Transcript Document
Morning Meeting Department of Thoracic cardiovascular PERFORATION OF THE ESOPHAGUS ETIOLOGY Iatrogenic Perforations Spontaneous Perforations Trauma to the Esophagus Esophageal Disease Iatrogenic Perforations Endoscopy and of endoscopic manipulation are the most cause of esophageal perforations about 0.4-1% Pharyngoesophageal junction C6-7 Stricture dilatation is 2nd most cause Others : Neck surgery and procedures Spontaneous Perforations Boerhaave's syndrome esophageal rupture induced by vomiting, Childbirth, defecation, lifting heavy objects, any acute rise in intra-abdominal pressure against a closed glottis Left lateral wall, Lower third above the diaphragm Trauma to the Esophagus Penetrating or blunt trauma Foreign bodies Self-induced esophageal lesions by alkali or acid may cause extensive necrosis and esophageal destruction. Esophageal Disease Gastroesophageal reflux disease Candidal, herpetic, and human immunodeficiency infections also cause pathologic perforations. Invasion and destruction of the esophageal wall by carcinoma Mallory-Weiss syndrome but rare CLINICAL PRESENTATION Symptoms Signs Vomiting Pain Hematemesis Dysphagia Dyspnea Tachycardia Fever Subcutaneous emphysema Chest hypersonarity/dullness Cardiac crunch TREATMENT Derbes and Mitchell 13 and Blichert-Toft 10 show a 60% to 100% mortality when conservative management or no treatment is offered Surgical treatment remains the mainstay of management in esophageal perforation. An early operative repair provides the best chances of survival. Sepsis, shock, pneumothorax, pneumoperitoneum, mediastinal emphysema, and respiratory failure are all absolute indications to intervene rapidly Non-operative management NPO, broad antibiotics, NG tube decompression, Fluid supply The criteria set by Cameron and colleagues : a well-contained leak in a stable patient without evidence of sepsis and without communication with the pleural or peritoneal cavity suggests a patient who has already defended himself against the perforation. Perforation with Early Diagnosis Primary repair of the perforation is the first choice of therapy The goals of the operation include extensive debridement of all nonviable tissue in the mediastinum and around the esophagus. Edema and necrotic tissue may be extensive even if the esophageal damage is recent. Perforation with Late Diagnosis Esophageal exclusion, T-tube drainage, and esophageal resection. Resection must be considered with cervical esophagostomy, jejunostomy, and gastric decompression CORROSIVE STRICTURES OF THE ESOPHAGUS ETIOLOGY Alkaline caustics, acid or acidlike corrosives, and household bleaches. Hydrochloric, sulfuric, nitric, and phosphoric acids are contained in automobile battery acids. Age 75% of injuries involving children younger than 5 years and a much lower, secondary peak occurring in 20-30 The severity of esophageal and gastric damage resulting from a caustic ingestion depends on Corrosive properties Concentration of the agent Quantity swallowed Pathophysiology Alkalis: bite the esophagus and lick the stomach Acids: Lick the esophagus and bite the stomach Alkali Liquefactive Necrosis Vascular thrombosis Cell membrances are destroyed as their lipids are saponified and cellular proteins are denatured Destroy the protein, may persist for 7 days Acid Coagulation Necrosis Clumping and opacification of the cellular cytoplasm The goals of emergency management Limit and treat the immediately lifethreatening consequences Control subsequent stricture formation Emergency management Keep airway The epiglottis or vocal cords are edematous endothracheal intubation is contraindication Trachostomy Contraindication The use of emetics Not OG or NG Neutralization Alkali may try Milk Acid not try anything Surgery is warranted if evidence Perforation of the esophagus or stomach, Mediastinitis Peritonitis exists. Corrosive stricture Esophagus is stricture formation, which usually develops between 3 and 8 weeks after the initial injury but sometimes requires a much longer period for evolution Treatment Corticosteroids to modify the inflammatory response to the burn injury Antibiotics to control secondary bacterial infection Esophagoscopy within 12-24 hrs On NG tube when severe burn CXR, endoscopy, Barium swallow 1. 2. Bougienage Esophageal stents Colon interposition Forearm tube Free jejunal flap Thanks!!