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A1-G Surg Note Esophagus > Esophageal Perforation > Flashcards

Esophageal Perforation Flashcards

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1
Q

What is the most common cause of esophageal perforation?

A

Iatrogenic injuries from endoscopic procedures, accounting for 60% to 70% of cases

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2
Q

What are some endoscopic procedures that can lead to iatrogenic esophageal perforation?

A

Diagnostic endoscopy,
biopsy,
dilation,
sclerotherapy,
laser therapy,
photodynamic therapy,
stent placement,
transesophageal echocardiogram,
and esophageal ultrasound

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3
Q

What is the second most common cause of esophageal perforation?

A

Spontaneous rupture, or Boerhaave’s syndrome

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4
Q

What are some less frequent causes of esophageal perforation?

A

Trauma (penetrating or blunt)
foreign body ingestion
caustic ingestion
cervical or nonesophageal surgery (thyroidectomy, mediastinoscopy, spine surgery)
and malignancies of the esophagus, lung, or mediastinum

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5
Q

In what patient population is esophageal perforation associated with infections more likely?

A

In immunocompromised patients, with infections from pathogens like candida, herpes, syphilis, and tuberculosis

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6
Q

What other conditions can lead to esophageal perforation?

A

Severe gastroesophageal reflux
Mallory-Weiss tears
and infectious processes

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7
Q

What recent events in a patient’s history might indicate an esophageal perforation?

A

Recent esophageal instrumentation or forceful vomiting.

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8
Q

What are the initial symptoms of esophageal perforation?

A

Vague pain localized to the neck, chest, shoulder, or epigastrium

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9
Q

What additional symptoms may develop as esophageal perforation progresses?

A

Dyspnea, dysphagia, and odynophagia.

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10
Q

What signs may be present in patients with esophageal perforation?

A

-Signs range from hemodynamic stability to signs of septic shock or mediastinitis, such as tachycardia and hypotension.

-Leukocytosis

-Pneumomediastinum, pleural effusion, pneumothorax, subcutaneous emphysema, or an abnormal cardiomediastinal contour.

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11
Q

What imaging studies are used to further evaluate esophageal perforation?

A

Contrast esophagram
computed tomography (CT) to assess injury extent, location, and contamination

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12
Q

Why is Gastrografin generally preferred over barium in esophagrams for suspected perforation?

A

Gastrografin has a lower risk of causing mediastinitis if leakage occurs.

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13
Q

In which area of the esophagus is Gastrografin less effective in detecting perforations, and why?

A

In the cervical esophagus

due to the rapid transit of the contrast agent

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14
Q

What advantage does barium offer over Gastrografin in an esophagram?

A

Barium provides better resolution for distinguishing between contained and noncontained perforations.

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15
Q

What is the usual protocol if a Gastrografin esophagram is inconclusive?

A

A repeat esophagram with diluted barium may be performed for improved sensitivity and specificity

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16
Q

What key information does CT provide in cases of esophageal perforation?

A

CT differentiates between contained and noncontained perforations
and assesses the extent of mediastinal, pleural, or peritoneal contamination

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17
Q

What characterizes a contained esophageal perforation on CT?

A

-No or minimal extravasation of contrast at the perforation site, without pleural or peritoneal contamination

-or drainage of contrast back into the esophagus

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18
Q

What challenge in critically ill patients does CT esophagography address?

A

It allows for contrast administration via nasogastric tube (NGT) if the patient is unable to swallow or stand

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19
Q

How is contrast administered in CT esophagography if a patient cannot swallow?

A

Contrast is administered via a nasogastric tube (NGT) positioned in the proximal esophagus.

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20
Q

What additional step is often taken following a negative CT esophagram before starting enteral nutrition?

A

A fluoroscopic esophagram may be performed to confirm findings

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21
Q

When should endoscopy be considered in patients suspected of having an esophageal perforation?

A

In patients with a high suspicion of perforation who cannot undergo a swallow examination or have had a nondiagnostic study

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22
Q

What diagnostic benefits does endoscopy offer in cases of esophageal perforation?

A

direct visualization of mucosal integrity
assessment of the injury’s location
and identification of other esophageal pathologies like strictures or neoplasms.

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23
Q

Why should minimal air insufflation be used during endoscopic examination of a suspected esophageal perforation?

A

Excessive air insufflation could

-enlarge the perforation
-or cause a tension pneumothorax

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24
Q

How can endoscopy serve a therapeutic purpose in the setting of esophageal perforation?

A

It allows for stent placement in the same session as the diagnostic procedure

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25
What is the primary aim of the PSS (Pittsburgh Severity Score) in managing esophageal perforation patients?
To identify clinical factors predicting survival and determining suitability for nonoperative management.
26
Pittsburgh Severity Score
* Age > 75 years * Tachycardia (> 100 bpm) * Leukocytosis (> 10.000 WBC/ mL) * Pleural effusion on imaging* each worth 1 point
27
Pittsburgh Severity Score
* Fever (> 38.5 ° C) * Noncontained perforation * Respiratory distress (> O2 requirements, RR > 30, need for mechanical ventilation) * Time to diagnosis > 24 hours Each worth 2 points
28
Pittsburgh Severity Score
* Hypotension * Malignancy Each worth 3 points
29
What determines the management approach for esophageal perforation?
Clinical and imaging characteristics
30
In which patients might a nonoperative approach be appropriate for esophageal perforation?
Patients with contained perforations.
31
What is the traditional surgical approach for free esophageal perforations?
Open primary repair of the perforation, especially when performed within 24 hours
32
What less invasive treatment has shown encouraging results for esophageal perforation?
Endoscopic stenting combined with thoracoscopic mediastinal and pleural drainage
33
What may be necessary in severe cases of esophageal perforation?
Esophageal resection and exclusion.
34
Where should initial management of esophageal perforation patients take place?
In a surgical critical care unit for close monitoring.
35
What initial supportive measures are recommended for all patients with esophageal perforation?
Nil per os (NPO) intravenous fluid resuscitation broad-spectrum antibiotics with fungal coverage and intravenous analgesia
36
Why is a proton pump inhibitor (PPI) started in esophageal perforation management?
To reduce gastric acid and prevent further esophageal injury.
37
When might early total parenteral nutritional support be considered in esophageal perforation management?
If a prolonged course of treatment is expected
38
What are the criteria for nonoperative management of esophageal perforation?
-Early diagnosis -contained perforations or perforations draining back into the esophagus -no significant mediastinal contamination absence of sepsis or multiorgan failure -and no malignancy or obstruction of the esophagus.
39
What are the initial steps if a patient meets the criteria for nonoperative management?
Admission to the surgical critical care unit for 48 to 72 hours of observation if hemodynamically stable without sepsis or multiorgan failure
40
What supportive care is provided during nonoperative management of esophageal perforation?
-NPO -head of bed elevated -given 72 hours of broad-spectrum antibiotics -PPI -considered for parenteral nutrition if necessary.
41
When should repeat imaging be obtained for a patient under nonoperative management?
At 72 to 96 hours to assess for any signs of free perforation ( 3-4 Days )
42
What dietary change is allowed if repeat imaging shows no evidence of free perforation?
started on a liquid diet.
43
What symptoms indicate that a patient may no longer meet criteria for nonoperative management?
Development of fever, leukocytosis, tachypnea, tachycardia, or mental status changes.
44
What steps should be taken if a patient's condition deteriorates during nonoperative management?
Repeat imaging and possible endoscopy are indicated.
45
What endoscopic techniques can be used as an alternative to open surgical repair for esophageal perforation? Free Perf
Endoscopic covered stent placement or endoluminal clipping to seal the perforation
46
Why is video-assisted thoracoscopic surgery (VATS) often required following stent placement?
VATS is needed for debridement and drainage of mediastinal and pleural contamination, which the stent does not address
47
What drainage setup is typically left after a VATS procedure for esophageal perforation?
At least one chest tube in the pleural space and a Blake drain adjacent to the esophagus
48
When is a contrast esophagram typically performed after stent placement?
48 hours after stent placement to check for sealing of the esophageal perforation
49
What dietary progression is recommended if the esophagram shows no extravasation?
Start with a clear liquid diet and advance to full liquids
50
What should be done if there is extravasation of contrast around the stent or if drainage character changes after liquids are started?
The patient should return to NPO status, and a jejunostomy tube may be needed for feeding
51
What is the typical recommended duration for esophageal stent placement, and what factors influence this duration?
Between 4 and 6 weeks, depending on perforation size smaller perforations may heal within 10 days while larger defects may require up to 8 weeks.
52
What is the next step if the esophagram shows the perforation has not healed after stent removal?
The stent can be replaced for an additional 4 to 6 weeks to promote further healing.
53
What can be done if the stent does not completely cover the perforation on the first attempt?
The stent can be repositioned endoscopically or balloon dilation can be used for complete contact with the esophageal mucosa.
54
After Stent placement what do you do ?
Place NGT for Decompression
55
What imaging is recommended immediately after stent placement, and why?
An anteroposterior and lateral chest X-ray to establish a baseline of the stent location for future assessments.
56
When should a contrast esophagram be performed after stent placement, and what is its purpose?
At 48 hours post-placement to confirm proper positioning and check for contrast extravasation
57
What are common complications associated with esophageal stents?
Complications include migration, bleeding, erosion, and tissue overgrowth
58
Which is the most frequently reported complication of esophageal stents, and in what percentage of cases does it occur?
Migration, occurring in about 8% to 40% of cases
59
How do migration rates differ between metallic and plastic stents?
Migration rates are lower with metallic stents compared to plastic stents
60
What endoscopic techniques are used to secure stents and prevent migration?
Endoscopic suturing or clipping is used to secure stents with favorable results
61
When might endoscopic suturing or clips be used as a primary treatment in esophageal perforations?
For small early perforations especially when the defect size is 8 mm or smaller
62
What are the reported closure success rates for esophageal defects greater than 13 mm?
Higher failure rates are seen in lesions larger than 13 mm
63
What type of clips are used for defects less than 1 cm, and for larger lesions?
Through-the-scope clips for defects less than 1 cm and over-the-scope clip systems for larger lesions.
64
How can suction aid in the deployment of clips for esophageal defect repair?
Suction helps approximate the lesion edges, allowing for better clip placement.
65
How does the timing of perforation influence the success of an open repair?
Success diminishes after 24 hours from the perforation event, but successful repairs have been reported even beyond 24 hours
66
Why might endoscopy be performed in the operating room before open repair
To identify the precise location of the perforation, which guides the surgical approach
67
What is recommended for closure during open repair when feasible?
A two-layer closure, reinforced with a pedicled buttress
68
What type of closure may be necessary in cases of delayed esophageal perforation?
A single-layer closure may be the only feasible option in delayed cases.
69
Through which approach should perforations of the upper and middle thirds of the esophagus be accessed?
Right posterolateral thoracotomy via the fourth or fifth intercostal space
70
Up to what landmark is the intercostal muscle (ICM) freed, and why is this important?
Up to the lumbar-dorsal fascia; further dissection risks injury to the intercostal vessels
71
How is the esophageal mucosa closed after debridement of the perforation edges?
With running or interrupted absorbable sutures, typically 4-0 Vicryl or PDS.
72
What type of sutures are used to close the muscularis layer in esophageal repair?
Interrupted 3-0 silk sutures.
73
How is the ICM flap positioned and secured in esophageal perforation repair?
The pleural side of the ICM flap is placed in contact with the repair and secured with interrupted silk sutures to the esophageal muscle layer.
74
Where should perforations of the lower third of the esophagus be accessed surgically?
Through a left posterolateral thoracotomy in the seventh or eighth intercostal space
75
What alternative to an ICM flap may be used as a buttress in lower esophageal perforations?
A diaphragmatic flap can be used. A posteriorly based full-thickness flap is mobilized and secured with interrupted silk sutures to cover the repair, and the diaphragm is closed with nonabsorbable suture
76
What is the preferred method of exposure for cervical esophageal perforation?
A left-sided neck incision along the anterior border of the sternocleidomastoid muscle (SCM)
77
Which structure may need to be ligated for improved exposure during cervical esophageal perforation repair?
The middle thyroid vein.
78
How is exposure of the esophagus achieved in cervical esophageal perforation repair?
By retracting the trachea and thyroid gland medially.
79
Which space is entered to access the esophagus, and what is preserved during this approach?
The retroesophageal space is entered along the prevertebral fascia, with care to preserve the recurrent laryngeal nerve.
80
How should dissection proceed to ensure complete drainage in cervical esophageal perforation repair?
Blunt dissection should continue down to the posterior mediastinum to drain all fluid collections.
81
What is done if the perforation defect is identified?
The defect is repaired primarily, often buttressed with a strap muscle
82
What approach is taken if the esophageal defect cannot be clearly identified?
Closed drainage of the area is performed.
83
What surgical incision is typically used to access an abdominal esophageal perforation?
An upper midline incision.
84
What can be used to buttress the primary closure of an abdominal esophageal perforation?
Omentum or, more commonly, a fundoplication.
85
Why has the routine placement of gastrostomy and jejunostomy tubes become less common?
If the repair is successful, oral nutrition may start within a week, making feeding tubes unnecessary, especially if patients are on inotropic support and cannot spend extra time in the OR
86
What alternative to surgical feeding tubes can be used for early enteral feeding?
A Dobhoff tube can be placed under direct vision during repair and advanced post-pylorically for early enteral feeding
87
What role does a nasogastric tube (NGT) play in postoperative care after esophageal repair?
An NGT may be placed for gastric decompression if needed
88
When is an esophagram typically obtained after esophageal repair, and why?
At 5 to 7 days post-surgery to check for leaks.
89
What dietary progression is recommended if no leak is identified on the esophagram?
Start with liquids, advancing gradually to a soft diet
90
What is the next step if a persistent leak is identified after repair?
Stent placement may be attempted to seal the leak.
91
What is recommended if a leak persists despite stent placement?
Placement of a jejunostomy tube, as several weeks may be needed for healing
92
What factors are essential for healing a persistent esophageal perforation
Adequate mediastinal debridement appropriate antibiotic therapy good nutritional support.
93
What are the key indications for esophageal exclusion rather than preservation?
-Long perforations (>6 cm) not amenable to stenting -large areas of devitalized esophagus due to delayed diagnosis -or large perforated cancers unsuitable for stenting.
94
What alternative option is available in stable patients with large esophageal defects?
Stenting with coverage of the defect using biodegradable mesh and a muscle flap (e.g., serratus anterior or latissimus dorsi).
95
Why is esophageal exclusion preferred over resection and immediate reconstruction in high-risk patients?
The risk of anastomotic failure is very high in hemodynamically unstable patients or those with significant mediastinal contamination
96
What approach is taken to mobilize the esophagus during esophageal exclusion?
The esophagus is mobilized as much as possible in the chest and divided near the gastroesophageal junction with a 45-mm stapler
97
Where is the neck incision made for cervical mobilization of the esophagus in exclusion procedures?
Along the anterior border of the sternocleidomastoid muscle (SCM) on the left side.
98
What should be avoided when dissecting the esophagus circumferentially during exclusion?
Injury to the recurrent laryngeal and vagus nerves.
99
What is done with the esophagus after transection in an exclusion procedure?
It is tunneled subcutaneously onto the left chest, and an end esophagostomy is created.
100
What additional steps are taken for feeding access in esophageal exclusion?
A jejunostomy tube is placed for nutritional support
101
What precaution should be taken if a gastrostomy tube is placed during esophageal exclusion?
Ensure that the stomach remains viable for potential use as a conduit in future reconstruction
102
What is the preferred initial management when esophageal perforation involves a malignancy with adequate drainage?
Placement of an esophageal stent to control contamination with resection and anastomosis reserved for later
103
What should be done if a patient with esophageal perforation and malignancy presents with massive contamination and hemodynamic instability?
Consider resection, cervical esophagostomy, and placement of a tube and gastrostomy.
104
Why is immediate resection often avoided in cases of malignant esophageal perforation with adequate drainage?
To control contamination initially and reserve more invasive procedures for a stable, later stage
105
What events can lead to esophageal perforation in patients with achalasia?
Pneumatic dilation, myotomy, or other mechanisms related to elevated intraluminal pressure
106
Why is healing of esophageal perforation challenging in achalasia patients?
Due to elevated intraluminal pressure proximal to the esophageal sphincter
107
What procedure is required for achalasia patients following esophageal perforation repair to facilitate healing?
Myotomy to reduce intraluminal pressure and support healing On the opposite side of the esophagus from the perforation

A1-G Surg Note Esophagus (15 decks)

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