ESOPHAGEAL PERFOnnnnnnnnnnnnRATION 5min.pptx

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1. MANAGEMENT OF OESOPHAGEAL PERFORATION IN CHILDREN 5 ’ talk Samuel kefyalew (PSR4) March 2022 1

2. Outline Introduction Etiology and Pathogenesis Clinical Features Diagnosis Management 2

3. Introduction Considered the most dire and life-threatening of all perforation of the alimentary tract In children: More often iatrogenic, More likely to occur within the cervical esophagus, and Not generally associated with an underlying malignant disease process. 3

4. Etiology and Pathogenesis Iatrogenic: 60 % to 77% of esophageal perforations in children Other causes: foreign body ingestion, caustic ingestion, or trauma Most common locations of perforation: Pharyngoesophageal junction in neonates and Thoracic esophagus in older children 4

5. Pathophysiological consequences of a thoracic esophageal perforation Spillage of digestive enzymes and bacteria from the esophageal lumen Lack of a surrounding loose connective tissue adjacent to the esophagus Body cannot wall off the perforation or mount an adequate immune response within the mediastinum Negative pressure within the pleural space Severe inflammatory and infectious response within the mediastinum and pleural cavity ensues within hours , leading to sepsis , shock , and eventually death . 5

6. Clinical Features Neonates and infants Spontaneous esophageal rupture: full-term babies, Respiratory distress with cyanosis, Vomiting, coughing, choking episodes, and mild hematemesis Premature infants: difficulty passing a NG tube in premature infants (63% of cases) Difficulty swallowing ( 75% ): characterized by drooling, increased oral secretions, and feeding problems Older children : severe pleuritic or substernal pain Fever, often high, and rapid, toxic progression to shock may occur in any age group Subcutaneous emphysema, often present in adults, is rare in infants unless massive pneumomediastinum occurs 6

7. Diagnosis Diagnostic testing must be conducted in a prompt and expeditious manner Chest radiographs: initial study Right-sided pneumothorax or hydropneumothorax Pneumomediastinum, pneumopericardium, subcutaneous emphysema Malpositioning of a nasogastric tube 7

8. Esophagography Gold standard: Establish the diagnosis , localize the perforation, and direct therapy Water-soluble contrast Barium: if anatomic definition is inadequate after water soluble contrast Higher density as well as its ability to adhere to extraluminal tissues Extravasation of contrast into the pleural space or mediastinum 10% false-negative Computed tomography with oral contrast Esophagoscopy 8

9. Management ≤ 80% of esophageal perforations, usually those that are contained and iatrogenic , can be treated by non-surgical management Non-surgical Management Nutritional support: NPO and post pyloric feeding Broad-spectrum intravenous antibiotics Intravenous H2 antagonists and/or proton pump inhibitors Drainage of all peri -esophageal collections 9

10. Surgical Management Thoracic Esophagus The “golden ” period for closure of esophageal perforations is the first 12 hours; after 24 hours the likelihood of a post-repair leak increases . Side for the thoracotomy: dictated by esophagography and other imaging studies Upper-third and middle-third thoracic esophagus: right thoracotomy through the 4 th or 5 th ICS Lower esophagus: left 6 th or 7 th intercostal spaces Perforations that occur within 24 h: reinforced primary closure 10

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12. Perforation that is not be amenable to reinforced primary closure: Tear cannot be readily visualized in the setting of significant mediastinal inflammation or because of extensive esophageal damage Options Decortication with wide mediastinal and pleural drainage Mobilize a local flap of vascularized tissue over the site T-Tube Fistula and Drainage Endoscopic interventions: extensive comorbidities 1–2-cm segmental resection: presence of a focal, non-dilatable caustic stricture Diverting cervical esophagostomy with distal exclusion: rarely indicated Esophagectomy with conduit reconstruction: for whom long-term salvage of the native esophagus seems unlikely. 12

13. Successful management of thoracic perforations is predicated on the following: Débridement and drainage of the mediastinum and pleural spaces Control of the esophageal leak Re-expansion of the lung Prevention of gastric reflux Nutrition and ventilatory support Appropriate antibiotics Postoperative localization and drainage of residual septic foci 13

14. Cervical esophagus Rarely lethal, and adequate drainage will generally suffice Esophageal injury is repaired in a primary fashion using fine, interrupted sutures, the suture line should be reinforced with a local flap of strap muscle Intra-abdominal esophagus Surgical repair is always indicated Left subcostal or upper midline laparotomy Primary repair or rarely a segmental resection of the distal esophagus Reinforced with a Nissen or Thal fundoplication Omental wrap 14

15. Outcome and Follow-up Broad-spectrum intravenous antibiotics until the leak has resolved Intravenous H2 antagonists and/or proton pump inhibitors Contrast esophagography : 7–10 days postoperatively Complete resolution of an esophageal leak, oral feeds can be initiated, and all catheters removed Persistent esophageal leaks: consider distal obstruction Esophageal stricture is the most common long-term complication Mortality : <5 % 15

16. References 16

17. Thank you 17