Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (30 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Early surgical intervention should be seriously considered if patients have profound sepsis upon admission, if adequate chest drainage cannot be achieved, or when clinical deterioration is observed after a period of aggressive non-operative management. In addition to thorough drainage of the mediastinum and the pleural space, three surgical manoeuvres for control of leakage may be applied:
Isolation and diversion (cervical oesophagostomy) followed by delayed staged reconstruction.
Primary repair of the perforation, with or without reinforcement and insertion of a T-tube, and external drainage.
Immediate oesophagectomy.
The technique of oesophageal exclusion and diversion was described several decades ago. It involves division and closure of the oesophagus proximal and distal to the site of injury, with creation of an end-cervical oesophagostomy. Subsequently it has evolved to a side cervical oesophagostomy for proximal diversion of saliva and a staple transection of the oesophagogastric junction to prevent reflux of gastroduodenal contents back into the oesophageal lumen. Nevertheless, such an incomplete diversion often ends up with continuous soiling in the mediastinum, leading to persistent thoracic sepsis. With time, it proves to be a suboptimal treatment and is now reserved mainly for patients who are too unstable to undergo definitive repair or resection.
Primary repair is an appropriate option for perforations occurring less than 24 hours after the injury, because surrounding tissues are neither excessively inflamed nor ischaemic. As the laceration on the mucosal side can be much longer/wider than is appreciated from the adventitial surface, a cautious longitudinal extension of the muscular defect is often required for better assessment of the extent of the mucosal injury. Following careful debridement of the necrotic tissues along the perimeter of the perforation, the edges are then closed with interrupted absorbable sutures (
Fig. 6.9
). It may be possible, in very early perforations with very healthy tissue, to close the defect wound in two layers: first the mucosa/submucosal layer, followed by the muscular layer. However, in the majority of circumstances a single all-layer suture is adequate. Enrolment of reinforcing autogenous vascular pedicle flap remains controversial.
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Most advocates of reinforcement flaps suggest an onlay patch rather than a wrap, to minimise the possibility of stricture at the repair site. A major concern with the wrap technique is the induction of an obstructive component distal to the repair site, rendering it more prone to leakage.
Figure 6.9
Primary repair with interrupted absorbable stitches for a lower oesophageal rupture.
Though technically feasible, primary repair is associated with a high failure rate and many surgeons now advocate insertion of a T-tube into the perforation, which is closed around it (after debridement), producing a controlled fistula. This can be removed at a later date, often many weeks/months later, once the patient has recovered and the surrounding leakage (managed by appropriately placed chest drains) has subsided.
Several series have pointed out that primary repair resulted in greater morbidity and even mortality than immediate oesophageal resection.
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However, this may well relate to the underlying cause of perforation and whether the cause remains.
In a series of 41 patients, of whom 25 patients underwent surgical repair of oesophageal perforation, about one-third had continued swallowing difficulty that mandated regular oesophageal dilation after an average of 3.7 years.
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A high incidence of functional or structural deficiency was observed after primary repair of oesophageal perforation, which indeed affected the quality of life of the patients.
Oesophagectomy is therefore a reasonable option (if the surgeon is experienced in this procedure) in patients with underlying disease (including carcinoma, if the lesion was considered operable before the perforation occurred) and if the diagnosis has been made early and the patient is in a good condition. Occasionally it may also be required in patients presenting late, in whom simple closure over a T-tube is not possible. This scenario is, however, very uncommon. (The reader is referred to the
Oesophagogastric Surgery
volume in this Companion to Specialist Surgical Practice series for more detailed information.)
Primary repair with or without T-tube drainage is the best option for the management of oesophageal perforations depending on time from occurrence to diagnosis. Patients with an underlying condition related to the perforation, in whom the diagnosis has been made early (< 24 hours) and who are in a good condition, can be considered for resection if the appropriate surgical expertise is available.
Corrosive injury to the upper gastrointestinal tract is an entity very different from other mechanical types of oesophageal perforation. It is a notoriously difficult situation associated with dreadful rates of morbidity and mortality. While more than 80% of accidental corrosive ingestion occurs in children, injuries in adults are usually intentional, and thus more severe in extent.
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The mortality rate ranges from 10% to 78% in cases of attempted suicide.
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The severity of damage depends on the type, concentration, volume and duration of contact of the agent with the mucosal surface. Making a distinction between acid and alkali as to the extent and severity of oesophagogastric damage has been elusive. It is well known that acid induces a coagulating burn injury, which tends to be self-limiting with the coagulum formation. In contrast, alkali causes a liquefactive necrosis to the tissue, leading to dissolution of protein and collagen, saponification of fats, and thrombosis of blood vessels. All these incur a deeper damage and even transmural perforation.
The acute management of corrosive ingestion entails a quick and efficient assessment of the patient's vital signs. Laryngeal oedema can be life threatening and establishing a patent airway is of paramount importance. Either an early endotracheal intubation or tracheostomy may be required in difficult cases before further resuscitation and management. It is generally agreed that early gentle endoscopic examination is of value for both prognostic consideration and decision-making.
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Surgical intervention, such as thoracotomy, drainage, mediastinal debridement, proximal diversion of saliva with a cervical oesophagostomy and exclusion from gastric reflux, are better performed early if signs of full-thickness perforation are evident on radiological or endoscopic investigations. Reconstruction should be deferred until sepsis has subsided. More often than not, reconstruction is done by fashioning a jejunal or colonic interposition loop through an extra-anatomical plane (e.g. the substernal or presternal routes).
Since its introduction in the 1980s, endoscopic mucosal resection (EMR) has been increasingly practised for upper gastrointestinal lesions identified at early stages.
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With the snaring technique, en bloc resection used to be a challenging task as the average size of lesion removed is limited (< 15 mm in diameter).
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The recent development of new endoscopic accessories, such as the insulated-tip knife and hook knife, has opened a new horizon for such purposes.
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The novel endoluminal procedure, endoscopic submucosal dissection (ESD), has virtually no limitation on the size of resection, provided that the lesion is superficial with a low chance of nodal spread.
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However, ESD is a technically demanding procedure with a significantly higher risk of perforation compared with conventional EMR.
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As most ESD-induced perforations can be recognised intraoperatively, attempts to close the defect by various techniques have been reported.
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Fujishiro et al. described a 100% success rate of closing ESD perforations using endoscopic clips.
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The average duration of hospital stay was only 12 days and none of the 27 patients in the series required surgical salvage. More importantly, as reported in an intermediate-term follow-up study by Ikehara et al., perforation during ESD for early oesophageal and gastric cancers has not been associated with increased risk of dissemination of the malignancy.
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Visceral perforations due to ERCP are not uncommon, with an incidence reported to range between 0.5% and 2.1%.
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The injury carries a death rate over 15%. Risk factors include older age of patients, suspected sphincter of Oddi dysfunction, a dilated duct, performance of sphincterotomy and longer duration of the procedure.
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ERCP-related perforation can be further subclassified according to the causative mechanism and location because management strategy may vary accordingly. Stapfer et al. first described a typing system in 2000 to guide the treatment for the situation (type I: duodenal wall injury; type II: peri-Vaterian injury related to sphincterotomy; type III: distal bile duct injury probably related to guidewire or basket injury; and type IV: retroperitoneal air alone).
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While perforation of the oesophagus and stomach due to insertion of the side-view duodenoscope can be managed as discussed in the previous sections, type I injury with lateral or medial duodenal wall tear is often related to difficult positioning of the endoscope in the attempt to obtain access to the papilla. Vulnerability further increases if there is anatomical deformity such as a stricture or tumour compression. This kind of perforation tends to be intraperitoneal, which is unlikely to be self-contained, and early surgical repair with debridement of devitalised tissue is recommended. Small perforations less than 1 cm in diameter can be closed primarily with transverse sutures in one or two layers. For perforations of a larger size, or when the diagnosis has been delayed, jejunal serosal patch, duodenal diversion or conversion to a Billroth II gastrectomy are alternative options, but to some extent the choice depends mainly on the patient's clinical condition and intraoperative findings.
Another prominent risk factor for ‘scope’ perforation is a history of previous Billroth II gastrectomy, because retrograde insertion of the endoscope along the afferent loop may overstretch and rupture the jejunum around the relatively fixed duodenojejunal flexure. The reported incidence under such circumstances can be as high as 10% even in expert centres and early surgical repair is usually necessary.
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In contrast, perforations resulting from endoscopic sphincterotomy (type II) or guidewire/basket (type III) are mostly retroperitoneal with a small size of leakage and therefore more amenable to non-operative therapy. Although some perforations can be identified at the time of the ERCP, many are not suspected until after the procedure. Clearly, early suspicion is raised by the presence of abdominal pain post-procedure, but the observation of a paraduodenal or perinephric gas shadow on plain abdominal radiographs is suggestive of retroperitoneal perforation. In such cases, and even if the plain X-rays are unremarkable, a CT scan of the abdomen with oral and intravenous contrast should be organised to confirm the diagnosis and extent of the perforation. Small perforations with minimal extravasation of contrast can be successfully managed by non-operative means, including nasogastric drainage, antibiotics and parenteral nutrition. Some surgeons also advocate biliary decompression by either an internal plastic stent or external nasobiliary drain. Radiologically guided percutaneous drainage is indicated if a sizeable collection is shown by the initial imaging. However, surgical intervention should be offered to patients with extensive extravasation of contrast or clinical deterioration despite initial non-operative treatment. This can be a formidable undertaking and is associated with significant morbidity and mortality. Thankfully they are relatively rare, but when they occur each patient will need to be managed according to first principles: debridement of ischaemic and damaged tissue, primary repair of the defect if possible, diversion of biliary contents (by means of a T-tube) and consideration given to duodenal exclusion (closure of pylorus and gastrojejunostomy). In such circumstances a feeding jejunostomy should also be inserted for long-term nutritional support.
It has been shown in various series that one of the key prerequisites for successful non-operative management of ERCP perforations is the early recognition and diagnosis of the situation.
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Key points
Perforations of the upper gastrointestinal tract are either spontaneous or iatrogenic.
Early surgery is generally required for the majority of perforations as delay in diagnosis and treatment is associated with increased morbidity and mortality.
For perforated duodenal ulcers omental patch repair followed by postoperative therapy with proton-pump inhibitors and eradication of
Helicobacter pylori
, if present, is the treatment of choice.
For perforated gastric ulcers, either ulcer excision (if feasible) or omental patch repair and biopsy of the ulcer is all that is required. Gastric resection should not be carried out without histology unless closure cannot be achieved using these other techniques.
Management of oesophageal perforations depends largely on whether the pleura has been breached. It can be a challenging condition and surgical strategies will depend on the expertise available. These include non-operative management, stent insertion (both permanent and removable), repair (with or without T-tube drainage) and occasionally oesophageal resection.
Early endoscopy is a very useful technique to assess many oesophageal emergencies including corrosive injury.
ERCP perforations vary from simple to extensive and management depends on early diagnosis and accurate assessment as to the degree of extravasation.