Esophageal perforation.pptx

Esophageal perforation.pptx

1. Esophageal perforation Presented by ; v.ramya, Tutor.

2. Esophageal perforation

3. INTRODUCTION * Esophageal perforation is rare but life threatening emergency. *Most lethal alimentary tract perforation . * Incidence is too low * Mortality is too high

4. • DELAY IN DIAGNOSIS Presentation similar to other various medical and surgical illnesses - one of most lethal gastrointestinal perforation incidence is too low Mortality is too high.

5. etiology Increased intraluminal pressure at the anatomical sites of narrowing, as well as sites narrowed by a malignancy, foreign body, or physiologic dysfunction. ETIOLOGY • More than one half of all esophageal perforations are iatrogenic and most of these occur during endoscopy.

6. etiology trauma spontaneous Other surgical foreign body malignancy peptic ulcer Operative injury Hsv/ Hiv / T b

7. Risk factors Malignant stricture Severe esophagitis Prior radiation therapy History of caustic ingestion

8. Risk factors Pill esophagitis NSAID KCL ALENDRONATE (osteoporosis) DOXYCYCLIN

9. Common anatomical location COMMON ANATOMICAL LOCATION Instrumentation Dilatation Foreign body Caustic Cricopharynx At / Proximal to lesion Cricopharynx Near LES

10. Boerhaave syndrome It is thought to occur due to a forceful ejection of gastric contents in an unrelaxed oesophagus against a closed glottis. Boerhaave syndrome It is 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 .

11. Boerhaave syndrome The first successful repair of post- emetic esophageal rupture was performed by Barrett in 1946. Boerhaave syndrome The tears 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.

12. Boerhaave syndrome

13. Delay in diagnosis Due to close similarity between other medical and surgical conditions. MEDICAL MI Pericarditis Spontaneous pneumotharx Pneumonia

14. Delay in diagnosis SURGICAL Peritonitis Acute Pancreatitis Perforated PUD Aortic aneurysm (leak or rupture) Biliary/ Renal colic Mesenteric ischaemia….

15. Diagnostic test Radiological study X- Ray . CT Gastrograffin T hin barium E ndoscopy

16. INITIAL MANAGEMENT NPO Fluid resuscitation Broad spectrum I/V antibiotics Opiate based analgesics Proton pump inhibitor Monitors Vitals Tube thoracostomy

17. SURGICAL MANAGEMENT Primary repair of the perforation site is the optimal procedure . Exceptions to performing a primary repair Cervical perforation that cannot be accessed but can be drained Diffuse mediastinal necrosis

18. SURGICAL MANAGEMENT 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

19. 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 perforation is closed in two layers (mucosa/sub mucosa and muscularis) with interrupted absorbable sutures

20. CERVICAL PERFORATION M ore easily 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.

21. 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 .

22. Abdominal esophageal perforation Laparotomy is the preferred approach. General principles for the management of an intra- abdominal esophageal perforation are the same.

23. 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. 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.

24. PRIMARY SURGICAL REPAIR ALTERNATIVES TO PRIMARY SURGICAL REPAIR Drainage Diversion Endoscopic stent placement Esophagectomy

25. 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. Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon.

26. ENDOSCOPIC STENT PLACEMENT * May be appropriate for patients *Extensive comorbidities *Advanced mediastinal sepsis *Large esophageal defects *Inability to tolerate more extensive surgery.

27. ESOPHAGECTOMY * A primary repair alone of an esophageal perforation should not be performed *Proximal to untreated achalasia, *An undilatable stricture, or *In malignancy

28. OPERATIVE MANAGEMENT The principal variables associated with mortality Delay in diagnosis Type of repair Location of perforation Etiology of the perforation

29. NON-OPERATIVE MANAGEMENT NON-OPERATIVE MANAGEMENT • Diagnosed quickly • Less extraluminal contamination • Cervical perforation is most commonly considered for nonoperative management

30. NON-OPERATIVE MANAGEMENT NON-OPERATIVE MANAGEMENT NPO I/V fluids Broad spectrum antibiotics Monitor the Patients Surgical intervention if patient deteriorates