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Esofago: quando e quali traumi restano da operare

Esofago: quando e quali traumi restano da operare. G. Zaninotto UOC Chirurgia Generale Ospedale S. Giovanni e Paolo Ulss 12 – Venezia- Università di Padova. Esophageal Perforations: Etiology. ( 1977). Spontaneous perforations. 2. 21. 24. Surgery. Operative Endoscopy.

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Esofago: quando e quali traumi restano da operare

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  1. Esofago: quando e quali traumi restano da operare G. Zaninotto UOC Chirurgia Generale Ospedale S. Giovanni e Paolo Ulss 12 – Venezia- Università di Padova

  2. Esophageal Perforations: Etiology ( 1977)

  3. Spontaneous perforations 2 21 24 Surgery Operative Endoscopy Iatrogenic perforations Esophageal Perforations: Etiology 1992-2003: 46 pts Clin Chir PD 2003

  4. Esophageal Perforations: Etiology 2002-2009 382 pts (Survey of Medical Literature) Spontaneous perforations Other 14 87 28 253 Trauma Iatrogenic perforations

  5. 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)

  6. Esophageal perforation Early diagnosis and survival * p < 0.05 Clin Chir PD 2003

  7. Esophageal Perforation: Influence of Site & Diagnostic Delay on Mortality Site Immediate & Early Late (>24 h) Muir AD, Europ J Cardio-Thorac Surg 2003

  8. Effect of Diagnostic Delay 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 • Propionibacterium SPP • Acinetobacter Baumanii • Candida albicans • Citrobacter SPP, • Klebsiella P • Enterococco faecium • Staphylococcus • Pseudomonas A. • Bacterioides

  9. 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

  10. Esophageal Perforation: Principle of Management • Rapid closure of the esophageal leak • Drainage of mediastinal or pleural collection • Broad spectrum antibiotics • Nutrition (parenteral & enteral)

  11. Main symptoms of perforation • Pain 95 % • Fever 80 % • Dysphagia 70 % • Rx signs 50 % • Emphysema 35 % First lesson: Believe the Patient !

  12. Esophageal Perforations: What we need to know? • 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? from Kiss, Br J Surg 2008, mod.

  13. Esophageal perforations: diagnostic tests • Chest Radiogram • Gastrographin swallow • CT scan • (Endoscopy)

  14. Esophageal perforation: Chest X–ray is enough! L.V. 63 yrs: esophageal cancer with liver metastasis 02/01/2001: stent 12/01/2001: esophageal perforation

  15. Gastrographin swallow: Locate the leakage from the cervical perforation down into the mediastinum.

  16. Esophageal Perforations: Diagnosis Johann Wolfgang von Goehte 1749 - 1832 Man sieht was man weiss

  17. Laparoscopic Heller Myotomy 1° post-op day (Saturday) Gastrographin swallow

  18. on Monday……

  19. ….the CT scan confirmed that the leak was communicating with the pleura…

  20. Management of Esophageal Perforations 1. • Non-operative treatment (NG Tube, parenteral nutrition, antibiotics) • Drainage only • Esophageal Stenting • Endoclip application Wu JT, J Trauma, 2007

  21. ….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….

  22. Cervical esophagus perforations: Drainage

  23. Esophageal Perforations afterPneumatic Dilations

  24. Esophageal Perforations after PD:a. Conservative treatment Gastrographin swallow a. Confined leakage b. Leakage diffused a. Confined leakage

  25. Esophageal Perforation: Stenting Minimal soiling; • Site of perforation (avoid the UES) • Type of stent: avoid metallic stent in benign disease

  26. Esophageal perforation: closure with endoclip Chronic Fistula Qadder MA Gastorintest Endoscopy, 2007

  27. Management of Esophageal Perforations Management of Esophageal Perforations 2. • 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 Wu JT, J Trauma, 2007

  28. Primary Closure after Necrosectomy (viable wound edges) Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed.

  29. Primary Closure Reinforced with Gastric Patch (Thal operation) Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed.

  30. Primary Closure and Buttressing with Diaphragmatic Flap Richardson JD Am J Surg 2005

  31. Management of Esophageal Perforations 3. • Esophagectomy • Immediate reconstruction • Delayed reconstruction • T-tube Drainage • Exclusion and Diversion Wu JT, J Trauma, 2007

  32. Management of Esophageal Perforations: Esophagectomy

  33. Management of Esophageal Perforation: Drainage and T tube Ancona et al, Perforazioni e fistole esofagee 1977, Piccin ed

  34. Management of Esophageal PerforationsBipolar Exclusion of the Esophagus Ancona et al, le perforazioni esofagee 1977, Piccin ed

  35. The Role of lateral esophagostomy Ann Thorac Surg 2003 Ancona et al, le perforazioni esofagee 1977, Piccin ed

  36. Mid to distal esophagus Minimal to no Mediastinal Soiling Mediastinal Soiling Drain Operate Antibiotics Management of Esophageal Perforations Esophageal Perforation Cervical – Upper esophagus (close to UES) Drain Operate Antibiotics Esophageal Stent

  37. 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

  38. Grazie per l’attenzione

  39. TABLE 1. Etiology and Location of Esophageal Perforations

  40. Endoscopic Pneumatic Dilation for Achalasia To be effective the dilation must tear the esophageal muscle wall: this depends on balloon size, pressure and duration

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