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1. Esophageal Perforation By : Dr Nima shtaya Department of General Surgery PMC

2. -25 cm in length Upper esophageal sphincter : C6( cricoid level ) Lower esophageal sphincter :T11 lined by non-keratinized stratified squamous epithelium -no serosa -segmental blood supply -4 anatomical constrictions Esophageal anatomy

3. Perforation of the esophagus constitutes a true emergency. With a very low incidence

4. Iatrogenic : It most commonly Spontaneous perforation: 15 % referred to as Boerhaave's syndrome (forceful retching ) foreign body ingestion :14% traumatic injury : 10% tumor perforation. Etiology :

5. History: Its difficult to diagnose esophageal perforation due to its vague symptoms ,But Suspicion of esophageal perforation increase with symptoms of : epigastric or chest pain, SOB neck or throat pain dysphagia.

6. Physical examination; crepitus on the chest, neck, or face; neck swelling epigastric tenderness nasal voice sometimes normal examination findings. If subcutaneous emphysema is present, the diagnosis is almost certain.

7. Spontaneous rupture of the esophagus is associated with a high mortality rate because of the delay in recognition and treatment. Although there usually is a history of resisting vomiting, in a small number of patients, the injury occurs silently, without any antecedent history.

8. Imaging : Chest x ray contrast esophagram Ct scan direct laryngoscopy or endoscopy

9. Chest-XR : In 9% of patients, the chest radiogram is normal The abnormalities are dependent on three factors: (a)the time interval between the perforation and the radiographic examination: Mediastinal emphysema , a strong indicator of perforation, takes at least 1 hour to be demonstrated, and is present in only 40% of patients. Mediastinal widening secondary to edema may not occur for several hours. (b) the site of perforation : In cervical perforation, cervical emphysema is common and thoracic perforations ,mediastinal emphysema is common (c ) the integrity of the mediastinal pleura . The integrity of the mediastinal pleura influences the radiographic abnormality in that rupture of the pleura results in pneumothorax , a finding that is seen in 77% of patients. If pleural integrity is maintained, mediastinal emphysema (rather than a pneumothorax) appears rapidly. A pleural effusion secondary to inflammation of the mediastinum occurs late

10. neck radiogram : air will be visible in the erector spinae muscles, before it can be palpated or seen on a chest radiogram , This is often the earliest sign of perforation and can be present without evidence of air in the mediastinum.(Fig. 25-74).

11. contrast esophagram : diagnostic modality , which will demonstrate extravasation in 90% of patients. The use of a water-soluble medium such as Gastrografin is preferred. Of concern is that there is a 10% false-negative rate. This may be due to obtaining the radiographic study with the patient in the upright position. When the patient is upright, the passage of water-soluble contrast material can be too rapid to demonstrate a small perforation. The studies should be done with the patient in the right lateral decubitus position. In this, the contrast material fills the entire length of the esophagus, allowing the actual site of perforation and its interconnecting cavities to be visualized in almost all patients.

12. CT scan: with oral administration of contrast material may also be acceptable if an esophagram cannot be obtained. If the results of these studies are normal but the level of suspicion is high, patients may require evaluation by direct laryngoscopy or endoscopy, depending on the clinical circumstance. Of note, procedural evaluation can convert a small or partial perforation into a more clinically significant process, so caution must be used with these procedures.

13. The principles of management after diagnosis : (1)treatment of contamination, (2) wide local drainage, (3) source control, (4) enteral feeding access.

14. (1)treatment of contamination: perforation is treated with broad-spectrum antibiotics, including antifungal, with duration that will vary on the basis of control of infection and the patients condition

15. (2) wide local drainage: Drainage of the area with chest tubes is most common the number, location, and duration to the drainage tube insertion vary by the degree of leak. In select cases, radiologically guided drains can be done , Video-assisted thoracoscopic surgery (VATS) open thoracic washout with decortication may be necessary, depending on the duration of the leak and amount of pleural space soiling.

16. 3) source control: Will also depend on: the patient condition the severity location of perforation the surgeon's experience.

17. (4) enteral feeding access : Gastrostomy and jejunostomy tubes at the first operation are important to provide: decompression drainage near the perforation enteral access for Nutrition .

18. Management : Non-operative management Operative management

19. Non-operative management: has been advocated in select situations. This course of management usually follows an injury occurring during dilation of esophageal strictures or pneumatic dilations of achalasia.

20. Cameron criteria for nonoperative management of esophageal perforation proposed three criteria : (a)the esophagram must show the perforation to be contained within the mediastinum and drain well back into the esophagus. (should not be used in patients who have free perforations into the pleural space ). (b) symptoms should be mild, (c) there should be minimal evidence of clinical sepsis.

21. If these conditions are met, it is reasonable to treat the patient with: TPN antibiotics C imetidine to decrease acid secretion and diminish pepsin activity. Oral intake is resumed in 7 to 14 days, dependent on subsequent radiographic examinations.

22. OPERATIVE AND INTERVENSION MANAGEMENT Source control via : Endoluminal therapy with covered stents endoscopic vacuum therapy (EVT) and OVER THE SCOPE CLIPS Surgical management

23. Endoluminal therapy with covered stents has become more widely popularized and can give good results when it is used in the appropriate patient population. the criteria are still debated , but to be considered in patients with early, small perforations, with minimal contamination and in a location amenable to stenting.

24. Advantage : less morbidity, less hospitalization time and less costs Disadvantage Stent migration (frequent chest X-rays are typically performed to evaluate the position of the stent). Developed stricture

25. Plastic vs. metallic stent : plastic stents had higher rates of migration and required more re-interventions than metallic one Plastic had lower stricture rates , compared to metallic stents;

26. endoscopic vacuum therapy (EVT) As traditional principles of wound healing in vacuum therapy for skin and soft tissue defects, This technique involves endoscopic placement of a sponge into the site of esophageal injury. Tubing from the sponge is connected externally to a vacuum device with continuous negative pressure applied to the site of perforation. Serial endoscopies are then performed every several days to weeks to examine the site of injury and to evaluate for appropriate granulation tissue and for exchange of the sponge. Once the mucosa has sufficiently healed, the sponge is removed and diet resume.

27. Another recent endoscopic option for esophageal perforation, particularly those identified acutely , is placement of over-the-scope clips to seal the site of injury. early evidence suggests these therapies may be safe and viable options with good outcomes in appropriately selected patients.

28. Surgical management : if the decision is made to intervene surgically , the approach depends on the location of the leak: high perforations are approached through a left-sided neck incision, midesophageal through a right thoracotomy, distal esophageal through a left thoracotomy or thoraco-abdominal approach.

29. After the area of perforation is identified, assessment continues with: myotomy to expose the full extent of mucosal injury, debridement of devitalized tissues, assessment of injury, and considerations for repair .

30. Small injuries with healthy tissues can be repaired primarily in two layers with tissue flap coverage (intercostal muscle, pericardial fat, pleura, omentum) E xtensive injuries with devitalized areas can be managed with controlled fistulization by T-tube. Very large or devitalized defect s will require esophageal exclusion with creation of a cervical esophagostomy and gastrostomy tube, with plans for future reconstruction by esophagectomy with typically a substernal gastric, colon, or small bowel conduit.

31. FISTULIZATION BY T-TUBE

32. Any sign of obstruction (achalasia, stricture, tumor) must be fixed at the time of the initial operation, else the perforation will not heal. In the setting of achalasia or a hypertensive LES, a contralateral myotomy should be performed to relieve the distal obstruction. Gastrostomy and jejunostomy tubes at the first operation are important to provide decompression and drainage near the perforation as well as enteral access for Nutrition.

33. Prognosis : The most favorable outcome is obtained following primary closure of the perforation within 24 hours, resulting in 80% to 90 % . After 24 hours, survival decreases to <50%, Survival prognosis not influenced by the type of operative therapy (i.e., drainage alone or drainage plus closure of the perforation).

34. Conclusion : It is generally regarded that better outcomes are possible if the intervention is within 24 hours of the event, poor outcomes are associated with cancer-related perforations. Spontaneous rupture of the esophagus is associated with a high mortality rate because of the delay in recognition and treatment.