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Morning Meeting

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Dysphagia Chest hypersonarity/dullness. Dyspnea Cardiac crunch. TREATMENT ... Esophageal exclusion, T-tube drainage, and esophageal resection. ... – PowerPoint PPT presentation

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Title: Morning Meeting


1
Morning Meeting
  • Department of Thoracic cardiovascular

2
PERFORATION OF THE ESOPHAGUS
3
ETIOLOGY
  • Iatrogenic Perforations
  • Spontaneous Perforations
  • Trauma to the Esophagus
  • Esophageal Disease

4
Iatrogenic Perforations
  • Endoscopy and of endoscopic manipulation are the
    most cause of esophageal perforations about
    0.4-1
  • ?Pharyngoesophageal junction ? C6-7
  • Stricture dilatation is 2nd most cause
  • Others Neck surgery and procedures

5
Spontaneous Perforations
  • Boerhaave's syndrome
  • ?esophageal rupture induced by vomiting,
    Childbirth, defecation, lifting heavy objects,
  • ?any acute rise in intra-abdominal pressure
    against a closed glottis
  • Left lateral wall, Lower third above the diaphragm

6
Trauma to the Esophagus
  • Penetrating or blunt trauma
  • Foreign bodies
  • Self-induced esophageal lesions by alkali or acid
    may cause extensive necrosis and esophageal
    destruction.

7
Esophageal Disease
  • Gastroesophageal reflux disease
  • Candidal, herpetic, and human immunodeficiency
    infections also cause pathologic perforations.
  • Invasion and destruction of the esophageal wall
    by carcinoma
  • Mallory-Weiss syndrome but rare

8
CLINICAL PRESENTATION
  • Symptoms Signs
  • Vomiting Tachycardia
  • Pain Fever
  • Hematemesis Subcutaneous emphysema
  • Dysphagia Chest hypersonarity/dullness
  • Dyspnea Cardiac crunch

9
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10
TREATMENT
  • Derbes and Mitchell 13 and Blichert-Toft 10 show
    a 60 to 100 mortality when conservative
    management or no treatment is offered
  • Surgical treatment remains the mainstay of
    management in esophageal perforation.

11
  • An early operative repair provides the best
    chances of survival. Sepsis, shock, pneumothorax,
    pneumoperitoneum, mediastinal emphysema, and
    respiratory failure are all absolute indications
    to intervene rapidly

12
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13
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14
Non-operative management
  • NPO, broad antibiotics, NG tube decompression,
    Fluid supply
  • The criteria set by Cameron and colleagues
  • a well-contained leak in a stable patient
    without evidence of sepsis and without
    communication with the pleural or peritoneal
    cavity suggests a patient who has already
    defended himself against the perforation.

15
Perforation with Early Diagnosis
  • Primary repair of the perforation is the first
    choice of therapy
  • The goals of the operation include extensive
    debridement of all nonviable tissue in the
    mediastinum and around the esophagus.
  • Edema and necrotic tissue may be extensive even
    if the esophageal damage is recent.

16
Perforation with Late Diagnosis
  • Esophageal exclusion, T-tube drainage, and
    esophageal resection.
  • Resection must be considered with cervical
    esophagostomy, jejunostomy, and gastric
    decompression

17
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18
CORROSIVE STRICTURES OF THE ESOPHAGUS
19
ETIOLOGY
  • Alkaline caustics, acid or acidlike
    corrosives, and household bleaches. Hydrochloric,
    sulfuric, nitric, and phosphoric acids are
    contained in automobile battery acids.

20
Age
  • 75 of injuries involving children younger than 5
    years and a much lower, secondary peak occurring
    in 20-30

21
  • The severity of esophageal and gastric damage
    resulting from a caustic ingestion depends on
  • Corrosive properties
  • Concentration of the agent
  • Quantity swallowed

22
Pathophysiology
  • Alkalis bite the esophagus and lick the stomach
  • Acids Lick the esophagus and bite the stomach

23
Alkali
  • Liquefactive Necrosis
  • Vascular thrombosis
  • Cell membrances are destroyed as their lipids are
    saponified and cellular proteins are denatured
  • Destroy the protein, may persist for 7 days

24
Acid
  • Coagulation Necrosis
  • Clumping and opacification of the cellular
    cytoplasm

25
The goals of emergency management
  • Limit and treat the immediately life-threatening
    consequences
  • Control subsequent stricture formation

26
Emergency management
  • Keep airway
  • The epiglottis or vocal cords are edematous
  • ? endothracheal intubation is contraindication
  • Trachostomy

27
Contraindication
  • The use of emetics
  • Not OG or NG
  • Neutralization
  • Alkali may try Milk
  • Acid not try anything

28
  • Surgery is warranted if evidence
  • Perforation of the esophagus or stomach,
  • Mediastinitis
  • Peritonitis exists.

29
Corrosive stricture
  • Esophagus is stricture formation, which usually
    develops between 3 and 8 weeks after the initial
    injury but sometimes requires a much longer
    period for evolution

30
Treatment
  • Corticosteroids to modify the inflammatory
    response to the burn injury
  • Antibiotics to control secondary bacterial
    infection
  • Esophagoscopy within 12-24 hrs
  • On NG tube when severe burn
  • CXR, endoscopy, Barium swallow

31
  • Bougienage
  • Esophageal stents
  • Colon interposition
  • Forearm tube
  • Free jejunal flap

32
Thanks!!
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