OESOPHAGEAL PERFORATION BREAKTHROUGH.ppt

OESOPHAGEAL PERFORATION BREAKTHROUGH

1. OESOPHAGEAL
PERFORATION
Presented by Olumuyiwa
Breakthrough Dolapo for
cardiothoracic surgery unit UITH

2. Outline
•Introduction
•Esophageal anatomy
•Definition
•Etiology
•Risk factors
•Boerhaave syndrome
•Clinical presentation
•Diagnosis
•Management

3. Introduction
•Esophageal perforation is rare but life
threatening emergency.
•Most lethal alimentary tract perforation.
•INCIDENCE IS TOO LOW
•MORTALITY IS TOO HIGH

4. ESOPHAGEAL ANATOMY

5. ESOPHAGEAL ANATOMY
Distance
from
Incisiors
40-45 cm
Cricopharyngeal
junction
Distance from 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

7. ESOPHAGEAL ANATOMY
Mucosa
Submucosa
Muscularis
Adventetia

8. ESOPHAGEAL ANATOMY

9. ESOPHAGEAL ANATOMY

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 intraluminal pressure 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.

12. ETIOLOGY

13. ETIOLOGY
•The estimated risk 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
•Chronic acid 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
•Eosinophilic esophagitis
•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
•A large hiatal hernia
•A history of previous esophageal
perforation
•A history of prior esophageal surgery
(such as for trauma or a congenital
abnormality)

17. COMMON ANATOMICAL
LOCATION

18. Boerhaave syndrome
•It is 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
•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. 

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

21. 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.

22. BOERHAAVE’S SYNDROME
TRIAD
•In case of Boerhaave’s Syndrome patient
may presented with the clinical triad
Mackler's
triad
Vomiting
Subcutaneous
emphysema
Chest pain

23. CLINICAL PRESENTATION
•The clinical 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

29. Chest X-ray

30. Contrast swallow

31. CT-Scan

32. CT-Scan

33. Endoscopy

34. NATURAL HISTORY
Pathophysiology
Perforation Mediastinitis Sepsis
MOF Death

35.  MANAGEMENT
•Initial Management
•Surgical emergency

36. INITIAL MANAGEMENT
•ICU care with 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 

39. ESOPHAGEAL REPAIR

40. CERVICAL PERFORATION-
SURGERY
•More 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

41. CERVICAL PERFORATION-
SURGERY

42. CERVICAL PERFORATION-
SURGERY

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
 

44. THORACIC ESOPHAGEAL
PERFORATION - SURGERY

45. ABDOMINAL ESOPHAGEAL
PERFORATION
•Laparotomy is the preferred approach.

•General principles for the management of
an intra- abdominal esophageal
perforation are the same.
 

46. 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.

47. POSTOPERATIVE
MANAGEMENT
•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.

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

49. 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.
 

50. DRAINAGE

51. DIVERSION
•The patient is unstable
•The defect is large due to tissue
destruction from contamination
•Pre-existing esophageal disease is
present

52. DIVERSION
•The goals
Control and drain extraluminal
contamination
Divert the esophagus proximally with a
cervical esophagostomy
Resection of the remaining esophagus 

53. DIVERSION
•The goals
Obtain gastric diversion with a
gastrostomy tube and feeding tube
access with a jejunostomy
Close the diaphragmatic hiatus

54. DIVERSION

55. DIVERSION

56. DIVERSION

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

58. ENDOSCOPIC STENT
PLACEMENT

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 is reserved 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 primary repair alone of an esophageal
perforation should not be performed…
Proximal to untreated achalasia,
An undilatable stricture, or
In malignancy
 

62. CONTD
• Esophagectomy should be 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 diagnosis and management is
critical to minimizing mortality.
•The mortality rate following operative
management of an esophageal perforation
is dependent on location of the perforation.

65. THE END.