1. Esofago: quando e quali traumi restano da operare G. Zaninotto UOC Chirurgia Generale Ospedale S. Giovanni e Paolo Ulss 12 – Venezia- Università di Padova

2. Esophageal Perforations: Etiology ( 1977)

3. Esophageal Perforations: Etiology 1992-2003: 46 pts 24 2 21 SurgeryOperative Endoscopy Spontaneous perforations Iatrogenic perforations Clin Chir PD 2003

4. 253 87 28 Spontaneous perforations Esophageal Perforations: Etiology 2002-2009 382 pts (Survey of Medical Literature) Iatrogenic perforations Trauma Other 14

5. 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)

6. 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

7. 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

8. 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

9. 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 1990-2001

10. Esophageal Perforation: Principle of Management Rapid closure of the esophageal leak Drainage of mediastinal or pleural collection Broad spectrum antibiotics Nutrition (parenteral & enteral)

11. First lesson: Believe the Patient ! Pain 95 % Fever 80 % Dysphagia 70 % Rx signs 50 % Emphysema 35 % Main symptoms of perforation

12. 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.

13. Esophageal perforations: diagnostic tests Chest Radiogram Gastrographin swallow CT scan (Endoscopy)

14. 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

15. Gastrographin swallow : Locate the leakage from the cervical perforation down into the mediastinum.

16. Esophageal Perforations: Diagnosis Man sieht was man weiss Johann Wolfgang von Goehte 1749 - 1832

17. Laparoscopic Heller Myotomy 1° post-op day (Saturday) Gastrographin swallow

18. on Monday……

19. ….the CT scan confirmed that the leak was communicating with the pleura…

20. Management of Esophageal Perforations Non-operative treatment (NG Tube, parenteral nutrition, antibiotics) Drainage only Esophageal Stenting Endoclip application 1. Wu JT, J Trauma, 2007

21. ….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….

22. Cervical esophagus perforations: Drainage

23. Esophageal Perforations after Pneumatic Dilations

24. Esophageal Perforations after PD: a. Conservative treatment a. Confined leakage b. Leakage diffused Gastrographin swallow a. Confined leakage

25. Esophageal Perforation: Stenting Minimal soiling; 1.Site of perforation (avoid the UES) 2.Type of stent: avoid metallic stent in benign disease

26. Esophageal perforation: closure with endoclip Qadder MA Gastorintest Endoscopy, 2007 Chronic Fistula

27. 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

28. Primary Closure after Necrosectomy (viable wound edges) Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed.

29. Primary Closure Reinforced with Gastric Patch (Thal operation) Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed.

30. Primary Closure and Buttressing with Diaphragmatic Flap Richardson JD Am J Surg 2005

31. Esophagectomy –Immediate reconstruction –Delayed reconstruction T-tube Drainage Exclusion and Diversion Management of Esophageal Perforations 3. Wu JT, J Trauma, 2007

32. Management of Esophageal Perforations: Esophagectomy

33. Management of Esophageal Perforation: Drainage and T tube Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed

34. Management of Esophageal Perforations Bipolar Exclusion of the Esophagus Ancona et al, le perforazioni esofagee 1977, Piccin ed

35. Ann Thorac Surg 2003 The Role of lateral esophagostomy Ancona et al, le perforazioni esofagee 1977, Piccin ed

36. 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)

37. 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

38. Grazie per l’attenzione

39. TABLE 1. Etiology and Location of Esophageal Perforations

43. Endoscopic Pneumatic Dilation for Achalasia To be effective the dilation must tear the esophageal muscle wall: this depends on balloon size, pressure and duration