Primary surgical repair-Thoracic perforation The perforation is localized; now the repair is planned based on: Size of the perforation. Friability of the esophagus. Degree of surrounding contamination. Clinical status of the patient. Then decide if the repair needs to be buttressed with a pedicled flap? Intercostal muscle flap or Parietal pleura flap if the intercostal muscle is not available or the intercostal blood supply has been compromised

36. Type of flaps The most common flap used is the intercostal muscle flap . Other options for a flap include Diaphragm flap Parietal pleura flap serratus muscle flap latissimus dorsi muscle flap Pectoralis major muscle flap Omentum flap Gastric fundus flap Used to close upper thoracic esophageal perforations Used to cover distal and abdominal esophagus

37. Identification of esophagus perforation Intercostal muscle flap

38. Isolation of perforated esophagus Parietal pleura flap

39. Follow types of flaps Diaphragmatic flap is prepared by Cutting the diaphragm in a U-shaped fashion Rotating the muscular flap to cover the repair site. Finally, the diaphragm is closed linearly.

40. Diaphragmatic flap

41. Primary surgical repair-Thoracic perforation Also, we can use in addition to primary repair: Nasogastric tube is guided past the site of repair and into the stomach, taking care to avoid damaging the repair site. A jejunostomy feeding tube can be inserted by a mini-laparotomy procedure at the time of the esophageal repair.  Drains used: One chest tube is positioned in proximity to the site of injury. second one posterior to the repair.

42. Primary surgical repair- Abdominal perforation Abdominal perforation     Laparotomy is the preferred approach to repair a perforation Following the primary suture repair: The hiatus is closed posteriorly. A Dor (partial 180° anterior wrap) or a Nissen (complete 360° posterior wrap) fundoplication is used to buttress the site of repair and patients’ with preoperative history of swallowing dysfunction . Feeding jejunostomy tube is placed for postoperative alimentation.

43. Alternatives to primary surgical repair Indications: If the diagnosis is delayed more than 24 hours.  Primary repair is technically not feasible or too large to be reapproximated. The patient is hemodynamically unstable . The perforation is diagnosed immediately after an intervention. As, severe mediastinitis associated with extraesophageal tissue friability and necrosis from a delay in diagnosis can preclude a primary repair. An esophageal malignancy .

44. Alternatives to primary surgical repair Options for the previously mentioned circumstances include: Drainage only is used for The perforation can not be clearly visualized and There is distal obstruction .

45. T-Tube Drainage It composed: Short limbs Long limb Fixation of long limb to diaphragm NGT

46. Exclusion and Diversion procedure Only indicated for: Unstable patient No other effective method is available Esophageal resection is not desirable . N.B : It should be an option of last resort.

47. Exclusion and Diversion procedure The method includes Primary suture of the perforation Wide drainage of contaminated tissue. Creation of a loop or end-cervical esophagostomy (and drainage of the distal esophageal remnant) Closure of the gastroesophageal junction with temporary suture or staples (without transection) Creation of a gastrostomy and jejunostomy

48. Home messages Esophageal  perforation  is a potentially life-threatening condition needs prompt diagnosis and management. Esophageal perforation by foreign body mostly misdiagnosed. Needs meticulous history of preceding events to the chief complain. Despite all these information, Esophageal perforation is an interprofessional challenge 😅

49. References UpToDate Fischer’s Mastery of surgery Kassem MM, Wallen JM. Esophageal Perforation and Tears. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532298/?log$=activity

50. Many Thanks For Your Attention