SYMPOSIUM10-01-2017

S3 UNIT

ESOPHAGEAL PERFORATION / INJURIES

DR JAMSHEER .VT 2nd year MS PG THANJAVUR MEDICAL COLLEGE

INTRODUCTION

• LACK OF SEROSA- EASY PERFORATION

• CHARECTERISTIC ANATOMICAL LOCATION-NOT COMMONLY INJURED IN BLUNT INJURY

• 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

ETIOLOGY

• INSTRUMENTATION MOST COMMON

• TRAUMA

• SPONTANEOUS

OTHER

• SURGICAL• FOREIGN BODY• MALIGNANCY• PEPTIC ULCER• OPERATIVE INJURY• HSV/HIV/TB

PILL ESOPHAGITIS

• NSAID

• KCl

• OSTEOPOROSIS-ALENDRONATE

• MINO/DOXYCYCLIN

FOREIGN BODY• ADULT-FISH MEAT BONE

• PAEDIATRIC

• NON CORROSIVE & SMALL - WAIT IF PASS CRICOPHARYNX

• LITHIUM BATTERY – WAIT IF PASS BEYOND LOWER ESOPHAGEAL SPHINTURE

• EMERGENCY IF IN ESOPHAGUS

COMMON ANATOMICAL LOCATION

• INSTRUMENTATION - CRICOPHARYNX

• DILATATION – AT/PROXYMAL TO LESION

• FOREIGN BODY - CRICOPHARYNX

• CAUSTIC – NEAR LES

SPONTANEOUS PERFORATION

• BOERHAAVES SYNDROME

• COMPLETE DISRUPTION OF WALL IN THE ABSENCE OF PRE-EXISTING PATHOLOGY

• FIRST 1723- 200YEARS NO CURE

• LOCATION – LOWER 3RD

• MALE & ALCOHOLIC

CAUSES

• RETCHING/VOMITING• BLUNT TRAUMA• WEIGHT LIFTING• PARTURITION• DEFECATION• STATUS EPILEPTICUS

CLINICAL FEATURES

DEPENDS ON • TIME SINCE INJURY• SITE OF LESION• SIZE OF LESION

• MOST IMPORTANT EVENT-PRIOR SEVERE VOMITING

MACKLER’S TRIAD• VOMITING / RETCHING• SEVERE CHEST PAIN• SUBCUTANEOUS EMPHYSEMA

• CLASSICALLY SEEN IN 12%

• COMPLETELY ABSENT IN 22%

• SO NOT AT ALL RELAIBLE

PATHOGNOMONIC SIGN

EARLIEST SIGN

CLINICAL FEATURES

• CHEST PAIN

• FEVER

• TACHYCARDIA

• TACHYPNOEA

DIAGNOSIS

• CHARECTERISTIC CLINICAL FEATURES

• RADIOLOGY

DELAY IN DIAGNOSIS

• DUE TO CLOSE SIMILARITY BETWEEN OTHER MEDICAL & SURGICAL CONDITIONS LIKE

MEDICAL

• MYOCARDIAL INFARCTION• PERICARDITIS• SPONTANEOUS PNEUMOTHORAX• PNEUMONIA• MALLORY WEISS TEAR…..

SURGICAL

• PERITONITIS

• ACUTE PANCREATITIS

• PERFORATED PEPTIC ULCER• AORTIC ANEURYSM (LEAK/RUPRTURE)• BILIARY COLIC / RENAL COLIC• MESENTERIC ISCHEMIA

INVESTIGATION

• XRAY – IF FAILS GASTROGRAFFIN IF FAILS- THIN BARIUM IF FAILS CT IF FAILS ENDOSCOPY

PLAIN X-RAY

CONTRAST ESOPHAGOGRAM

C T

• CT

• INDICATION

• USES- POST OP FOLLOW UP OF IMPROVEMENT

ENDOSCOPY – BLUNT INJURY

TREATMENT

• INITIAL RESUSCITATION

• NON OPERATIVE

• OPERATIVE

INITIAL RESCUCITATION• MONITOR VITALS.• SPo2• URINE OUTPUT

• OPIATE BASED ANALGESIA• ANTIBIOTIC.• PROTON PUMP INHIBITORS• NPO/NASOGASTRIC TUBE• TUBE THORACOSTOMY.

NON OPERATIVE

• ICU• CT GUIDED ASPIRATION• NASO GASTRIC WASH• FEEDING JEJUNOSTOMY

SURGERY

• AIM-MOST IMPORTANT –THOROUGH DEBRIDEMENT

• THEN REPAIR

• FEEDING JEJUNOSTOMY

PRIMARY REPAIR & REINFORCEMENT

• MYOTOMY

• SINCE MUCOSAL LESION MORE THAN MUSCLE

T-TUBE REPAIR

• DELAYED BUT TOLERATED PATIENT

• PRINCIPLE – MAKE CONTROLLED ESOPHAGO CUTANEOUS FISTULA

• SERIAL CT

• VIABLE OPTION FOR ALL PERFORATION

IATROGENIC PERFORATION

• ENDOSCOPY & SURGICAL

• ANATOMICAL SITE- CRICOPHARYNX

• STENT PLACEMENT CARRY A RISK OF ABOUT 5-25%• HIGHEST

MANAGEMENT

• SINCE PATIENT IS IN NPO IS VERY LOW CONTAMINATION

Cameron’s criteria – NON OPERATIVE

Shaffer - NON OPERATIVE

Indication for surgery

CAUSTIC INJURIES

• ADULT SUICIDAL – MORE INJURY

• CHILDHOOD – ACCIDENTAL LESS INJURY

• ACID –CHARRING – PREVENT FURTHER PROGRESSION

• ALKALI – LIQIFACTIVE NECROSIS – TRANSMURAL INVOLVEMENT

INVESTIGATION

• CHEST X-RAY

• EARLY FLEXIBLE SCOPY

• RESPIRATORY COMPROMISE/PERFORATION

• ESOPHAGEAL ENDOSONOGRAPHY

GRADE FINDING

1 MUCOSAL EDEMA / HYPEREMIA

2 EROSION/EXUDATES

3 NECROSIS

FIRST 1723-200

FUTURE COMPLICATION

• STRICTURE

• MALIGNANCY

•THANK YOU