Esofago: quando e quali traumi restano da operare G. Zaninotto UOC Chirurgia Generale Ospedale S. Giovanni e Paolo Ulss 12 – Venezia- Università di Padova
Esophageal Perforations: Etiology ( 1977)
Esophageal Perforations: Etiology : 46 pts SurgeryOperative Endoscopy Spontaneous perforations Iatrogenic perforations Clin Chir PD 2003
Spontaneous perforations Esophageal Perforations: Etiology pts (Survey of Medical Literature) Iatrogenic perforations Trauma Other 14
Esophageal Perforations: Prognostic Factors Diagnostic and therapeutic delay Location (cervical, thoracic, abdominal esophagus) Presence of esophageal diseases (primary, secondary) Size of perforation Extent of mediastinal and pleural contamination Patient’s general status (septic shock)
Esophageal perforation Early diagnosis and survival Delay < 48 h> 48 h Number of patients 358 Death rate 0 (0%) 3 (37.5%)* * p < 0.05 Clin Chir PD 2003
Esophageal Perforation: Influence of Site & Diagnostic Delay on Mortality Thoracic (60)9 %43 % Cervical (11)10 %0 Abdominal (3)0 %100 % Thoracic & abd.(1)0 %0 SiteImmediate & EarlyLate (>24 h) Muir AD, Europ J Cardio-Thorac Surg 2003
Effect of Diagnostic Delay Propionibacterium SPP Acinetobacter Baumanii Candida albicans Citrobacter SPP, Klebsiella P Enterococco faecium Staphylococcus Pseudomonas A. Bacterioides C.F, (M), 27 years old, admitted to the Hospital for “gastric fullness”and dyspnea during his first day of honey-moon: 24 hours of diagnostic delay
Mortality according to the cause of perforation & underlying esophageal disease Endoscopy for foreign bodies 3.7% Dilation of achalasia 4.1% Dilation of benign strictures 6.3% Diagnostic endoscopy 8% Palliation of esophageal cancer20% Varices sclerotherapy 31% Medline
Esophageal Perforation: Principle of Management Rapid closure of the esophageal leak Drainage of mediastinal or pleural collection Broad spectrum antibiotics Nutrition (parenteral & enteral)
First lesson: Believe the Patient ! Pain 95 % Fever 80 % Dysphagia 70 % Rx signs 50 % Emphysema 35 % Main symptoms of perforation
Where is the perforation (cervical, thoracic or abdominal esophagus)? Size of the perforation Is the leakage confined or free? Is there any backflow of contrast material towards he esophageal lumen Is there any underlying esophageal abnormality? Esophageal Perforations: What we need to know? from Kiss, Br J Surg 2008, mod.
Esophageal perforations: diagnostic tests Chest Radiogram Gastrographin swallow CT scan (Endoscopy)
Esophageal perforation: Chest X–ray is enough! 02/01/2001: stent L.V. 63 yrs: esophageal cancer with liver metastasis 12/01/2001: esophageal perforation
Gastrographin swallow : Locate the leakage from the cervical perforation down into the mediastinum.
Esophageal Perforations: Diagnosis Man sieht was man weiss Johann Wolfgang von Goehte
Laparoscopic Heller Myotomy 1° post-op day (Saturday) Gastrographin swallow
on Monday……
….the CT scan confirmed that the leak was communicating with the pleura…
Management of Esophageal Perforations Non-operative treatment (NG Tube, parenteral nutrition, antibiotics) Drainage only Esophageal Stenting Endoclip application 1. Wu JT, J Trauma, 2007
….A chest drain was inserted and a tube was positioned laparoscopically in front of the 2 mm hole, in the upper part of the myotomy 8 days later….
Cervical esophagus perforations: Drainage
Esophageal Perforations after Pneumatic Dilations
Esophageal Perforations after PD: a. Conservative treatment a. Confined leakage b. Leakage diffused Gastrographin swallow a. Confined leakage
Esophageal Perforation: Stenting Minimal soiling; 1.Site of perforation (avoid the UES) 2.Type of stent: avoid metallic stent in benign disease
Esophageal perforation: closure with endoclip Qadder MA Gastorintest Endoscopy, 2007 Chronic Fistula
Primary closure Primary Closure with buttressing of repair –Pleural flap –Pericardial fat pad –Diaphragmatic pedicle graft –Omentum onlay graft –Rhomboid muscle –Latissimus dorsi muscle –Intercostal muscle –Gastric Fundus Management of Esophageal Perforations 2. Wu JT, J Trauma, 2007
Primary Closure after Necrosectomy (viable wound edges) Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed.
Primary Closure Reinforced with Gastric Patch (Thal operation) Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed.
Primary Closure and Buttressing with Diaphragmatic Flap Richardson JD Am J Surg 2005
Esophagectomy –Immediate reconstruction –Delayed reconstruction T-tube Drainage Exclusion and Diversion Management of Esophageal Perforations 3. Wu JT, J Trauma, 2007
Management of Esophageal Perforations: Esophagectomy
Management of Esophageal Perforation: Drainage and T tube Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed
Management of Esophageal Perforations Bipolar Exclusion of the Esophagus Ancona et al, le perforazioni esofagee 1977, Piccin ed
Ann Thorac Surg 2003 The Role of lateral esophagostomy Ancona et al, le perforazioni esofagee 1977, Piccin ed
Management of Esophageal Perforations Esophageal Perforation Esophageal Stent Drain Operate Antibiotics Mid to distal esophagus Drain Operate Antibiotics Mediastinal Soiling Minimal to no Mediastinal Soiling Cervical – Upper esophagus (close to UES)
Esophageal Perforations: Conclusion Potentially life-threatening event with considerable mortality and morbidity Thoughtful and individualized approach Surgery is still the “gold standard” Endoscopic therapy (stenting) is effective, provided that diagnosis is early, mediastinal soil minimal, perforation is in thoracic esophagus and “round a clock” expert surgeon available
Grazie per l’attenzione
TABLE 1. Etiology and Location of Esophageal Perforations
Endoscopic Pneumatic Dilation for Achalasia To be effective the dilation must tear the esophageal muscle wall: this depends on balloon size, pressure and duration