Editing Oesophageal perforation


== Aetiology: ==

* Iatrogenic (60%)
** Endoscopy - diagnostic and      therapeutic - usually in distal oesophagus with an associated pathology
** Intra-operative - especially      cervical
** Intubation - NGT and ETT
** ''Overall      mortality 19%''
* Boerhaave's - spontaneous     rupture of oesophagus in the absence of prior pathology
** Secondary to barogenic      trauma, likely caused by failure of cricopharyngeus relaxation, leading      to immediate and gross gastric content contamination of the mediastinum      +/- pleural cavity. There may be an underlying anatomical predisposition      to this which we have not yet discovered.
** Differs from a Mallory-Weiss      tear (shearing forces) vs barogenic forces in a perforation
** Most common injury location      is just above GOJ in the left posterolateral position
** Mackler's triad: vomiting,      chest pain, surgical emphysema - uncommon
** Pleural effusion on left      (can go to right in hiatus hernia)
** Endoscope: visual defect
* FB
* Caustic ingestion
* Malignancy
* Trauma
** Penetrating - cervical stab      wounds, mediastinal gunshot wounds
** Blunt - rare - secondary to      blast
** Needs high index of      suspicion to diagnose

{| class="wikitable"
|Medical  Instrumentation
|Percentage  Risk of Iatrogenic Oesophageal Disruption
|-
|Dilatation

Dilatation  for achalasia

Endoscopic  mucosal resection

Stent  placement

Endoscopic  thermal therapy

Treatment  of variceal bleeding

Endoscopic  laser therapy

Photodynamic  therapy

Stent  placement
|0.5

2

2

2

1–2

1–6

1–5

5

5-25
|}

== Presentation ==

* Vague complaints are common,     and thus the diagnosis is often delayed, and confused with other medical     or surgical catastrophes
** Pain
** Dyspnoea
** Nausea
** Dysphagia
** Fever
** Sepsis
** Mediastinitis (tachycardia,      hypotension)
* Differentiate between     cervical (localised) and thoracic (severe chest and back pain, sepsis and     mediastinitis more common)
* Check for crepitus, neck     swelling, epigastric tenderness, and nasal voice
* Hamman's sign - a crunching,     rasping sound, synchronous with the heartbeat, hard over the precordium in     spontaneous mediastinal emphysema

== Imaging ==

* CXR - pneumomediastinum,     pleural effusion, PTX, subcutaneous emphysema, abnormal cardiomediastinal     contour


* CT - first-choice     investigation
** PO contrast is not strictly      necessary in most cases
** Mediastinal air, or      peri-oesophageal air or fluid
* Gastrografin swallow     (preferred over barium due to risk of mediastinitis) is the standard for     diagnosis
** Can subsequently get barium      swallow if necessary for improved sensitivity/specificity, but only if      it's contained perf
* Endoscopy (gastroscopy or     laryngoscopy) - use if high suspicion, but no evidence of injury on     non-invasive imaging
** Careful not to make the      injury larger with investigation
** Highly sensitive and      specific for diagnosis



== Principles of management ==

* Treat sepsis
* Provide organ support as     required
* Source control of leak
* Evacuate/drain contamination     from mediastinal and pleural cavities
* Enteral feeding access

== Approach ==

* Important questions:
** Degree of contamination, and      clean/dirty
** Size and location of defect
* Non-operative if possible
* If not meeting criteria for     non-op management:
** Endoscopic if possible -      small/clean perforations
*** Clips
*** Stents - rarely used in       benign
*** Endo-VAC
** Surgical
*** Indications
**** Sepsis/shock
**** Gross contamination
**** Obstructing pathology
**** Retained foreign body
**** Major caustic injury
**** Failed non-op management
*** Primary repair
*** T-tube repair
*** Resection

== Initial management ==

* Non-operative management     (majority of patients can be managed non-op!)
** Contained perforation
*** Cavity confined to       mediastinum on endoscopy
*** Drains back into oesophagus       on contrast radiography
** No symptoms or signs of      mediastinitis
** Haemodynamically stable with      no evidence of ongoing sepsis, or only low-grade fevers
** No solid food contamination      of mediastinum OR tolerance to pleural contamination (over 72 hours)
** Perforation through an      oesophageal malignancy
** ICU for 2-3 days - if      deteriorates, will need intervention still
** NPO, head of bed elevated
** NGT decompression
** Broad-spectrum Abx, and      consider antifungal cover for distal perfs
** PPI
** Consider TPN/distal enteral      nutrition
** Repeat imaging in 3-4 days,      and if no further free perf, consider upgrading to liquid diet (serial      contrast studies)
* Source control in chest
** Chest tubes can be used to      drain the area in some cases
** Radiologically-guided drains      also useful
** VATS/open thoracic washout      with decortication might be necessary

== Endoscopy ==

=== Stenting ===

** Very commonly migrate with      benign perforations - not a good option
** Good option in frail      patients or patients with small, early perforations and minimal      contamination
** Can also be considered with      a delay to diagnosis, where tissue would be of poor quality. Will      generally need VATS and chest tube placement in that situation.
** May need VATS after 2-3 days      for debridement of pleural space
** Need to do regular CXR to      monitor for stent migration. Plastic stents have higher rate of migration      compared to metal stents, but lower rate of stricture

=== Endoscopic vacuum therapy ===

** Described for both      oesophageal perforation and anastomotic leak after oesophagectomy
** Endoscopic placement of a      sponge to the site of perforation
** Tubing from the sponge      connected externally to a vacuum device with continuous negative pressure
** Serial endoscopies every      several days to weeks to evaluate for granulation tissue and exchange the      sponge
** Once the mucosa has      sufficiently healed, the sponge is removed and diet liberalised

=== Over-the-scope clips ===

** Good for early leaks
** May need wide local      drainage, decortication and feeding access still

== 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


== Specific situations: ==

=== Malignancy ===

** Perforation through a cancer      makes the cancer incurable
** Stenting is favoured - get      situation under control, then resect later
** Disseminated disease, unfit      for surgery -> palliation
** Problem is that any      perforation means disease dissemination and survival is hopeless (0% at 2      years in one series) - therefore shouldn't be dilating potentially      operable tumours
** Could consider resection if      the perforation is separate to the malignancy

=== Achalasia ===

** Healing is often worsened      because of higher pressures
** Most of the time, perf will      be distal
** Myotomy should be done at      same time - on opposite side of oesophagus to perforation

=== Perforation as a complication     of fundoplication ===

** Laparotomy, dismantle      fundoplication, primary repair, repeat fundoplication

=== Leak after oesophagectomy ===

** Bad
** Evaluate conduit for      viability
*** If it's necrotic, will have       to resect everything

=== Prognosis ===

* Overall mortality 15-30%
* Worse prognosis with     increased time to intervention

[[Category:UGIS]]