Morning Meeting

1
Morning Meeting

• Department of Thoracic cardiovascular

2
PERFORATION OF THE ESOPHAGUS
3
ETIOLOGY

• Iatrogenic Perforations
• Spontaneous Perforations
• Trauma to the Esophagus
• Esophageal Disease

4
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

5
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

6
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.

7
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

8
CLINICAL PRESENTATION

• Symptoms Signs
• Vomiting Tachycardia
• Pain Fever
• Hematemesis Subcutaneous emphysema
• Dysphagia Chest hypersonarity/dullness
• Dyspnea Cardiac crunch

9
(No Transcript)
10
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.

11

• 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

12
(No Transcript)
13
(No Transcript)
14
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.

15
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.

16
Perforation with Late Diagnosis

• Esophageal exclusion, T-tube drainage, and
  esophageal resection.
• Resection must be considered with cervical
  esophagostomy, jejunostomy, and gastric
  decompression

17
(No Transcript)
18
CORROSIVE STRICTURES OF THE ESOPHAGUS
19
ETIOLOGY

• Alkaline caustics, acid or acidlike
  corrosives, and household bleaches. Hydrochloric,
  sulfuric, nitric, and phosphoric acids are
  contained in automobile battery acids.

20
Age

• 75 of injuries involving children younger than 5
  years and a much lower, secondary peak occurring
  in 20-30

21

• The severity of esophageal and gastric damage
  resulting from a caustic ingestion depends on
• Corrosive properties
• Concentration of the agent
• Quantity swallowed

22
Pathophysiology

• Alkalis bite the esophagus and lick the stomach
• Acids Lick the esophagus and bite the stomach

23
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

24
Acid

• Coagulation Necrosis
• Clumping and opacification of the cellular
  cytoplasm

25
The goals of emergency management

• Limit and treat the immediately life-threatening
  consequences
• Control subsequent stricture formation

26
Emergency management

• Keep airway
• The epiglottis or vocal cords are edematous
• ? endothracheal intubation is contraindication
  
• Trachostomy

27
Contraindication

• The use of emetics
• Not OG or NG
• Neutralization
• Alkali may try Milk
• Acid not try anything

28

• Surgery is warranted if evidence
• Perforation of the esophagus or stomach,
• Mediastinitis
• Peritonitis exists.

29
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

30
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

31

• Bougienage
• Esophageal stents
• Colon interposition
• Forearm tube
• Free jejunal flap

32
Thanks!!