23/9/10. a 50 years old male was transferred from other hospital. one day before referal, he was...
TRANSCRIPT
![Page 1: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/1.jpg)
Ruptured esophagus after resection of thoraco abdominal aorta aneurysm23/9/10
![Page 2: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/2.jpg)
Case presentation• A 50 years old male was transferred from other
hospital.• One day before referal, he was admitted to that
hospital because of severe epigastric pain, the doctor suspected peptic perforation. Exploratory laparotomy was done and found retroperitoneal hematoma in upper part of abdoment. The wound was closed and the patient was transferred.
![Page 3: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/3.jpg)
• CT angiogram was done after surgery, it showed large thoraco abdominal aortic aneurysm – Crawford type 5
• CAG was done, it was normal.
![Page 4: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/4.jpg)
Chest X ray admission day
![Page 5: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/5.jpg)
• Left thoracotomy incision was made through 6th intercostal space. The aneurysm extended from mid thoracic to just above celiac artery. The maximal diameter was 10 cm.
• Hematoma surrounded the aneurysm.• Left femoral vein was exposed but cannula could not be
passed into right atrium. So, the aorta was cross clamped just above the aneurysm. It was opened, clots evacuated, and transected above celiac artery.
• A 22 mm dacron graft was anastomosed to distal aorta first , and proximal anastomosis was completed. Aortic clamps were released. The operation and his post operative course was uneventful. Until post operative day 14, he complained of dysphagia and vomitting. He was febrile and chilled.
![Page 6: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/6.jpg)
![Page 7: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/7.jpg)
• Chest CT scan showed presence of air in aneurysmal sac surrounding the graft
• Emergency left thoracotomy was done.• A large amount of pus and food particles
surrounding the graft.• Longituidinal necrosis of lower esophagus about 2
cm long.
![Page 8: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/8.jpg)
![Page 9: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/9.jpg)
![Page 10: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/10.jpg)
• Esophagectomy was done with closure of cardia.• Debridement and excision of aneurysmal wall and
cleansing of graft.• Open diaphragm and mobilize omental flap.• Cover the graft with omental flap. • Gastrostomy, feeding jejunostomy and cervical
esphagectomy were done.
![Page 11: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/11.jpg)
culture
• Aortic wall Streptococcal fecalis
• Pus Steptococcus fecalis Yeast cell lactobacilli.
![Page 12: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/12.jpg)
CT scan after chest re thoracotomy
![Page 13: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/13.jpg)
![Page 14: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/14.jpg)
![Page 15: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/15.jpg)
![Page 16: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/16.jpg)
Postoperative course after rethoracotomy • Clinically well, he became afebrile and he tolerated
jejunostomy feeding fairly.• Two weeks later reopened midline laparotomy was done,
while mobilizing the cardia, there was pus from the aneurysmal sac, the omental flap covered the graft well and no necrotic tissue, the space was cleaned and irrgated.
• A redivac drain was left in the aneurysmal sac and the abdomen was closed
• Post operatively he was well, tolerated jejunostomy feeding, two weeks later the redivac drain was removed and IV antibiotic continued for total two months.
• He was discharged to the referring hospital.
![Page 17: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/17.jpg)
CT after re laparotomy
![Page 18: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/18.jpg)
![Page 19: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/19.jpg)
Near complete disappearance of perigraft fluid before esophageal bypass
![Page 20: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/20.jpg)
![Page 21: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/21.jpg)
2nd admission• 3 months after previous admission, he was well
and wanted to drink and eat by mouth.• Repeated CT chest showed small about of fluid in
the aneurysmal sac, much smaller than before.• Right thoracotomy was done and total thoracic
esophagectomy was done• One week later, the abdomen was reopened, left
side colon was mobilized preserving left colic vessel and the colon was pulled up via retrosternal space and anastomosed to cervical esophagus. Cologastrostomy, colo-colostomy were done.
![Page 22: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/22.jpg)
• There was superficial abdominal wound infection. • His post operative course was uneventful
otherwise.• Oral diet was resumed on 8th post operative day
after contrast study showed no leakage no obstruction.
![Page 23: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/23.jpg)
discussion• Esophageal necrosis after surgery of descending
thoracic aortic aneurysm is not rare.• Mechanisms ruptured aneurysm caused pressure on the esophagus surgery excluded aortic branches to esophagus, ischemic necrosis
![Page 24: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/24.jpg)
• Prognosis is almost always fatal due to sepsis, mediastinitis prosthetic graft infection extra anatomical bypass – difficult or impossible infection involving suture lines – aortic anastomotic dehiscence -> fatal hemorrhage
![Page 25: 23/9/10. A 50 years old male was transferred from other hospital. One day before referal, he was admitted to that hospital because of severe epigastric](https://reader035.vdocuments.site/reader035/viewer/2022062620/5519c9b955034649768b463c/html5/thumbnails/25.jpg)
• Omental graft bactericidal blood supply and white blood cell to combat bacteria cover the prosthetic graft is an important strategy to combat graft infection filling the space surrounding the graft prevent reinfection