Esophageal Injury

Question 1

Key issues to consider to determine managment of patient with esophageal injury

Answer 1

• Characteristics of injury
  
  • Etiology (caustic, penetrating truam, iatrogentic, FB)
  • Location (cervical, upper, mid, lower esophagus)
  • Severity
  • Timing of injury relative to presentation
• Characteristics of patient (age, comorbidities, immune status)
• Characteristivs of pre-existing esophagus
  
  • tumor
  • achalasia
  • distal obstruction

Question 2

Two categories of esophageal stricture

Answer 2

Benign

Malignant

Question 3

Categories of benign esophageal strictures

Answer 3

• Congenital
• Acquired
  
  • peptic (Schatzki’s rings)
  • pill-induced
  • autoimmune (eosinophilic esophagitis, Crohn’s scleroderma)
  • iatrogenic (anastomotic, XRT induced)
  • infectious (fungal, bacertial, mycobacterial)

Question 4

% narrowing of esophagus before dysphagia presents

Answer 4

Typically ~ 50%

Question 5

Diagnosis and Treatment of esophageal strictures

Answer 5

• Diagnosis
  
  • Esophagram and EGD
• Treatment:
  
  • Dilation (may need to be repeated)
    
    • Long-segment or near total obstruction stricutes require dilation under fluoroscopy with a guide wire
  • Esophagectomy with reconstruction
    
    • Strictures not responsive to dilation

Question 6

Characteristics of alkali corosive agents and injury

Answer 6

Alkalies (vs. acids)

• Viscous (long exposure)
• Deep tissue penetration
• Liquifactive necrosis

Question 7

Characteristics of acid corosive agents and injury

Answer 7

Acid (vs. alkali) injury:

• Less viscous (rapid transit time)
• More superficial coagulative necroiss

Question 8

3 phases of corrosive esophageal injury and healing

Answer 8

• Inflammation/necrosis
• Sloughing/ulceration
• Fibrosis/scarring

Question 9

MC presentation of corrosive esophageal injuries

Answer 9

• Dysphagia
• Odynophagia
• Chest/abdominal pain
• May present with sepsis

Question 10

Initial managment of corrosive esophagel injuries

Answer 10

• IVF resuscitation
• Emperic broad-spectrum antibiotics
• Plain X-ray (CXR and AXR - evaluate for obvious perforation)
• Laryngoscopy
• Early endoscopy
• NO BLIND NGT and NO ATTEMPT AT NEURTALIZATION of burn

Question 11

3rd degree burns of esophagus

Answer 11

Full thickness involvement with possiblity of:

• perforation
• mediastinitis
• peritonitis

Question 12

Potential late complicaton of corrisive esophageal injury

Answer 12

Long-segment esophageal stricture (not responsive to dilation)

• Tx: esophagectomy with reconstruction (gastric conduit preferred if not injured)

Question 13

MCC of esophageal perforation

Answer 13

Iatrogenic (during endoscopy and dilation)

Question 14

MC site of perforation during endoscopy on a patient with a hiatal hernia

Answer 14

GEJ or the gastric cardia

Question 15

2nd and 3rd MCC of esophageal perforation

Answer 15

2 Spontaneous (Boerhaave’s syndrome)

(MCC iatrogenic perforation)

Question 16

Diagnostic eval for suspected esophageal perforation

Answer 16

• CXR (pleural effusion, pneumomediastinum, pneumoperitoneum)
  
  • First modality (sensitivity low: 10-20%)
• Esophagogram (water soluable contrast)
  
  • Thin barium if Gastrograffin study negative
  • Sensitivity 80%
• CT (oral contrast)
  
  • Eval surrounding structures and associated injuries (trauma)
• EGD (foreign body and penetrating trauma)

Question 17

Sensitivity of CXR and Esophagogram for diagnosis of esophageal perforation

Answer 17

• CXR: 10-20%
• Esophagogram: 80%

Question 18

Indications for non-operative managment of esophageal perforation

Answer 18

• Clinically stable
• Recent injury
• No evidence of extraluminal contrast
• No distal obstruction

Question 19

Treatment approach for non-operative management of esophageal perforation

Answer 19

• Emperic broad-spectrum Abx
• NPO
• IVF hydration

Question 20

Indications for operative managment of esophageal perforation

Answer 20

• Extraluminal contrast
• Medistinal or peritoneal contamination
• Sepsis

Question 21

Surgical approach to cervical perforation

Answer 21

Debridement and drainage via oblique incisoin anterior to SCM on ipsilateral side of injury

Question 22

Surgical approach for intrathoracic esophageal perforations

Answer 22

• Access:
  
  • Upper and middle esophageal perforations (righ thoracotomy)
  • Lower 1/3 esophageal perforations (left thoracotomy)
• Exposure of perforation (extend myotomy)
• Debridement to healthy tissue
• Primary repair (2 layers, absorbable mucosa, silk muscularis)
• Butress repair
  
  • pedicled intercostal muscle flap
  • pericardium, pleura, omentum
• Drain widely

Question 23

Use of t-tube for esophageal perforation

Answer 23

Development of controlled esophageal fistula that closes over time as the tube is withdrawn

Question 24

Approach for perforation during dilation for achalasia

Answer 24

Primary repair with contralateral esophagomyotomy (180 degrees opposite the perforation

Question 25

Surgical options for:

• Delayed diagnosis
• Unrepairable tissue
• Poor patient physiology

Answer 25

• Initial management:
  
  • Debridement
  • Drainage
  • Control further contamination with proximal and distal diversion

Question 26

Patients at highest risk for foreign body ingestion and impaction

Answer 26

• Children
• Elderly
• Psychiatric

Question 27

Diagnostic w/u for foreign body aspiration

Answer 27

• CXR
• Swallow study (occasionally)
• Upper endoscopy (snare and remove foreign body)
  
  • If object’s orientation is such that removal is likely to lacerate esophagus, rigid esophagoscopy can be used.
• Most objects can be advanced into stomach and allowed to pass distally without consequence.
  
  • Objects that must be removed:
    
    • Watch batteries
    • Two magnets or multple magnet pieces