Clinical Case Presentation. Jared B. Smith, M.D. Surgical Grand Rounds, August 21, 2006

Transcription

1 Clinical Case Presentation Jared B. Smith, M.D. Surgical Grand Rounds, August 21, 2006

2 Clinical History CC: Can t swallow anything HPI: 50 y.o. male from western Colorado, greater than 2 years of emesis with oral liquids Cannot maintain > 50% of recommended caloric intake Complete intolerance of solid food 30 lb weight loss over prior 2 years

3 Clinical History HPI (continued): Poor historian, but has history of deliberate lye ingestion 2 years ago Diagnosed with esophageal stricture by barium swallow at outside hospital Refractory to 3 esophageal dilations over 1 year

4 Clinical History PMH: Premature birth Depression Chronic neck pain Chronic left upper and left lower extremity paresthesias after motor vehicle accident

5 Clinical History PSH: Unknown abdominal operation through right paramedian incision as newborn Repair of right lower extremity near- amputation after MVC Bilateral inguinal hernia repairs in his 20s Esophageal dilations August & November 2005, June 2006

6 Clinical History: Medications: Prescription for Zoloft (non-compliant) Roxicodone elixir prn Family: Father, died of MI age 49 Mother, experienced MIs in her 50s Grandmother, unknown cancer

7 Social: Clinical History: Homeless, former coal miner Smokes 1 ppd x 35 years Occasional EtOH Denies illicit drugs Review of Systems: Uses wheelchair secondary to chronic fatigue and leg pain Chest pain with emotional distress Required temporary home O2 for a COPD exacerbation

8 VS: Physical Examination: Ht 5'8', Wt 112 lbs, T 99.2, HR 127, BP 123/76, R16 General: Thin, cachectic male sitting in wheelchair Chest: Clear, but poor air movement at bases Abdomen: Soft, non-tenter, no organomegaly. Right paramedian scar

9 Laboratory Studies: Normal Complete blood count and chemistry panel Albumin 3.6

10 Assessment: 50 y.o. male with caustic injury-induced esophageal stricture, refractory to esophageal dilation Significant nutritional deficiency and dehydration Pulmonary and potential cardiac comorbidities difficult to quantify Surgical therapy warranted; anatomy unknown

11 Initial Hospital Course: Admitted from clinic for IV hydration Pre-operative risk assessment: Cardiac stress test normal PFTs: FEV (47%) Barium swallow performed...

12 Barium Swallow:

13 Operative Therapy: Esophagocologastroplasty using left colon Resection of lateral segment of liver Antrectomy with Billroth I anastomosis

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19 Corrosive Esophageal Injuries: Most common agents: Caustics (sodium hydroxide, ammonia) Bleaches (sodium hypochlorite) Corrosives (hydrocholric acid, hydrofluoric acid, sulfuric acid) Most self-inflicted strictures are created by lye ingestion.

20 Management of Caustic Ingestion: Resuscitation Evaluation Observation and/or operative therapy

21 Corrosive Esophageal Strictures: Pathophysiology Ulceration from ingested corrosive substance, with secondary infection and reflux of gastric juice creates intense fibrotic reaction Stricture results within 3 weeks to 3 months

22 Corrosive Esophageal Strictures: Indications for Operative Therapy: Complete stenosis with failed attempt to establish a lumen Severe periesophagel reaction or mediastinitis complicating dilation procedures Fistula Repeated unsuccessful dilation Patient unable to undergo repeated dilation

23 Type of Reconstruction: General Considerations: Choice of conduit (stomach, colon, or jejunum) Specifics of conduit construction (whole stomach or gastric tube; left or right colon) Location of anastomosis (thoracic or surgical) Route of reconstruction (posterior or anterior mediastinum) Need for gastric drainage procedures

24 Esophageal Reconstruction: Choosing a conduit: Stomach is conduit of choice if unaffected and available If stomach unavailable, long-segment colon interposition is favorable

25 Conduits: Stomach Advantages: Dependable vascularity Relatively simpler operation Need for only one anastomosis Low graft necrosis rate (1-2%) Disadvantages: Often involved in the disease process after caustic injury Loss of gastric reservoir function Early and late reflux complications

26 Conduits: Left Colon Advantages Small diameter/less prone to dilation More reliable blood supply Can reach neck easier than right colon Effective propulsion of food bolus Disadvantages: Blood supply less reliable than that of stomach

27 Conduits: Right Colon Advantages: Viability can rival that of left colon Disadvantages: Blood supply less reliable than that of stomach More difficult to reach neck than is left colon

28 Conduits: Jejunum Advantages: Flexibility of free jejunal autograft for salvage of failed conduits, with 15% leak rate Jejunal interposition can be created safely, with acceptable complication rates Disadvantages: Technical difficulty

29 Bowel Interposition for Benign Esophageal Stricture: Overall Complication Rates: Overal postoperative complications: 38 % Anastomotic leak: 15% Wound infection: 6% Overall mortality: 6% Ann Thor Surg 1997;64:752-6

30 References: Mansour et al. Bowel interposition for esophageal replacement: Twenty-five-year experience. Ann Thorac Surg 1997;64: Popovici Z. A new philosophy in esophageal reconstruction with colon. Thirty-years experience. Diseases of the Esophagus 2003:16: Urschel JD. Does the interponat affect outcome after esophagectomy for cancer? Diseases of the Esophagus 2001:14;