FRCA Notes

Oesophageal Injuries

This page may be outside the purview of the examination as oesophageal injuries or Boerhaave's syndrome aren't explicitly mentioned in the curriculum.

Resources

  • Oesophageal injuries are associated with high morbidity and mortality

Iatrogenic (60%)

  • From diagnostic or therapeutic endoscopic procedures
  • Increased risk if:
    • Underlying oesophageal pathology
    • Long or complex interventions
    • Existing systemic disease
  • Typically at level of cricopharyngeus or just proximal LOS
  • Intra-operative trauma

Spontaneous (15%)

  • Boerhaave's syndrome; mortality up to 75% even if treated rapidly
  • Deceleration injury

Traumatic

  • Foreign body ingestion e.g. dentures, animal bones
  • Penetrating or blunt thoracic trauma

Other

  • Secondary to oesophageal malignancy

  • Following rupture there is passage of food, gastric secretions/acid and air into the mediastinum
  • Contamination of the mediastinum leads to:
    • Emphysema
    • Inflammation i.e. mediastinitis
    • Necrosis

  • There may be perforation into the overlying pleura
    • Here, the negative intrathoracic pressure during respiration draws oesophageal contents into the pleura
    • This manifests more frequently on the left hand side owing to the proximity of the oesophagus to the left pleura
    • Pneumothorax and pleural effusions ensue
    • Lung abscesses can occur

Symptoms

  • Dysphonia or hoarseness (cervical rupture)
  • Dysphagia
  • Vomiting
  • Pain (67%)
    • The more common cervical oesophageal perforations cause anterior neck pain which is exacerbated by movement and palpation
    • Retrosternal chest or epigastric abdominal pain with lower ruptures
    • There may be pleuritic pain too
  • Dyspnoea (39%)

Signs

  • Surgical emphysema (69%)
    • Neck
    • Chest
    • Mackler's triad = vomiting, thoracic chest pain and subcutaneous emphysema

  • Percussion
    • Resonant due to pneumothorax
    • Dull due to atelectasis, consolidation or pleural effusion

  • Auscultation
    • Reduced air entry due to atelectasis, consolidation or pleural effusion
    • 'Hamman crunch' - cracking sound of pneumomediastinum with each heartbeat

  • Fever (33%)
  • SIRS-type response (82%) including fever, tachypnoea and tachycardia
  • Other features of sepsis develop hours of perforation, rapidly progressing to septic shock and multi-organ failure

  • Bloods: acute inflammatory process

Chest X-ray

  • May be normal (15%)
  • Cervical or thoracic surgical emphysema
  • Pleural effusion (typically left-sided)
  • Atelectasis
  • Pneumothorax
  • Pneumomediastinum

CT chest/adomen with contrast

  • Surgical emphysema
  • Pneumo-mediastinum / -peritoneum / -thorax / -pericardium
  • Peri-oesophageal air
  • Oesophageal wall discontinuity
  • Pleural effusion (typically left-sided)
  • Lung abscess

Other

  • Gastrograffin contrast study may demonstrate contrast leak and has a high sensitivity

  • Tap or drain pleural effusion; if contains gastric content should have:
    • pH<6
    • Elevated amylase level
    • ± food particulate matter

  • Prompt identification and management is imperative for reducing otherwise high morbidity and mortality

Immediate

  • Treat infection and prevent septic contamination
    • Broad-spectrum prophylactic antibiotics with cover against aerobic Gram-negatives and anaerobes
    • E.g. cephalosporin + metronidazole, cephalosporin + clindamycin, tazocin, carbapenem
    • Some argue in favour of additional anti-fungals due to oesophageal colonisation by Candida

  • Treat critical illness with individualised resuscitation with IV fluid therapy ± use of vasoactive drugs

Conservative

  • May be appropriate if there is limited injury and contained leakage, or in the case of inoperable malignancy
  • Management involves nutritional support and restoration of GI continuity:
  • Allows the acute inflammatory process to settle and surgical options to be employed at a later date

Minimally invasive

  • Endoscopic endoluminal stent placement under sedation
    • Prevents further contamination
    • Permits early resumption of oral nutrition
  • Stent typically removed 12 weeks later once the defect has healed
  • Most appropriate for:
    • Small or incomplete tears not associated with sepsis
    • Malignancy-associated ruptures

Surgical

  • Primary repair is considered the gold standard operative approach
  • Provides optimal visualisation of perforation and assessment of surrounding tissue damage

  • Incisions may be:
    • Cervical for cervical perforations
    • Left- or right-sided thoracoscopy/thoracotomy for mid-thoracic perforations
    • Abdominal laparoscopy/laparotomy for intra-abdominal perforations
  • Repair usually involves debridement of non-viable tissue, lavage and then support of the repair with a buttressing, vascularised pedicle flap

  • Other options include:
    • Exclusion and oesophageal diversion e.g. with a T-tube to allow healing without contamination
    • Delayed resection and reconstruction (i.e. oesophagectomy)
    • Drainage ± decortication of pleural effusion

Perioperative management of the child undergoing pyloromyotomy for pyloric stenosis


Monitoring and access

  • AAGBI
  • A-line ± pulse-contour analysis CO monitoring
  • CVC
  • Urinary catheter
  • Temperature probe (not oesophageal!)

Anaesthetic technique

  • Often in septic shock ± multi-organ failure so a 'cardiac stable' induction may be necessary
  • High aspiration risk so an RSI technique is indicated
  • Avoid positive pressure or bask-mask ventilation until intubated as positive pressure can exacerbate pneumomediastinum ± cause tamponade
  • Typically DLT or single lumen tube + endobronchial blocker

NG tube

  • Inserted into the proximal oesophagus by the anaesthetist
  • Surgeon then manipulates it to a site beyond the repaired oesophagus, ensuring the stomach remains decompressed
  • Is not used for feeding; feeding jejunostomy is formed instead

Fluid therapy

  • Individualised goal-directed fluid therapy
  • Balance between:
    • Avoiding excessive fluid which can exacerbate lung injury
    • Administering enough fluid to avoid hypovolaemia, hypoperfusion and AKI

Analgesia

  • Thoracic epidural although may be relatively indicated if floridly septic
  • Paravertebral blocks/catheters or wound infusion catheters
  • Opioids e.g. intra-operative remifentanil TCI followed by morphine boluses

  • Often managed in an ICU setting
  • Ongoing analgesia e.g. morphine PCA, local anaesthetic infusions
  • Continued goal-directed fluid therapy
  • Early extubation
  • Enteral nutrition via jejnuostomy
  • Early mobilisation