Editing Oesophageal perforation (section)

== Surgery ==

* Trans-hiatal vs trans-pleural
** Distal perforations where      contamination is confined to mediastinum can have laparoscopic      trans-hiatal drainage
** If pleura is breached, won't      be able to drain it adequately from abdomen, need thoracic approach via      either VATS or thoracotomy
* Exposure:
** Cervical perf
*** Left-sided neck incision       along anterior SCM (?ligate middle thyroid vein)
*** Enter retrooesophageal       space bluntly along prevertebral fascia (preserve RLN)
*** Identify defect and repair       primarily
*** Closed drainage if not       identified
*** Can buttress with strap       muscles
*** Gastrografin on day 5 to       demonstrate healing
** Thoracic perf - upper 2/3
*** Left lateral decubitus
*** Double-lumen ETT for       single-lung ventilation
*** Right posterolateral       thoracotomy (fifth interspace)
*** Open pleura, dissect       oesophagus free
*** Close mucosa with PDS
*** Close muscularis with PDS
*** Irrigate
*** Intercostal muscle flap
*** Drainage tube
** Thoracic perf - lower third
*** Left posterolateral       thoracotomy in seventh interspace
*** Same as above
*** Can also use abdominal       approach
** Abdominal perf
*** Upper midline incision
*** Can use rotational flap
* Repair technique:
** Solid debris removed, and      the pleural cavity thoroughly cleaned
** Debride devitalised tissues
** Longitudinal myotomy to      expose the full extent of mucosal injury (mucosal injury usually longer)
** '''Closure      over T-tube'''      (recommended if damage control surgery required by general surgeon)
*** 6-10mm T-tube placed into       the defect, and close oesophageal wall loosely over the tube with       interrupted absorbable sutures (PDS)
*** Consider anchoring the tube       to the oesophagus
*** Place at least one more       Blakes drain around the repair
*** Monitor with Gastrografin       swallows
*** Aim to remove around six       weeks post-op

* '''Primary     closure''' (not     recommended for general surgeons)
** Assess the injury and      repair, in two layers if possible, using a 2/0 or 3/0 interrupted      absorbable suture, perhaps over a 40-46Fr bougie
** Leak rate of primary repair      is 20-50% so should be reserved for the best candidates
** Tissue flap coverage      (intercostal muscles, pericardial flat, pleura, omentum) is preferred
** Extensive injuries with      devitalised tissues can be managed with controlled fistulisation over a      T-tube
** Very large or devitalised      defects will require oesophageal exclusion with creation of a cervical      oesophagostomy and gastrostomy tube, and planned for future      oesophagectomy and conduit reconstruction
* Consider remedying any sign     of obstruction (achalasia, stricture, tumour) at the index operation
** See below


* Oesophagectomy

* Resection
** Major undertaking
** Reserved for damage to a      diseased oesophagus or in cases of extensive oesophageal trauma