Esophageal perforation Flashcards
Cause of perforation (6)
- Iatrogenic (endoscopy and TEUS) 60%
- Boerhaave 15-30%
- Foreign body
- Caustic ingestion
- Malignancy
- Trauma
Underlying Predisposition (4)
Reflux esophagitis
Hiatal hernia
Stricture
Achalasia
Symptoms
May be atypical !
Chest, shoulder, epigastrium, dyspnea, nausea, dysphagia, fever.
Exam
Wide range !
Unspecific
Septic shock
Mediastinitis (tachycardia, hypotension)
Lab
Leukocytosis
Imaging
Chest X ray : pneumomediastinum, pleural effusion, pneumothorax, subcutaneous emphysema, abnormal cardiomediastinal contour.
Esophagography
Gastrografin real time images
CT
Helps to determine well between contained and noncontained
CT with oral contrast even better
Fat stranding, pneumomediastinum, pleural effusion, empyema, pneumoperitoneum, contrast extravasation.
Endoscopy (4)
- High risk of tension pneumothorax
- Multidisciplinary team
- Can investigate if underlaying disease or malignancy
- Can stent
Conservative treatment if
- Contained leak
- Heart rate < 100
- Normotension
- Lc < 12-14
- No sepsis
Conservative treatment how
- ICU 48 - 72h
- NPO
- Head elevation 45°
- Broad Spectrum ATB
- (antifungal therapy if distal + reflux)
- PPI
- parenteral nutritional support
- Repeat imaging at 72h
if no free perforation : start liquid diet.
Operative TTT
Primary repair with 2 layered suture.
Primary muscle flap if possible.
Cervical esophageal perforation TTT
Left sided neck incision along anterior border of scm.
Preserve recurrent laryngeal nerve.
Gastrographin at D5
Upper 2/3 thoracic esophageal perforation TTT
- Right posterolateral thoracotomy (5th ICS)
- Edges of perforation debrided
- If fresh, mucosa closed with non resorbable, muscularis closed with interrupted resorbable.
- Intercostal muscle flap
- CH32 TD
- Gastrografin at day 5
Lower 1/3 thoracic esophageal perforation TTT
- Left posterolateral thoracotomy (7th ICS)
- Intercostal or diaphragmatic flap
- Gastrografin at day 5
