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A1-G Surg Note Esophagus > Esophageal Perforation > Flashcards

Esophageal Perforation Flashcards

1
Q

What is the most common cause of esophageal perforation?

A

Iatrogenic injuries from endoscopic procedures, accounting for 60% to 70% of cases

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2
Q

What are some endoscopic procedures that can lead to iatrogenic esophageal perforation?

A

Diagnostic endoscopy,
biopsy,
dilation,
sclerotherapy,
laser therapy,
photodynamic therapy,
stent placement,
transesophageal echocardiogram,
and esophageal ultrasound

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3
Q

What is the second most common cause of esophageal perforation?

A

Spontaneous rupture, or Boerhaave’s syndrome

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4
Q

What are some less frequent causes of esophageal perforation?

A

Trauma (penetrating or blunt)
foreign body ingestion
caustic ingestion
cervical or nonesophageal surgery (thyroidectomy, mediastinoscopy, spine surgery)
and malignancies of the esophagus, lung, or mediastinum

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5
Q

In what patient population is esophageal perforation associated with infections more likely?

A

In immunocompromised patients, with infections from pathogens like candida, herpes, syphilis, and tuberculosis

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6
Q

What other conditions can lead to esophageal perforation?

A

Severe gastroesophageal reflux
Mallory-Weiss tears
and infectious processes

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7
Q

What recent events in a patient’s history might indicate an esophageal perforation?

A

Recent esophageal instrumentation or forceful vomiting.

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8
Q

What are the initial symptoms of esophageal perforation?

A

Vague pain localized to the neck, chest, shoulder, or epigastrium

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9
Q

What additional symptoms may develop as esophageal perforation progresses?

A

Dyspnea, dysphagia, and odynophagia.

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10
Q

What signs may be present in patients with esophageal perforation?

A

-Signs range from hemodynamic stability to signs of septic shock or mediastinitis, such as tachycardia and hypotension.

-Leukocytosis

-Pneumomediastinum, pleural effusion, pneumothorax, subcutaneous emphysema, or an abnormal cardiomediastinal contour.

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11
Q

What imaging studies are used to further evaluate esophageal perforation?

A

Contrast esophagram
computed tomography (CT) to assess injury extent, location, and contamination

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12
Q

Why is Gastrografin generally preferred over barium in esophagrams for suspected perforation?

A

Gastrografin has a lower risk of causing mediastinitis if leakage occurs.

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13
Q

In which area of the esophagus is Gastrografin less effective in detecting perforations, and why?

A

In the cervical esophagus

due to the rapid transit of the contrast agent

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14
Q

What advantage does barium offer over Gastrografin in an esophagram?

A

Barium provides better resolution for distinguishing between contained and noncontained perforations.

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15
Q

What is the usual protocol if a Gastrografin esophagram is inconclusive?

A

A repeat esophagram with diluted barium may be performed for improved sensitivity and specificity

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16
Q

What key information does CT provide in cases of esophageal perforation?

A

CT differentiates between contained and noncontained perforations
and assesses the extent of mediastinal, pleural, or peritoneal contamination

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17
Q

What characterizes a contained esophageal perforation on CT?

A

-No or minimal extravasation of contrast at the perforation site, without pleural or peritoneal contamination

-or drainage of contrast back into the esophagus

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18
Q

What challenge in critically ill patients does CT esophagography address?

A

It allows for contrast administration via nasogastric tube (NGT) if the patient is unable to swallow or stand

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19
Q

How is contrast administered in CT esophagography if a patient cannot swallow?

A

Contrast is administered via a nasogastric tube (NGT) positioned in the proximal esophagus.

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20
Q

What additional step is often taken following a negative CT esophagram before starting enteral nutrition?

A

A fluoroscopic esophagram may be performed to confirm findings

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21
Q

When should endoscopy be considered in patients suspected of having an esophageal perforation?

A

In patients with a high suspicion of perforation who cannot undergo a swallow examination or have had a nondiagnostic study

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22
Q

What diagnostic benefits does endoscopy offer in cases of esophageal perforation?

A

direct visualization of mucosal integrity
assessment of the injury’s location
and identification of other esophageal pathologies like strictures or neoplasms.

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23
Q

Why should minimal air insufflation be used during endoscopic examination of a suspected esophageal perforation?

A

Excessive air insufflation could

-enlarge the perforation
-or cause a tension pneumothorax

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24
Q

How can endoscopy serve a therapeutic purpose in the setting of esophageal perforation?

A

It allows for stent placement in the same session as the diagnostic procedure

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25
Q

What is the primary aim of the PSS (Pittsburgh Severity Score) in managing esophageal perforation patients?

A

To identify clinical factors predicting survival and determining suitability for nonoperative management.

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26
Q

Pittsburgh Severity Score

A
  • Age > 75 years
  • Tachycardia (> 100 bpm)
  • Leukocytosis (> 10.000 WBC/ mL)
  • Pleural effusion on imaging*

each worth 1 point

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27
Q

Pittsburgh Severity Score

A
  • Fever (> 38.5 ° C)
  • Noncontained perforation
  • Respiratory distress (> O2 requirements, RR > 30, need for mechanical ventilation)
  • Time to diagnosis > 24 hours

Each worth 2 points

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28
Q

Pittsburgh Severity Score

A
  • Hypotension
  • Malignancy

Each worth 3 points

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29
Q

What determines the management approach for esophageal perforation?

A

Clinical and imaging characteristics

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30
Q

In which patients might a nonoperative approach be appropriate for esophageal perforation?

A

Patients with contained perforations.

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31
Q

What is the traditional surgical approach for free esophageal perforations?

A

Open primary repair of the perforation, especially when performed within 24 hours

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32
Q

What less invasive treatment has shown encouraging results for esophageal perforation?

A

Endoscopic stenting combined with thoracoscopic mediastinal and pleural drainage

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33
Q

What may be necessary in severe cases of esophageal perforation?

A

Esophageal resection and exclusion.

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34
Q

Where should initial management of esophageal perforation patients take place?

A

In a surgical critical care unit for close monitoring.

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35
Q

What initial supportive measures are recommended for all patients with esophageal perforation?

A

Nil per os (NPO)
intravenous fluid resuscitation
broad-spectrum antibiotics with fungal coverage
and intravenous analgesia

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36
Q

Why is a proton pump inhibitor (PPI) started in esophageal perforation management?

A

To reduce gastric acid and prevent further esophageal injury.

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37
Q

When might early total parenteral nutritional support be considered in esophageal perforation management?

A

If a prolonged course of treatment is expected

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38
Q

What are the criteria for nonoperative management of esophageal perforation?

A

-Early diagnosis
-contained perforations or perforations draining back into the esophagus
-no significant mediastinal contamination
absence of sepsis or multiorgan failure
-and no malignancy or obstruction of the esophagus.

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39
Q

What are the initial steps if a patient meets the criteria for nonoperative management?

A

Admission to the surgical critical care unit for 48 to 72 hours of observation if hemodynamically stable without sepsis or multiorgan failure

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40
Q

What supportive care is provided during nonoperative management of esophageal perforation?

A

-NPO
-head of bed elevated
-given 72 hours of broad-spectrum antibiotics
-PPI
-considered for parenteral nutrition if necessary.

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41
Q

When should repeat imaging be obtained for a patient under nonoperative management?

A

At 72 to 96 hours to assess for any signs of free perforation ( 3-4 Days )

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42
Q

What dietary change is allowed if repeat imaging shows no evidence of free perforation?

A

started on a liquid diet.

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43
Q

What symptoms indicate that a patient may no longer meet criteria for nonoperative management?

A

Development of fever, leukocytosis, tachypnea, tachycardia, or mental status changes.

44
Q

What steps should be taken if a patient’s condition deteriorates during nonoperative management?

A

Repeat imaging and possible endoscopy are indicated.

45
Q

What endoscopic techniques can be used as an alternative to open surgical repair for esophageal perforation? Free Perf

A

Endoscopic covered stent placement
or
endoluminal clipping to seal the perforation

46
Q

Why is video-assisted thoracoscopic surgery (VATS) often required following stent placement?

A

VATS is needed for debridement and drainage of mediastinal and pleural contamination, which the stent does not address

47
Q

What drainage setup is typically left after a VATS procedure for esophageal perforation?

A

At least one chest tube in the pleural space
and a Blake drain adjacent to the esophagus

48
Q

When is a contrast esophagram typically performed after stent placement?

A

48 hours after stent placement to check for sealing of the esophageal perforation

49
Q

What dietary progression is recommended if the esophagram shows no extravasation?

A

Start with a clear liquid diet and advance to full liquids

50
Q

What should be done if there is extravasation of contrast around the stent or if drainage character changes after liquids are started?

A

The patient should return to NPO status,
and a jejunostomy tube may be needed for feeding

51
Q

What is the typical recommended duration for esophageal stent placement, and what factors influence this duration?

A

Between 4 and 6 weeks, depending on perforation size

smaller perforations may heal within 10 days
while larger defects may require up to 8 weeks.

52
Q

What is the next step if the esophagram shows the perforation has not healed after stent removal?

A

The stent can be replaced for an additional 4 to 6 weeks to promote further healing.

53
Q

What can be done if the stent does not completely cover the perforation on the first attempt?

A

The stent can be repositioned endoscopically

or balloon dilation can be used for complete contact with the esophageal mucosa.

54
Q

After Stent placement what do you do ?

A

Place NGT for Decompression

55
Q

What imaging is recommended immediately after stent placement, and why?

A

An anteroposterior and lateral chest X-ray

to establish a baseline of the stent location for future assessments.

56
Q

When should a contrast esophagram be performed after stent placement, and what is its purpose?

A

At 48 hours post-placement to confirm proper positioning and check for contrast extravasation

57
Q

What are common complications associated with esophageal stents?

A

Complications include

migration, bleeding, erosion, and tissue overgrowth

58
Q

Which is the most frequently reported complication of esophageal stents, and in what percentage of cases does it occur?

A

Migration, occurring in about 8% to 40% of cases

59
Q

How do migration rates differ between metallic and plastic stents?

A

Migration rates are lower with metallic stents compared to plastic stents

60
Q

What endoscopic techniques are used to secure stents and prevent migration?

A

Endoscopic suturing or clipping is used to secure stents with favorable results

61
Q

When might endoscopic suturing or clips be used as a primary treatment in esophageal perforations?

A

For small
early perforations

especially when the defect size is 8 mm or smaller

62
Q

What are the reported closure success rates for esophageal defects greater than 13 mm?

A

Higher failure rates are seen in lesions larger than 13 mm

63
Q

What type of clips are used for defects less than 1 cm, and for larger lesions?

A

Through-the-scope clips for defects less than 1 cm

and over-the-scope clip systems for larger lesions.

64
Q

How can suction aid in the deployment of clips for esophageal defect repair?

A

Suction helps approximate the lesion edges, allowing for better clip placement.

65
Q

How does the timing of perforation influence the success of an open repair?

A

Success diminishes after 24 hours from the perforation event, but successful repairs have been reported even beyond 24 hours

66
Q

Why might endoscopy be performed in the operating room before open repair

A

To identify the precise location of the perforation, which guides the surgical approach

67
Q

What is recommended for closure during open repair when feasible?

A

A two-layer closure, reinforced with a pedicled buttress

68
Q

What type of closure may be necessary in cases of delayed esophageal perforation?

A

A single-layer closure may be the only feasible option in delayed cases.

69
Q

Through which approach should perforations of the upper and middle thirds of the esophagus be accessed?

A

Right posterolateral thoracotomy via the fourth or fifth intercostal space

70
Q

Up to what landmark is the intercostal muscle (ICM) freed, and why is this important?

A

Up to the lumbar-dorsal fascia; further dissection risks injury to the intercostal vessels

71
Q

How is the esophageal mucosa closed after debridement of the perforation edges?

A

With running or interrupted absorbable sutures, typically 4-0 Vicryl or PDS.

72
Q

What type of sutures are used to close the muscularis layer in esophageal repair?

A

Interrupted 3-0 silk sutures.

73
Q

How is the ICM flap positioned and secured in esophageal perforation repair?

A

The pleural side of the ICM flap is placed in contact with the repair and secured with interrupted silk sutures to the esophageal muscle layer.

74
Q

Where should perforations of the lower third of the esophagus be accessed surgically?

A

Through a left posterolateral thoracotomy in the seventh or eighth intercostal space

75
Q

What alternative to an ICM flap may be used as a buttress in lower esophageal perforations?

A

A diaphragmatic flap can be used.

A posteriorly based full-thickness flap is mobilized and secured with interrupted silk sutures to cover the repair, and the diaphragm is closed with nonabsorbable suture

76
Q

What is the preferred method of exposure for cervical esophageal perforation?

A

A left-sided neck incision along the anterior border of the sternocleidomastoid muscle (SCM)

77
Q

Which structure may need to be ligated for improved exposure during cervical esophageal perforation repair?

A

The middle thyroid vein.

78
Q

How is exposure of the esophagus achieved in cervical esophageal perforation repair?

A

By retracting the trachea and thyroid gland medially.

79
Q

Which space is entered to access the esophagus, and what is preserved during this approach?

A

The retroesophageal space is entered along the prevertebral fascia, with care to preserve the recurrent laryngeal nerve.

80
Q

How should dissection proceed to ensure complete drainage in cervical esophageal perforation repair?

A

Blunt dissection should continue down to the posterior mediastinum to drain all fluid collections.

81
Q

What is done if the perforation defect is identified?

A

The defect is repaired primarily, often buttressed with a strap muscle

82
Q

What approach is taken if the esophageal defect cannot be clearly identified?

A

Closed drainage of the area is performed.

83
Q

What surgical incision is typically used to access an abdominal esophageal perforation?

A

An upper midline incision.

84
Q

What can be used to buttress the primary closure of an abdominal esophageal perforation?

A

Omentum or, more commonly, a fundoplication.

85
Q

Why has the routine placement of gastrostomy and jejunostomy tubes become less common?

A

If the repair is successful, oral nutrition may start within a week, making feeding tubes unnecessary, especially if patients are on inotropic support and cannot spend extra time in the OR

86
Q

What alternative to surgical feeding tubes can be used for early enteral feeding?

A

A Dobhoff tube can be placed under direct vision during repair and advanced post-pylorically for early enteral feeding

87
Q

What role does a nasogastric tube (NGT) play in postoperative care after esophageal repair?

A

An NGT may be placed for gastric decompression if needed

88
Q

When is an esophagram typically obtained after esophageal repair, and why?

A

At 5 to 7 days post-surgery to check for leaks.

89
Q

What dietary progression is recommended if no leak is identified on the esophagram?

A

Start with liquids, advancing gradually to a soft diet

90
Q

What is the next step if a persistent leak is identified after repair?

A

Stent placement may be attempted to seal the leak.

91
Q

What is recommended if a leak persists despite stent placement?

A

Placement of a jejunostomy tube, as several weeks may be needed for healing

92
Q

What factors are essential for healing a persistent esophageal perforation

A

Adequate mediastinal debridement
appropriate antibiotic therapy
good nutritional support.

93
Q

What are the key indications for esophageal exclusion rather than preservation?

A

-Long perforations (>6 cm) not amenable to stenting
-large areas of devitalized esophagus due to delayed diagnosis
-or large perforated cancers unsuitable for stenting.

94
Q

What alternative option is available in stable patients with large esophageal defects?

A

Stenting with coverage of the defect using biodegradable mesh and a muscle flap (e.g., serratus anterior or latissimus dorsi).

95
Q

Why is esophageal exclusion preferred over resection and immediate reconstruction in high-risk patients?

A

The risk of anastomotic failure is very high in hemodynamically unstable patients or those with significant mediastinal contamination

96
Q

What approach is taken to mobilize the esophagus during esophageal exclusion?

A

The esophagus is mobilized as much as possible in the chest and divided near the gastroesophageal junction with a 45-mm stapler

97
Q

Where is the neck incision made for cervical mobilization of the esophagus in exclusion procedures?

A

Along the anterior border of the sternocleidomastoid muscle (SCM) on the left side.

98
Q

What should be avoided when dissecting the esophagus circumferentially during exclusion?

A

Injury to the recurrent laryngeal and vagus nerves.

99
Q

What is done with the esophagus after transection in an exclusion procedure?

A

It is tunneled subcutaneously onto the left chest, and an end esophagostomy is created.

100
Q

What additional steps are taken for feeding access in esophageal exclusion?

A

A jejunostomy tube is placed for nutritional support

101
Q

What precaution should be taken if a gastrostomy tube is placed during esophageal exclusion?

A

Ensure that the stomach remains viable for potential use as a conduit in future reconstruction

102
Q

What is the preferred initial management when esophageal perforation involves a malignancy with adequate drainage?

A

Placement of an esophageal stent to control contamination

with resection and anastomosis reserved for later

103
Q

What should be done if a patient with esophageal perforation and malignancy presents with massive contamination and hemodynamic instability?

A

Consider resection, cervical esophagostomy, and placement of a tube and gastrostomy.

104
Q

Why is immediate resection often avoided in cases of malignant esophageal perforation with adequate drainage?

A

To control contamination initially and reserve more invasive procedures for a stable, later stage

105
Q

What events can lead to esophageal perforation in patients with achalasia?

A

Pneumatic dilation, myotomy, or other mechanisms related to elevated intraluminal pressure

106
Q

Why is healing of esophageal perforation challenging in achalasia patients?

A

Due to elevated intraluminal pressure proximal to the esophageal sphincter

107
Q

What procedure is required for achalasia patients following esophageal perforation repair to facilitate healing?

A

Myotomy to reduce intraluminal pressure and support healing

On the opposite side of the esophagus from the perforation

A1-G Surg Note Esophagus (15 decks)

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