Esofago: quando e quali traumi restano da operare

G. Zaninotto

UOC Chirurgia Generale Ospedale S. Giovanni e Paolo

Ulss 12 – Venezia- Università di Padova

AZIENDA U.L.S.S. N.12 “VENEZIANA”

Esophageal Perforations: Etiology

( 1977)

Esophageal Perforations: Etiology1992-2003: 46 pts

24

221

Surgery Operative Endoscopy

Spontaneous perforations

Iatrogenic perforationsClin Chir PD 2003

253

8728

Spontaneous perforations

Esophageal Perforations: Etiology 2002-2009 382 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

35 8

Death

rate0

(0%)

3

(37.5%)*

* p < 0.05Clin 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

Site Immediate & Early Late (>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 cancer 20%

• Varices sclerotherapy 31%

Medline 1990-

2001

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 Goehte1749 - 1832

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 afterPneumatic 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 PerforationsManagement of Esophageal Perforations2.

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 PerforationsBipolar 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

DrainOperateAntibiotics

Mid to distal esophagus

DrainOperateAntibiotics

MediastinalSoiling

Minimal to noMediastinalSoiling

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