CASE PRESENTATION

CASE PRESENTATIONSurgical Unit 1CASE 1

DR. SAJID MAHMOODName: Najma Shaheen W/O AsifAge: 30 YearsSex: FemaleOccupation: House WifeAddress: Dhok Farman Ali Rwp.DOA: 26-12-14MOA: Referred from MU IIPresenting ComplaintsHistory of corrosive intake .5 months back.

Difficulty in swallowing..5 monthsHistory of presenting complaintsMy patient had argument with her husband 5 months back following which she intentionally ingested acid

Amount and nature of which is not known

She had severe burning sensation in epigastrium and was brought to hospital

Initial management was done. Later after 2 weeks she started having difficulty in swallowing for semi solids and solid food.

Symptoms worsened over the next 02 months

She was able to swallow her saliva and tolerate liquids.

No history of vomiting.

No H/O odynophagia, retrosternal burning pain, dyspepsia , acid or water brash.

No H/O cough, choking sensation or chest pain.

No H/O anorexia , she gives history of weight loss She underwent endoscopy 6 weeks after corrosive intake and lower esophageal stricture was noted, dilatation was done

Symptoms were relieved temporarily.

Later she had multiple sessions(10 times) of upper GI endoscopies and dilatation of esophageal stricture was attempted.

However her last endoscopic dilatation was not successful.

Her last endoscopy, done on 20th December 2014 ,shows : Tight stricture 30 cm from incisors

Dilatation was not possible beyond 9 fr for the 4th consecutive time.

She was referred to surgical department for definitive surgical management

Past medical history

No H/O D.M., T.B., I.H.D., H.T.N., Asthma.No past history of hospital admission.No past history of any psychiatric illness.

Past surgical historyHistory of C section 9 years back

Family history No family history of psychiatric illnessNo family history of DM , HTN , TB, any malignancy

Personal historyNon smokerNon addictNormal sleep habits

Drug history No H/O any drug allergy.

Obstetric history3 sons and 1 daughterAge of eldest child is 13 yearsAge of youngest child is 7 years

Socio economic statusBelongs to middle class family

General physical examinationA young lady of average built, lying comfortably on the bed with i/v cannula on left forearm , well oriented in time place and person. Pulse=78/minBP=100/60Temp=A/FR/R=14/minPallor absent Body weight : 48 kg Jaundice absent Height : 156cmCyanosis absent BMI=19.7 kg/m2Clubbing absent Koilonychia absent Pedal edema absent JVP not raised Skin - normalThyroid not enlargedNo lymph nodes palpable

Systemic examinationGASTROINTESTINAL SYSTEM

Oral mucosa, teeth, gums ,tongue and palate =normal

Scaphoid abdomen, moving with respiration, umbilicus central & inverted, no visible swelling, scar mark or veins.

Soft, non-tender abdomen with no mass or viscera palpable and hernial orifices intact.

Percussion note resonant . Bowel sounds audible. RESPIRATORY SYSTEMNormal vesicular breathingNo added sounds

CARDIOVASCULAR SYSTEMS1 + S2 +no added sounds

CENTRAL NERVOUS SYSTEMHigher mental functions..intactSensory systemintactMotor system: power 5/5 on both sides reflexes normalCranial nerves..intact

SUMMARYA 30 years female , normotensive and normoglycemic , presented to surgical floor ,being referred from mu2 after failure of endoscopic esophageal dilatation.

Provisional DiagnosisEsophageal stricture secondary to corrosive intakeINVESTIGATION

Endoscopy findingsTight stricture 30 cm from incisors.For 4 consecutive times the dilatation not possible beyond 9 Fr.HB=11.3 g/dlWBC=3400/ulPLT=204000/ulS/Urea=28 mg/dlS/Creat=0.7mg/dlT/bilirubin=.8mg/dlS/ALT=33u/lS/ALP=186ULSerum albumin 4.5 g/ dl

ECG : NormalCXR : NormalDIAGNOSISBenign Esophageal Stricture secondary to corrosive intake.PlanDefinitive surgical intervention was plannedPre-operative preparationCalculate BMINutritional Assessment & Diet Charting.Counseling Of Patient & Attendants about the Operative Procedure and PrognosisPre op psychiatric consultationAvailability of Bed/Vent in SICU.Informed consent.Anesthesia fitness.Arrange Blood & Blood Products.Pass CVPPROCEDUREUpper mid line abdominal incision given , abdomen openedStomach was found to be normal left lobe of liver mobilized by cutting the coronory ligament, left gastric artery, short gastric and left gastro- epiploic arteries ligated and divided.Stomach mobilized and tube made and hinged to lower esophagus with stitch after dividing the GE junction.Feeding jejunostomy done Abdomen closed, skin closed with skin staples

RIGHT THORACOTOMYRight sided thoracotomy donePer op Findings : Middle and lower esophageal stricture with very narrow lumen.Azygous vein ligated between ligaturesThoracic part of esophagus mobilized under visionStomach pulled up through the diaphragm.Haemostasis securedChest tube placedThoracotomy wound closed in layers.NECK DISSECTIONNeck incision given on right side Esophagogastric anastomosis done Drain placed in neck.Skin closed with skin staples.Per operative 01 RCC and 3 bags of platelets were transfusedPatient was successfully extubated.Then shifted to surgical ICU for monitoring.Post op ordersNPO till further orderOxygen at 4L/min via face mask.I/V fluids x TDS with K+ replacement.Inj. Omeprazole 40 mg I/V BDInj. imipenum 1g I/V TDSInj. Vancomycin 1 g i/v BDEpidural top up QIDEsophagectomy sample for H/P

Post operative course Patient had fits and Oxygen saturation dropped on first POD, was put on mechanical ventilation.Work up done for fits which showed hypocalcemiaCalcium replacement done.Extubated after 12 hoursNutrition according to standard protocol was started in feeding jejunostomy.Remained in SICU for 3 daysShifted to HDU on 3rd PODPost operative courseNGT and Foley catheter removed on 4th POD.

Neck drain removed on 5th POD.

Chest tube was removed on 8th POD after getting CXR

Oral sips were allowed on 8th POD after contrast study

Semi solid diet started on 9th POD

Patient was discharged on 11th POD.

Right thoracotomy wound

Abdominal wound

Neck wound

Barium swallow (AP view)

Lateral view

CASE 2

DR AFIYA ZULFIKARName :AdnanAge :18 yearsSex: MaleOccupation: studentAddress :kot P/O AbbasspurDate of admission:13-01-2015Mode of admission: ER History of corrosive intake 3 months back.

Iatrogenic Esophageal perforation secondary to endoscopic dilatation....2 months back

Unable to swallow..2 months

History of presenting complaintsMy patient had argument with his father 3 months back following which he intentionally ingested acid Amount and nature of which is not known

He had severe burning sensation and was brought to hospital(HFH)

Initial management was done.

Later he started having difficulty in swallowing for semisolids and solid foods.Worsened over 2 next weeksLiquids well tolerated ( till esophageal perforation)No history of vomitingNo h/o odynophagia, retrosternal burning pain, dyspepsia , acid or water brashNo h/o cough, choking sensation, chest pain present

He underwent endoscopy 2 weeks after corrosive intake and lower esophageal stricture was noted, dilatation was doneSymptoms relieved temporarilyLater he had 3 sessions of upper GI endoscopies and dilatation of strictured part of esophagus was attemptedDuring the 4th session he developed iatrogenic esophageal perforation

Esophageal exclusion procedure was done which consists ofCervical oesophagostomyClosure of oesophagogastric junctionFeeding jejunostomyBilateral Chest intubation for drainageRemained admitted in SICU for 8 days Later shifted to surgical ward and was discharged in stable condition. Plan of definitive surgery was made after nutritionally building the patient

Readmitted on 13 -01-2015Complete work up done and patient was prepared for definitive surgical managementPast medical history

No h/o D.M., T.B., I.H.D., H.T.N., Asthma.No past history of hospital admission.No past history of any psychiatric illness.

Past surgical history

Not significant

Family history No family history of psychiatric illnessNo family history of DM +HTN +TB +malignancy

Personal history

Non smokerNon addictNormal sleep habits

Drug historyNo h/o any drug allergy.

Socio economic statusBelong to lower class family

General physical examinationA young male of average built sitting comfortably on the bed well oriented in time place and person with following vitalsPulse=70/minBP=120/80Temp=A/FR/R=14/min

Pallor -ve body wt =51 kg Jaundice -ve height= 160 cmCyanosis -ve BMI= 19.92Clubbing -ve

Pedal edema -ve Koilonychia -veJVP not raised Skin normalThyroid not enlargedNo lymph nodes palpable

Systemic examinationGASTROINTESTINAL SYSTEMOral mucosa, teeth, gums ,tongue and palate =normal (Spit fistula in neck) Scaphoid abdomen, moving with respiration, umbilicus central & inverted, no visible swelling, scar mark, or veins.Soft, non-tender abdomen with no mass or viscera palpable and hernial orifices intact.Percussion note resonantBowel sounds audible

53 RESPIRATORY SYSTEMNormal vesicular breathingNo added sounds

CARDIOVASCULAR SYSTEMS1 + S2 +no added sounds

CENTRAL NERVOUS SYSTEMHigher mental Functions..intactSensory systemintactMotor system: power 5/5 on both sides reflexes normalCranial nerves..intact

summary18years male having esophageal exclusion done after iatrogenic esophageal perforation. Now admitted for definitive surgical managementinvestigationsWBC : 9.4/ulHb : 14.9mg/dlPlt : 253/ulUrea: 46mg/dls/creat :1.4 mg/dlS/E : WNLS/Albumin : 4.1g/dlCXR : NECG : NPre operative preparationCalculate BMINutritional Assessment & Diet Charting.Counseling Of Patient & Attendants about the Operative Procedure and PrognosisPre op psychiatric consultationAvailability of Bed/Vent in SICU.Informed consent.Anesthesia fitness.Arrange Blood & Blood Products.Pass CVPOperation Mckeown esophagectomy Per op findingsInflammed middle and lower esophagusNormal stomachPost op ordersNPO till further orderI/V fluids x TDS with K+ replacement.Inj Omeprazole 40 mg I/V BDInj . imipenum 1g I/V TDSInj. vancomycin 1 g i/v BDEpidural top up QIDEsophagectomy sample for H/P

Post operative course Shifted to ICURemained on ventilatory support for 1dayExtubated after 24 hoursNutrition started in feeding jejunostomy according to standard protocolRemained in SICU for 3 daysShifted to HDU on 3rd PODPost operative courseNGT and Foley catheter removed on 4th POD.

Neck drain removed on 5th POD.

Chest tube removed on 7th post op day

Oral sips allowed on 8th POD after getting CXR

Discharged on 13th POD

Right thoracotomy wound

Abdominal wound

Neck wound

Barium swallow

CORROSIVE INTAKEDR GOHAR RASHEEDAP SU1OBJECTIVESMechanism of injuryInitial managementLater managementSurgical managementTYPES OF CORROSIVESTypically Acids or Alkali.

Alkali dissolve tissue thus penetrate more and result in perforation.Acids cause coagulative necrosis that limit there penetration and present with more strictures.Causes severe injury to mouth , pharynx, esophagus and stomach.Phases of injury3 phases

Acute necrotic phase (1-4 days)coagulation of intracellular protein >cell necrosis> surrounding tissue inflammation

Ulceration +granulation phase (3-5days)necrotic tissue slough leaving ulcerated base + granulation tissue

Phase of cicatrization and scarring (10-12) previously formed connective tissue begins to contract resulting in narrowing of esophagus

It is during this phase efforts should be made to reduce stricture formation(PPI+H2 blockers)Outcomes Of Corrosive Intake:Depends upon

Caustic properties.

Amount, concentration and physical form.

Duration of contact.

Clinical Presentation:Larynx & PharynxEsophagusStomachPerforation StridorDysphagiaEpigastric PainHypotensionHoarsenessOdynophagiaHematemesisFeverChest PainLaryngitis-------------PeritonitisALGORITHM

ENDOSCOPIC VIEWS OF CORROSIVE INJURY

Indications For Emergency Surgery:Signs of Perforation.

Peritonitis Extra visceral air. Mediastinitis.

Patients with complex/multiple perforations and widespread necrosis may require extensive debridement, esophagectomy or even esophagogastrectomy.

With more devastatiing injuries burns can be found in bowel distal to stomach. Adjacent organs like Transverse Colon, Liver, Pancreas and Spleen.

These injuries have high mortality.

Late Complications:Stricture Formation.

Peak incidence 02 months.Occurs as early as two weeks or as late as years after ingestion.Barium swallow examination is useful in evaluation.

Gastric Outlet Obstruction.

Takes about 05-06 weeks up to several years.Usually acid ingestion.

Late Complications:Esophageal Carcinoma. 3% have history of caustic ingestion.Begin 15-20 years after ingestion.Stricture due to corrosive intake increases the risk of esophageal CA by 1000 times in 10-25 years more than normal population*

Gastric CarcinomaRare occurrence.Tracheo-esophageal Fistula:

*Update on diagnosis and treatment of caustic ingestion, Michael Lupa, Jacqueline Magne, Ochsner J. 2009 Summer ;9(2): 54-59Management Of Benign Esophageal stricture:Strictures caused by caustic ingestion are often complex (>2cm long, tortuous or diameter precludes the passage of endoscope).

Complex stricture is more difficult to treat and tend to recur.

Refractory strictures : Recur in 2-4days or require more than 7-10 dilatations Balloon or Bougie dilatation. No data to support the superiority of one over the other.

Stents. (intraluminal self expandable plastic stents), an option in refractory stricture.

Goal is to hold the stricture open for a prolonged time allowing tissue to remodel before removing the stentIndications of Surgical InterventionsComplete stenosis in which all attempts have failed to establish patent lumenMarked irregularity and pocketing on barium swallowInability to dilate or maintain the lumen above 40 Fr bougieDevelopment of severe peri-esophageal reaction or mediastinitis with dilatationFistula FormationPatient who is unwilling or unable to prolong period of dilation

SURGICAL MANAGEMENT OF STRICTURE ESOPHAGUSDamaged and strictured esophagus may be left in place but it constitutes increased risk of malignancy and gastro esophageal reflux.Peri esophageal inflammation may cause formation of abscess years later.But at the same time surgical dissection of the scarred esophagus may be difficult and technically demanding due to adhesions with surrounding structures.COMPONENTS OF SURGERYMainly Comprises of two steps

Resection of the Damaged esophagus/ Stomach.

Reconstruction via stomach , colon , jejunum

IVOR LEWIS ESOPHAGECTOMY

Surgical lnterventions: Distal esophagectomy and primary esophagogastric anastomosis in the chest.

Subtotal esophagectomy with gastroesophageal anastomosis in neck.

Esophagectomy + gastrectomy and colonic interposition graft.

Esophagectomy + Jejunal free graft with microvascular anastomosis.

Esophageal Reconstruction:No replacement organ that is able to mimic the function of a healthy esophagus.

All suffer from lack of effective peristalsis & the absence of a physiologic barrier to reflux.

Esophageal replacement organ permits most patients to eat satisfactorily.

Swallowing significantly improved in patients with severe stricturesStomach--Most Common Esophageal Substitute. Advantages:

Stomach can be mobilized with relative speed & ease.

Need for only one anastomosis.

Generally reliable good blood supply through the Rt. Gastroepiploic arcade along the greater curvature Disadvantages:

Relative ischemia at tip of the fundus.

Leak and stricture rate of cervical esophagogastric anastomosis can be as high as 30%.

Long term presence of acid secreting gastric mucosa can lead to complications of reflux.

Tumors near GE junction, use of stomach may compromise the oncologic resectionStomach TubeThe stomach is the conduit of choice because of ease in mobilization and its ample vascular supply

Colon As Esophageal Substitute: Advantages:

Excellent oncologic resection of tumors near GE junction.

Acid resistant, by virtue of its long length prevents reflux.

Excellent blood supply, tip of colon graft well perfused

Stricture rate significantly reduced

Disadvantages:

Colon interposition is difficult to mobilize.

Three anastomosis rather than one.

Takes longer time in operating room Results.

Mortality: 5 10%

Leak rate: 4 -15%

Early function satisfactory.

Long-term function very goodJejunal Grafts:More suitable for limited esophageal replacement.

Long Roux-en-Y limbs are useful to reconstruct alimentary tract following gastrectomy & distal esophagectomy.

Free grafts are used to bridge gaps either between the esophagus itself or between esophagus & another conduit such as stomach or colon.

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Advantages:

Peristaltic tube

No acid/alkaline reflux (Rouxen-Y).

Free graftDisadvantage:

Limited length.

Size.

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