Perforation of Esophagus
Anatomy
--- Content provided by FirstRanker.com ---
The primitive foregut forms during the fourth week of
gestation by a longitudinal folding and incorporation of the
--- Content provided by FirstRanker.com ---
dorsal part of the yolk sac into the embryo.34th day: The distal esophagus elongates first, followed by
the proximal.
--- Content provided by FirstRanker.com ---
6th week: Mesenchymal circular muscle coat develops
Three to nine weeks later, longitudinal musculature
--- Content provided by FirstRanker.com ---
appears.Seventh to eighth week: Esophageal lumen is almost
filled with cells from the proliferated esophageal epithelium.
--- Content provided by FirstRanker.com ---
During the 4th month, the muscularis mucosa appears
narrowest tube of the gastrointestinal tract
--- Content provided by FirstRanker.com ---
Midline structure anterior to the spine and posterior
to the trachea
--- Content provided by FirstRanker.com ---
Length: ranges from 21 cm-34 cm (27 cm average).Classical anatomy divides the esophagus into three
parts:
--- Content provided by FirstRanker.com ---
Cervical
Thoracic
Abdominal
--- Content provided by FirstRanker.com ---
Function divides the esophagus according to its differing
forms of motility into the following three zones :
--- Content provided by FirstRanker.com ---
Upper esophageal sphincter (UES)Esophageal body
Lower esophageal sphincter (LES)
--- Content provided by FirstRanker.com ---
Arterial Supply
Venous Supply
--- Content provided by FirstRanker.com ---
Innervation
Lymphatic drainage
--- Content provided by FirstRanker.com ---
Histology
It lacks a serosal coating
--- Content provided by FirstRanker.com ---
The four layers are:mucosa
Submucosa
muscularis
--- Content provided by FirstRanker.com ---
tunica adventitiaCorrosive stricture
--- Content provided by FirstRanker.com ---
Stricture formation, which usually develops between 3and 8 weeks after the initial injury but sometimes
requires a much longer period for evolution
--- Content provided by FirstRanker.com ---
EtiologyAlkaline caustics, acid or acidlike corrosives, and
household bleaches. Hydrochloric, sulfuric, nitric, and
--- Content provided by FirstRanker.com ---
phosphoric acids are contained in automobile battery
acids.
--- Content provided by FirstRanker.com ---
Age75% of injuries involving children younger than 5
years and a much lower, secondary peak occurring in
--- Content provided by FirstRanker.com ---
20-30
Type of caustic related to injury
Acid
--- Content provided by FirstRanker.com ---
Alkaline
? Generally less severe
--- Content provided by FirstRanker.com ---
? Liquefactive necrosisinjury
? Sodium hydroxide
--- Content provided by FirstRanker.com ---
? Coagulative necrosis
? Very hazardous
--- Content provided by FirstRanker.com ---
? Coagulum lessen tissue? 30% causes full
penetration
--- Content provided by FirstRanker.com ---
thickness necrosis
The severity of esophageal and gastric damage resulting
from a caustic ingestion depends on
--- Content provided by FirstRanker.com ---
Corrosive properties
Concentration of the agent
--- Content provided by FirstRanker.com ---
Quantity swallowedPathogenesis
Corrosive enter to stomach > reflex pyloric spasm
--- Content provided by FirstRanker.com ---
Limit passage of corrosive to duodenumRegurgitation of corrosive against a closed cricopharyngeus
> damage to esophagus and Stomach
--- Content provided by FirstRanker.com ---
35 mins > gastric atonia > opening of pylorusGoal of emergency management
Limit and treat the immediately life-threatening
--- Content provided by FirstRanker.com ---
consequences
Control subsequent stricture formation
Endoscopic findings
--- Content provided by FirstRanker.com ---
Zargar et al GIE 1991; Orringer 1993
Early management
--- Content provided by FirstRanker.com ---
Resuscitation
Upper airway
--- Content provided by FirstRanker.com ---
? Assessment of severity of damage? Secure the airway
Fiberoptic intubation
--- Content provided by FirstRanker.com ---
TracheostomyContraindication
Emetics
--- Content provided by FirstRanker.com ---
OG or NG
Neutralization
--- Content provided by FirstRanker.com ---
Alkali ---try MilkAcid---- do not try anything
Surgery is warranted if evidence of
--- Content provided by FirstRanker.com ---
Perforation of the esophagus or stomach
Mediastinitis
--- Content provided by FirstRanker.com ---
Peritonitis existsTreatment
Corticosteroids to modify the inflammatory response
--- Content provided by FirstRanker.com ---
to the burn injury
Antibiotics to control secondary bacterial infection
--- Content provided by FirstRanker.com ---
Esophagoscopy within 12-24 hrs
Bougienage
--- Content provided by FirstRanker.com ---
Esophageal stents
Colon interposition
--- Content provided by FirstRanker.com ---
Forearm tubeFree jejunal flap
Perforation of Esophagus
--- Content provided by FirstRanker.com ---
Introduction
Grand Admiral of Holland died of spontaneous
--- Content provided by FirstRanker.com ---
rupture of the esophagus in 1724J. R. Meyer of Berlin was the first to recognize this
disease prior to death
--- Content provided by FirstRanker.com ---
Barrett made the first early diagnosis and performed
the first surgical repair in 1946
Anatomy
--- Content provided by FirstRanker.com ---
Esophagus lacks serosa
More likely to rupture
--- Content provided by FirstRanker.com ---
Site of rupture:More commonly on left side
Due to instrumentation: distal esophagus
Spontaneous: posterolateral esophagus
--- Content provided by FirstRanker.com ---
Tears are usually longitudinal
Etiology
--- Content provided by FirstRanker.com ---
IatrogenicInstrumentation (MC cause)
most common site of perforation during endoscopy is at
--- Content provided by FirstRanker.com ---
the cricopharyngeusSurgical injury
--- Content provided by FirstRanker.com ---
Boerhaave Syndrome (barogenic perforation,postemetic perforation,spontaneous esophageal rupture)
Always occurs on the left side of the distal third of esophagus
--- Content provided by FirstRanker.com ---
Most tears occur along the longitudinal axis (0.6 to 8.9 cm) long
The mucosal tear is often longer than the muscle tear, which is
--- Content provided by FirstRanker.com ---
important to repair the esophageal wall completelyTrauma (8% to 15.3%)
The MC cause is chest injury by a steering wheel in a traffic
--- Content provided by FirstRanker.com ---
accident
The incidence of esophageal perforation by penetrating injuries
--- Content provided by FirstRanker.com ---
is 11% to 17%Perforation is more common in the cervical than thoracic
--- Content provided by FirstRanker.com ---
esophagusThe overall mortality rate remains high (15% to 40%).
--- Content provided by FirstRanker.com ---
TumorForeign Body ( 7-14%)
Caustic Injury
--- Content provided by FirstRanker.com ---
Drug Induced eg. tetracycline, KCL,quinidine, NSAID's
Infection
--- Content provided by FirstRanker.com ---
Other Causes eg.Barrett ulcer and ulcerative esophagitiswith Zollinger-Ellison syndrome
Pathophysiology
--- Content provided by FirstRanker.com ---
Air, Saliva, and Gastric contents released
mediastinitis
--- Content provided by FirstRanker.com ---
pneumomediastinum
empyema
--- Content provided by FirstRanker.com ---
can progress to sepsis, shock, resp failureDiagnosis
Chest X ray
--- Content provided by FirstRanker.com ---
Chest radiographs appear normal in the early phaseEmphysema becomes manifestated by 1 hour after the
--- Content provided by FirstRanker.com ---
perforationPleural effusion is detected several hours after the
perforation
--- Content provided by FirstRanker.com ---
Pneumomediastinum is present in 60% of cases.
Perforation of the mid-thoracic esophagus is associated with right-sided pleural
--- Content provided by FirstRanker.com ---
effusion and perforation of the distal thoracic esophagus is associated with left-sided pleural effusion
--- Content provided by FirstRanker.com ---
EsophagographyThe detection rate is 60% for cervical perforation and 90%
for surgically confirmed perforations.
--- Content provided by FirstRanker.com ---
Computerized tomography (CT)
Endoscopy
--- Content provided by FirstRanker.com ---
Diagnostic thoracentesisTreatment
--- Content provided by FirstRanker.com ---
The goal of treatment is to:Prevent further contamination
Eliminate infection produced by contamination
--- Content provided by FirstRanker.com ---
Restore the integrity and continuity of the GIT
Restore and maintain adequate nutrition
--- Content provided by FirstRanker.com ---
There are two major types of treatmentSurgical
Nonsurgical
--- Content provided by FirstRanker.com ---
Surgical treatmentPrimary closure
Reinforced closure
--- Content provided by FirstRanker.com ---
Resection
Drainage alone
--- Content provided by FirstRanker.com ---
T-tube drainageExclusion and diversion
Intraluminal stents
--- Content provided by FirstRanker.com ---
Primary repair of Esophagus
The principles of surgical treatment are :
--- Content provided by FirstRanker.com ---
Debridement of all infected and necrotic tissue
Secure closure of the perforation
--- Content provided by FirstRanker.com ---
Correction or elimination of distal obstructionDrainage of contaminated and infected areas
An enteral nutrition route, such as a jejunostomy, should be
--- Content provided by FirstRanker.com ---
added for nutritional support to any surgical method
Choice of Treatment
--- Content provided by FirstRanker.com ---
SurgicalNon Surgical
Patient selection according to strict criteria is necessary to
--- Content provided by FirstRanker.com ---
make such comparisons
Indications for nonsurgical treatment are limited.
--- Content provided by FirstRanker.com ---
Survival depends on rapid diagnosis and surgery
Within 24 hours of rupture: 70-75% survival
--- Content provided by FirstRanker.com ---
Within 25-48 hours: 35-50% survivalBeyond 48 hours: 10% survival
Conclusion
--- Content provided by FirstRanker.com ---
Diagnosis & treatment of esophageal perforation remains a
challenge to surgeons
--- Content provided by FirstRanker.com ---
Early diagnosis and treatment are important to preventmorbidity and mortality
Optimal treatment consists of complete repair with tissue
--- Content provided by FirstRanker.com ---
reinforcement and elimination of distal obstruction
Esophagectomy should be performed in patients with cancer
--- Content provided by FirstRanker.com ---
or extensive necrosis of the esophagusNonsurgical treatment may be used in carefully selected
patients
--- Content provided by FirstRanker.com ---
Thank you