Case PresentationSurgery Grand Round

Amid Keshavarzi, MDUCHSC 4/9/2006

Case Presentation• 12 y/o female Presented to OSH after

accidental swallowing of plastic fork in the bus, CXR/AXR form OSH did not show any foreign body, then she was transferred to TCH for further care.

• SH/FH: noncontributory• PMH: None• Medications: None• ROS: Denied any difficulty breathing,

nausea, vomiting. Mild LUQ pain.• VS:

BP: 107/65 / Pulse: 76 / Temp: 99.7 / Resp: 16 / SaO2: 98%

• Exam: – Lungs: Clear to auscultation

bilaterally. Unlabored respirations. – Abdomen: Mild pain beneath left ribs.– Otherwise normal exam

• Initial CXR normal

• Initial esophagram negative for leak.

• Patient underwent gastroesophagoscopy.

• Following removal of the fork, repeat endoscopy revealed several areas of abrasion of both the stomach and esophagus, without significant bleeding or obvious perforation.

• Patient recovered form anesthesia and transferred to PACU.

Case Presentation

Case Presentation

• Right chest tube was placed, and esophagram was repeated.

•In the PACU, found to be agitated, and on exam, she was tachypneic, decrease BS in the right chest, with right chest wall and neck crepitus.

• Patient admitted to PICU.

• Initial VS: Temp: 99.7 / HR: 76 / RR: 16 / BP: 107/65

• HD #1: Temp: 38.7 / HR 120’s / RR 20’s, WBC 18 / BP 112/49

Hospital Coarse

OR for exploration.

Underwent right thoracotomy, debridment of pleural cavity, repair of esophageal perforation with pleural patch.

Found to have 1.5 cm vertical perforation of right lateral mid-esophagus, behind the azygus vein, with moderate pleural soiling and mediastinitis.

Reinforced primary repair was performed using pleural patch.

Hospital Coarse• POD # 1:

– Gastric feed started, HD stable, WBC: 14

• POD # 2:– Chest tubes were placed to waterseal, WBC: 10.8

• POD # 3:– Anterior chest tube D/C’s, WBC: 7.5

• POD # 4: – No major event

• POD # 5:– Esophagram negative for leak– Postosterior chest tube D/C’d– NGT D/C’d– Diet advanced

• POD # 6: – Discharged home

Esophageal Perforation: Historical Facts

• Esophageal perforation was first described ~ 250 years ago.

• In 1723, Herman Boerhaave first described barogenic esophageal rupture.

• In 1947, first reports of successful esophageal repair were performed by Barrett, Olsen and Clagett, separately.

• In 1952, Satinsky and Kron performed the first successful esophagectomy for perforation.

• In 1965, Mengoli and Klasser were the first described the conservative management.

Esophageal Perforation

0%10%20%30%40%50%60%

Instru

mentat

ion

Forei

gn Bod

y

Operat

ive In

jury

Others

Etiology

Etiology of Esophageal Perforation

• Esophageal perforations are associate with 15-30% mortality.• Extremely high mortality before the era of antibiotics.• Increase in frequency of iatrogenic injuries (60-70%) due to more frequent instrumentation in

last 40 years.• Most common site are areas of anatomic narrowing.

Abdominal

Cervical

Brinster CJ et al. : Ann Thorac Surg (2004) 77: 1475-83

Esophageal Perforation• Diagnosis:

– Contrast esophagography:• Gastrographin study positive in 50% of cervical

perforations and 75-80% of esophageal perforations

• Contrast studies have overall false negative rate of 10%.

– CT– Flexible esophagoscopy– Pleural effusion sampling

• Surgical options:– Primary repair– Reinforced primary repair– Esophagectomy– T-tube drainage– Exclusion and diversion– Thoracoscopic repair– Delay primary repair

• Criteria for non-surgical treatment:– Early diagnosis.– Contained leak within neck or

mediastinum.– Drainage into esophageal lumen.– Injury not related to neoplasm, in

abdomen and not proximal to obstruction.

– No sign or symptom of sepsis.– Availability experienced radiologist and

CT surgeon.

S. Hasan et al. Eur J CT Surgery 28 (2005) 7-10 Brinster CJ et al. : Ann Thorac Surg (2004) 77: 1475-83

Brinster CJ et al. : Ann Thorac Surg (2004) 77: 1475-83

Esophageal Perforation

Conservative management of iatrogenic esophageal perforation – a viable option

• Retrospective study, over 10 years.• 9/26 had carcinoma and 17/26 had benign

pathology.• 22/26 diagnosed within 6 h, and 4/26 over 24 h.• Treatment plan : NPO, IVF, and Abx• 22/26 (84.6%) success rate with this regimen.• All four death (15.3%) was caused by other

cases than mediastinitis, but all had contamination of pleural cavity.

• 46% of patient complicated with empyema.• Conservative management give comparable to

or better result than surgical intervention. • Perforations which involves pleural or

peritoneal cavity carries the worst prognosis.

S. Hasan et al. Eur J CT Surgery 28 (2005) 7-10

Clinical Findings in Iatrogenic Esophageal Perforation

0 20 40 60 80 100

Chest pain

Pyrexia

Neck Emphysema

Back pain

Shock

X-Ray Findings

0% 10% 20% 30% 40% 50% 60%

LME

Pneu

momed

iastin

um

Pneu

mothora

x

Pneu

moperi

toneiu

m

Subd

iaph.

Exrav

asati

on

Extra

vasa

tion t

o pleu

ra

Algorithm for Management of Esophageal Perforation

Huber-Lang M et al. : Surg Today (2006) 36:332–340 Brinster CJ et al. : Ann Thorac Surg (2004) 77: 1475-83

Conclusion

• Conservative management of esophageal perforation is a viable option but mostly dependent on patients pre-existing conditions.

• Primary repair of esophageal perforations with or without reinforcement is the best therapeutic approach.

References:

• Huber-Lang M, et al. : Esophageal perforation: principles of diagnosis and surgical management. Surg Today. 2006;36(4):332-40.

• Chambers AS, et al. : A new management approach for esophageal perforation. J ThoracCardiovasc Surg. 2005 Nov;130(5):1470-1.

• Richardson JD et al. : Management of esophageal perforations: the value of aggressive surgical treatment. Am J Surg. 2005 Aug;190(2):161-5.

• Hasan S, et al. : Conservative management of iatrogenic oesophageal perforations--a viable option. Eur J Cardiothorac Surg. 2005 Jul;28(1):7-10.

• Eroglu A, et al. : Esophageal perforation: the importance of early diagnosis and primary repair. Dis Esophagus. 2004;17(1):91-4.

• Brinster CJ, et al. : Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004 Apr;77(4):1475-83.