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to Behind the Knife with your thoracic surgery team from Swedish Medical Center in Seattle. I'm Megan Lenehan and I'm joined by the esteemed Drs. Brian Louie. Hello. And Peter White. Hi. On this episode, we're going to discuss esophageal perforations as part of the Clinical Challenges in Surgery series.
Since you're just listening, I'm going to paint you a picture of what's going on in the recording room right now. Dr. Louie is grinning like a maniac. I've never seen this man. So excited. I'm sure everyone listening shares his enthusiasm for the goose. I do love this. This is a huge topic, and we won't be able to cover everything, but we'll try to get through most of the topics.
Our goals are to go through the management of the most common pathologies you are likely to encounter, and then talk more briefly about some of the nuanced scenarios, and finally cover endoscopy and nutrition. Let's get started with our first case, Megan. Okay. This is a 61-year-old man, no known medical history other than heavy alcohol use and a recent binge. The night of presentation, he had been retching and began complaining of severe chest pain and epigastric pain.
So he came into the ED. He was diaphoretic and grunting with respirations, obviously in pain, a bit altered. And his lab work showed a lactate of 6, white count of 19, and creatinine of 1.6. So clearly he's sick. They got a chest X-ray that showed pneumomediastinum and a left lung base infiltrate with pleural effusion.
And a CT of the chest, abdomen, and pelvis showed a hiatal hernia, extensive pneumomediastinum, and a moderate left pleural effusion. So with all this together, the ED called our service to discuss possible Bohrhoff syndrome. Dr. Louis, please tell us about Borhoff syndrome. So, Megan, as you know, Borhoff syndrome is a spontaneous rupture of the esophagus related to increased intra-abdominal pressure.
that occurs with retching and vomiting, and it really accounts for about 15% of all esophageal perforations. As you know, most esophageal perforations are currently related to endoscopy, but outside of that... Borhoff's is one of the more common ones you'll see. You can also see perforations from swallowing caustic substances, foreign bodies, food impaction, trauma. Rarely we also see perforations associated with surgery and malignancy.
In Borhoff's, the perforation almost always tends to be on the left side of the distal esophagus, just above the diaphragm. How does this present? Well, about 70% of intrathoracic perforations present with chest pain, and they may also have dyspnea, dysphagia, subcutaneous gastroemphysema, or epigastric pain. And actually, a macularist triad is an epigastric. for vomiting, followed by chest pain and subcutaneous emphysema, suggesting Borges syndrome.
The perforation leads to mediastinitis, and they can develop tachycardia, fever, hypotension, and quickly spiral into SIRS and sepsis and multisystem organ failure. So as you can imagine, the differential diagnosis for this presentation would be quite broad, likely including MI, aortic dissection, pancreatitis, pneumothorax, pneumonia, all these things.
And most commonly, CT scans are already done by the time the surgeons are consult because the ER has gotten it. And that helps rule out a lot of these things. But the key things that we're interested in are... Is the pneumomediastinum? Is the presence of a pleural effusion? Because those are the things that are going to push us towards thinking about esophageal perforation. But for me, the best test and the most useful one for diagnosing perforation is really an upper GI esophagogram.
usually with gastrographin and or thin barium if necessary, because it provides a lot of detail about the perforation site, its location, whether it goes into the left chest, the right chest. To me, I still prefer an upper GI esophage program as my key test. That is what we were thinking when we got called about this gentleman. Unfortunately, his respiratory status declined and he required intubation.
What we were able to do once we had the secure airway was put some contrast down through an enteric tube into his esophagus and take a series of x-rays that way. and that showed extravasation of contrast into the left chest. If that had not convinced us, the next step would probably have been an EGD, which is nearly 100% sensitive in detecting perforation. Okay, so we've determined that this gentleman has a perforation. Dr. White, how do you address this in the operating room?
Well, before we jump to the operation, let's take a step back and review some of the key goals for anyone with an esophageal perforation. Obviously, first is control sepsis, so broad-spectrum antibiotics, including an antifungal since it's the upper GI tract. Next, you've got to resuscitate the patient and make sure they're otherwise stable enough to get to the operating room, control their hemodynamic instability, respiratory failure with intubation if necessary.
And then we're working on how do we control the contamination source. We have to stop further soilage of the mediastinum, and also we have to control existing soilage with a washout and drainage.
And then lastly, you have to understand what your long-term nutrition plan is going to be. You don't necessarily have to act on it right this moment, but you have to be thinking about, are they going to need TPN? Could we place a Dopov tube, surgical feeding tube? Whatever that plan is, you just... have to know ahead of time.
Once the patient's been confirmed to have a perforation, they've been resuscitated, they're intubated, now you're in the operating room. There's a key decision point that helps decide what you do next, and that's where an EGD is necessary. So you always do an EGD even if that upper GI showed a clear perforation?
Well, right, exactly. If I hadn't done one previously, then I'd do it on table in the operating room, because we really want to characterize the perforation. We've got to be looking for where the defect is, especially in relation to the GE junction in the diaphragm, because that can affect what we... can do while we're there.
We've also got to check the stomach, especially in boar haves, because you can present with perforation in the proximal stomach, which may require an abdominal approach, though often you'll see pneumoperitoneum in that case on the CT scan. And remember, you've got to be mindful of insufflation during this. If the mediastinum is violated into the pleural space, you can create a large pneumothorax if the chest isn't already drained. Okay. So for this man...
We did the EGD, and we confirmed the perforation along the left side of the esophagus. Pieces of food were contaminating the mediastinum. There was a 6-centimeter tear. It ended about 2 centimeters above the GE junction. and there were clear-appearing tissue edges. The patient's on low-dose pressers for support, but otherwise making urine, and our anesthesiologist said he was doing just fine. So what are your next steps?
Well, let's go through a classic treatment pattern for this patient. And in this situation, if we were going to go classically, we would operate on him. And so we would put him in left lateral decubitus. right lateral decubitus and we'd make a left post-to-lateral thoracotomy and somewhere between the seventh or eighth intercostal space we'd enter the chest.
I generally would mobilize up the intercostal muscle bundle at that point in time because that's my preferred buttress. So I take it when we go in. And then after mobilizing the ligament, opening the mediastinum in front of the esophagus or anterior and behind the esophagus along the aorta, you're able to sort of open up the mediastinal tissues. And then you need to sort of encircle it with Penrose drains and whatnot to sort of allow it to be retracted. And then...
I often like to have the EGD scope in the patient at that time because I think it's easier to identify the perforation site. And then as... as the principles that we always teach everybody, you need to extend the myotomy until you find the top edge of the mucosal defect and the bottom edge of the mucosal defect. So once you've done that, then we know we've exposed the entire
perforation site. I tend to close the mucosa with interrupted vicryl, and then I tend to close the muscle secondarily as a two-layer closure with interrupted silks. And then I put my muscle flap on top of the two-layer closure. If I've dissected out the heidel hernia, I will repair that at the same time. And that's sort of how I tend to repair these perforations. So what about, this gentleman had a hiatal hernia. As you mentioned, what about a fundoplication? Well, I think we've...
Fundification is certainly one way you can buttress the perforation site if it's right above the GE junction. If you do do a fundification... I think in this situation, a partial. But what we've learned over the last several years in repairing large hiatal hernias is that often if you repair the hiatus without a fundification,
you still end up controlling the patient's reflux a good chunk of the time. And fundification adds an obstruction, adds time. And so perhaps we might skip that at this point in time. And then there are other options to sort of buttress it, such as a pleural flap, a pericardial fat pad flap, and whatnot. What about your nutrition plan?
I think that entirely depends on the patient's clinical status. If he's stable after we've completed the chest, closed it, then I certainly would put in a feeding degenostomy. I know the textbook says you should put a G-tube in for drainage. I don't find that a G-tube actually drains the stomach very well, so I often prefer to leave the NG-tube in and go with a J-tube. But if he's not stable, I think we're sort of hanging on to that option.
Exactly. So we'll explain a little bit more on nutrition options later on. But Megan, Dr. Louis mentioned a couple things about potential buttress options. Aside from what he's mentioned, do you know of any others? Yes. There are a bunch. So we've talked about intercostal muscle, pericardium, diaphragm, pleura, pedicle thymus or pericardial fat. But intercostal muscle seems to be the most common. You harvest that as you enter. the chastrate.
Yeah, exactly. If you don't enter it or if you don't harvest it when you enter the chest and you put in your retractor, a lot of times you damage the neurovascular bundle, making that muscle flap much less useful. But what you can do is actually go in. to a different intercostal space and take the muscle from that flap if you do still want to use intercostal muscle. So great. In this case, let's say the patient developed a leak on post-update 5. So how would you address this?
My goal would be to control the leak and make sure there's adequate drainage. So ideally, I would take the patient back for EGD and place a stent to control it. And then you may need to adjust your existing drains or place new percutaneous drains. I think if you're well-drained and there's no significant fluid collections on imaging...
and there's favorable anatomy, my preference would be an esophageal stent to salvage a situation. And as long as your stent has, you know, four or five centimeters of overlap with where you think the leak is, then usually you can establish or reestablish source control that allows you to heal things. Now, let's go back and we'll change this case a little bit. If in the original case with this gentleman, what if the mucose on the muscle edges...
are not salvageable for repair. They are necrotic and the repair may be, maybe the defect's a little larger or you've got sort of a narrow esophagus. What are the options there? So you could place a T-tube. Or as a last resort, a partial esophagectomy with esophagostomy. And I'd love to talk more about the technical details of placing a T-tube, but I have never done one. So Dr. White, do you mind walking us through how you do that?
Yeah, of course. So a T-tube, it's similar to the tubes used in the biliary procedures where you need to control the bile duct leakage. It's essentially a tube that has a side port on it, and you generally want to... Place one that's as large as possible, 16 or 18 French. And here you'll have your anesthesiologist pass an NG tube down. You'll pull the NG tube out through the esophageal defect and into your field. Then you thread the T-tube over the NG tube and pass the NG tube.
end of the ng-distally into the stomach. Then you can take your time to seat the T-tube into the esophageal defect so that you end up with the T-tube in the esophagus, the NG, running through the T-tube down into the stomach, and you've got the side port out of your defect.
Next, you've got to try and close that defect as best you can around the side port of the T-tube. And here's where you can use that buttressing, either through muscle, pleura, or thymus. And then lastly, to give you controlage of that, you put a... chest tube to the side port.
You can either go with a larger chest tube to have it slide over the top of the side port or a smaller chest tube to seat it on the inside. But either way, you're going to want to secure it with a vicral tie so that it's in place. I've also heard of others.
use a proline tie that you'll end up cutting endoscopically later but we prefer a vicryl tie because you know that after four weeks to six weeks that vicryl tie will largely be dissolved and it'll be easy to remove the tube when you want to and remember It's draining the esophagus, and we normally swallow air, so it will have an intermittent air leak, and you can expect the nurses to page you about it. I remember those pages well.
What happens to that hole that you leave in the esophagus though where the T-tube comes out? All right, well, you're turning an uncontrolled leak into a controlled leak. So after four to six weeks, sometimes even longer, you can endoscopically remove the T-tube. And now you've turned your chest tube into an empyema tube with a long track leading to that.
esophageal hole. Gradually you'll pull the chest tube back. That tract will seal behind it and now you're going to end up with a fully sealed hole in the esophagus that redevelops its mucosal layer and as you pull that tube back, the tract collapses, and eventually you'll able to pull it out. Now for our last bailout, or sort of plan D after everything that we've been through, would be to resect the esophagus and create a spit fistula.
And so in that situation, we would simply staple the proximal end of the perforation site, the distal end of the perforation site, and take that section of the esophagus out. We would drain the mediastinum widely. close the chest. Then we would turn the position supine, open up a left neck incision, extirpate the esophagus out there, and then create an esophagostomy.
below the clavicle on the anterior chest wall to allow for the ostomy bag to sit nicely on a flat surface. And if the patient's really, really unstable, a true sort of... damage control scenario would be just staple off both ends, resect it, close it, and live to fight another day. Often in that situation, I simply leave an NG tube in the remaining proximal esophagus.
Some folks have sown a Malakot drain in there and done other things, but I think in the short term, you just leave it blind-ended and get out and wait to fight another day. Okay. So to summarize, we have a patient with Borhoffs and an early distal perforation into the left chest. We've controlled the contamination with a primary two-layered closure with a muscle buttress, widely drained the mediastinum and pleura, and placed a feeding jejunostomy tube for enteral feeding access.
Let's move on to our second case. This is a 56-year-old fisherman with achalasia. He came into the emergency department when he developed chest pain, emesis, fever, and chills, and a CT scan showed PO contrast extravagating into the left chest. You go to the... OR, you do your EGD, you see your perforation, and you do not see any masses or findings concerning for malignancy. So what are some special considerations for this scenario?
Right. So a perforation in someone with known achalasia is going to be treated a little differently. As you know, achalasia is a combination of aperistalsis of the esophageal body combined with non-relaxation of the lower esophageal sphincter.
manage it because any distal obstruction is going to immediately cause failure of a... proximal repair and so once you've completely dissected out the esophagus and you've done your primary repair you then flip it 180 degrees and you would then perform an esophagogastric myotomy. So, Peter, I think there's a couple points to also make in patients with achalasia. The first is...
When you make your myotomy, the distal myotomy needs to get onto that stomach wall and ideally two centimeters to ensure that we have divided the collar sling fibers. And so I think you sometimes need to... Pull that stomach up through the hiatus to complete it if you're in the chest. The second point would be that in a patient with achalasia who's had a...
food impaction and a perforation. I just want to reinforce that we would do, as you said, close the perforation site, two layers, flip it over, do the myotomy on the other side. It's highly likely in that situation that we will not do a fund application. We'll just deal with the repair because that's our primary objective and we'll live to fight another day in the future. If...
The third point would be if it's an iatrogenic perforation, I certainly would consider, just as you said, repair one side, myotomize the other side. But in that situation, I'm more likely to consider adding a fundipication. either a belsey in the chest or a door or toupee in the belly, because it's iatrogenic, the esophagus is clean, and we should be there right after the perforation. Anyway, so I think that completes the actual treatment for the patient's achalasia at that time.
Right, because with achalasia, when you cut that muscle, you're accepting they're going to get a 40% chance of pretty severe esophagitis if you don't add the fundoplication. So if they are stable enough to add it, I agree, add the fundoplication, save yourself a repeat operation. All right. Our next case is a bit less common, but there's a lot to consider, so we felt it important to discuss. The patient comes in presenting pretty similar to our previous gentleman.
However, on the CT scan, he has a mass in his distal esophagus with a perforation proximal to that mass. Dr. Louis, what are you thinking? Well, I think the perforated malignancy is particularly challenging because at that point in time, unless they have a known malignancy, you really are sort of in the dark. You have no idea about staging. And so my first go-to scenario is to place an esophageal stent to provide source control.
I might place chest tubes to drain whatever effusion there is. I might consider vats to help us sort of convert the emergent situation to an urgent situation. because it allows us to plan, coordinate, have a more stable patient, which would allow us to perform a resection or reconstruction in one setting. But to me, I'm thinking...
If stenting is a viable option, then I hope it gets us from an emergent situation to an urgent situation. Okay, so what if the perforation wasn't amenable to stenting? So they force your hand. You're required to do a thoracotomy to really wash them out. They're sick. They're stable, but they're more sick than this.
Yeah, so when you're doing your initial EGD to identify the perforation site, you'd also want to get biopsies and send them for frozen sections. And as we all know, these always come in the middle of the night. So even if that happens, you're calling in your pathologist because for cancer... primary repair just is not an option. You can't fix that and expect it to hold. So in that situation, if I can't stent it...
Really, you've got to resect the esophagus. And in almost all cases at that point, you've now gone down the pathway of diverting with an esophagostomy. So I transect the esophagus proximally to get adequate margins. And then your issue is getting appropriate. distal margins because you can't just staple through the tumor. So you've got to dissect out the hiatus.
dunk the esophagus and the mass into the abdomen, close the hiatus, and that's an important key because you don't want them to get a hernia, and then complete the esophageal dissection to make your dissection at the base of the neck easier. We go supine, perform a laparotomy, resect the rest of the tumor along the proximal stomach, left gastric artery, and lymph nodes. Or if the patient can handle it, you could consider doing this laparoscopically because really the goal is to just...
resect the rest of that tumor, and then leave yourself the option for reconstruction down the line. So you're essentially partially forming your conduit for future reconstruction away from the tumor. And any GE junction cancer should be able to be managed in this way.
Next, we'd place a feeding judge in ostomy. And then I'd place a venting G-tube in the remnant stomach, close up the abdomen, head to the neck, and then create the esophagostomy, as Dr. Louie had previously described. So, Megan, in this situation, where on the stomach...
are you placing that venting g-tube? Well, you're thinking about your conduit and reconstruction, so I'd place it away from the greater curve and probably pretty high up on the funic tip so that it would end up getting resected when you make that. conduit eventually. Is there any situation which you would immediately reconstruct?
Well, that's really the ultra-rare case where you've got a patient with cancer, you already know their staging, and maybe they went for their repeat staging endoscopy and they were getting a dilation, and then they had an ejection. iatrogenic perforation. Well, here you've got a clean field. They've already completed treatment. They've already got their staging work up. So in that situation,
If you couldn't stent, which still would be a good option, maybe you could go back and do an immediate resection and reconstruction. But really, that's a very select number of patients that would ever meet that. So Peter mentioned closing the hiatus when he was doing the resection in the chest and pushing things through the hiatus. So at the time of reconstruction...
How do you get the stomach pull-up up into the neck to meet the esophagostomy? Based on the way you're asking the question, I don't think I want to go back through the posterior mediastinum. So I would go for a substernal approach, probably.
Yeah, you're right, Megan. So often in the case of a perforated esophagus where we have created the esophagostomy and got the patient out of the perforation site, you're almost required to go back through the substernal space because the posterior... mediastinum will be scarred down the perforation site was there so theoretically you spilled cancer cells there and there's a risk of recurrent cancer which will which will
which over time, if it's true, will take out your esophageal, your gastric pull-up, if you ever try to put it back there. So in this situation, we tend to go substernally. And after forming the conduit and taking down the spitfish in the left neck, We'll do a left hemimaneubriectomy, take out the head of the clavicle to make room for that conduit, and we'll create the esophageal gastric anastomosis just where the maneuvering used to sit high on the anterior chest.
All right, so let's move on to the next case. So Megan, you've already heard a few cases so far, so this one's for you. So another recent one our team has dealt with. You get paged to the PACU for a GI patient that's been undergoing a dilation for a benign peptic stricture just an hour. hour ago. She's mildly tachycardic and complaining of some chest discomfort, but otherwise hemodynamically stable. So what do you do from here? Same thing we do every case, Pinky.
I'm worried for an iatrogenic perforation. Most esophageal perforations are related to endoscopy, particularly endoscopic interventions such as dilations, therapy, endoscopic mucosal resections, POEMs. So whatever level that intervention is being performed is usually where they occur. For diagnostic EGDs, perforations most commonly happen at the level of the cricopharyngeus, since that's the most narrow anatomic area of the esophagus.
So I would start as we do with the chest x-ray, but we know that our favorite test is going to be a gastrographin swallow, and if that doesn't show anything as far as a... perforation, then I would get a thin barium swallow following that. So, Megan, you're already in the pack. What about skipping that and going straight back to the endoscopy suite or the OR for a diagnostic EGD?
Okay. Yep. That would be an option. I would say whichever is fastest for the patient to get evaluated. But I see what you're saying that going back to endoscopy would offer. the option for treatment at the same time is diagnosis.
In a swallow study, we'll definitely give you the answer in this case. And here it showed a small contained perforation at the level of the stricture, small amount of contrast extravasating into the mediastinum, but you don't see any tracking into the left chest. So what other signs can you... look for to see if the pleur is ruptured? On the chest x-ray, you could look for pneumothorax or pleural effusion. But I would take her for endoscopy, as we've been discussing.
expecting that she'd probably be pretty reasonable to stent. I think stent's certainly one option, Megan, but could you manage her non-operatively? So... You can manage some esophageal perforations, especially iatrogenic recent small contained perforations. You can manage them non-operatively. If they're hemodynamically stable, you would potentially just observe them. In her case, she was tachycardic and symptomatic, and I think that would push me to intervene.
Okay, so as we all know, there are some pretty widely used criteria for managing patients non-operatively. They're named after Dr. Cameron, and it's worthwhile reviewing them. They are as follows, a well-contained perforation within the mediastinum. It has to drain back from the cavity into the esophagus. You have to have minimal symptoms. and no evidence of sepsis and then you can consider managing these folks non-operatively but in this situation with what you described
A lot of gastroenterologists might simply clip that right then and there. And if it's my case, I might simply use endoscopic clips to close it right then and there as one option to mitigate against this. then we can watch her non-operatively see how she does. Well, let's move on to a couple of the smaller cases. The first one is location, location, location. So let's talk about where we can find perforations aside from just the distal esophagus. So if a patient's undergoing diagnostic EGD,
presented a few hours later with neck pain, dysphagia, dysphonia, and you can feel some subcutaneous crepitus in the neck. That's pretty classic for a cervical perforation. So Brian, how do you address these? Peter, as you know, our approach would be through a left neck incision. Most of the time, simply drainage of the area with Penrose drains is sufficient. But if you can see the perforation,
Most of us will try to repair that in two layers and then still widely drain it. Megan, what do you always need to be mindful of with this exposure? You want to look out for the recurrent laryngeal nerve running in the tracheoesophageal groove. And next up, let's talk about when you would go through the right chest for an esophageal perforation. So for me...
A right chest approach is used for mid-esophageal perturbations that are largely just above or just below the carina. Those are best approaches to the right because the esophagus is predominantly on that side. And in the left chest, the aortic arch sits over top of there, and getting access to that is quite difficult. But if the perforation is tracking into the right chest but is distal,
In the distal third, below the pulmonary veins, a left chest approach is still better to access a right-sided perforation because it's easily mobilized. You can rotate the esophagus. and you have much better access to the hiatus. So in the distal third, it doesn't matter which side you're on, it should be through the left chest, and the right side is really left to those around the carina. Okay. So last but not least, how do you approach esophageal perforations in the abdomen, Dr. White?
So we've alluded to this a few times earlier, but essentially they're going to present with pneumoperitoneum and peritonitis. And so here you have to go through the abdomen, typically upper midline incision or a subcostal incision. your distal esophageal exposure up within the mediastinum, you can easily divide the diaphragm anteriorly. You'd close this at the end, but it really improves your access to the esophagus when you're going transabdominal.
Great. So the time has come, the moment Dr. Louis has been waiting for. Let's get into the weeds on advanced endoscopy for these perforations. Dr. Louis, with all the options now, what... things do you look for when deciding on treatment? How do you decide whether you choose clipping, stenting, endovac? Well, you know, Megan, all of these are relatively newcomers to the situation of the esophageal perforation.
And, you know, we've covered the classic go to the OR sort of scenarios, which I think are a little easier to sort of think about and visualize the endoscopic options. require a good understanding of the full clinical picture because is the... field clean? Do you still have food in there? Is there gross media-style contamination? Is it early, within hours, or are we talking this happened several days ago? And I think the endoscopic options are really ones that are...
earlier in the course as opposed to later. And often I'm going to make that assessment when I do the endoscopy. And so it's based on size, length, location of the mucosal defect. how healthy the tissues look, and whether I can clean out the food, I can irrigate it, wash it out. If it's a small defect with a clean field that was from a dilation, I think clipping is an excellent option there because we can get to it right away. Larger defects that... Where the pleura appears to be intact.
We have recently used the endovac as a way to manage those. But you still have to follow the surgical principles, which is you need source control. And you need to sort of... clean out the small cavity of all the food before you put the endovac in there, into the space. And then if there is a pleural effusion or you develop one, you certainly need to drain it with tubes. You might need to do a vats, but those are all important things.
Any endoscopic option still has to follow the general rules that Dr. White outlined earlier, which is source control, drainage of the effusion, control of the mediastinum, antibiotics. All those things are important. Otherwise, any of these endoscopic things... endoscopic procedures will fail. If we have a patient who presents in a delayed fashion, maybe 48 hours after symptoms started, food impaction kind of scenario, would
Would you still try something endoscopic? Like I said, I think all the standard principles that Dr. White outlined still apply. I think there's a much higher likelihood that we are going to do an open repair, primary repair and buttress, or we're headed for a T-tube because it's been 48 hours. But in that situation... I think an endovac might be a salvageable option because if it's a small contained area that I can get treated with the endovac, that might save us some time.
I think if anything endoscopic starts to fail, I think you're headed to the OR. And I think you've got to be very vigilant if you're going to try these endoscopic options. Yeah. With that... Being said, could you review for us what an endovac entails? Of course. I think there are a number of things that folks can find. YouTube and whatnot in terms of how to describe the use the end of act but for us we use a 14 French NG tube
And then we use the black sponge. And we often call it arts and crafts because we try to measure the defect that we're going to fill with the endovac. And we'll tailor the sponge to look like that. The endovac sponge then needs to be mounted over top of the distal and G-tube.
to the most proximal side hole, and then you have to trim the NG tube so all the holes are contained within the sponge. This is the sponge just from a wound back set. This is just the sponge from a wound back set. So cool. And that's why it's called Arts and Crafts.
We sew the sponge to the NG tube with proline. We make sure that we have a loop at the very end so we can pull it down. And you have to remember, there's only so much that will go down the esophagus, and usually it's some cylindrical shape. and then you've got to drag it down there, and then you have to have enough endoscopic skills to get it into the position you want. We use the settings at 125 suction. We do it continuously, and we end up changing them.
every three to five days. So it's a labor of love if you're going to manage them with an endovac. Yeah, when I did these in training, we would oftentimes use a Blake drain made out of silicone. It's a little bit more comfortable than an NG tube, and you don't have to worry about all the holes because you just cut it to size, but you would want the sponge to completely cover.
of the slits for the Blake drain and we would taper the sponge so that the distal end was much more narrow. It makes it a little bit easier to get it through the oropharynx and through the upper esophageal sphincter, and then down into any cavity that you're trying to drive it into. That's a great tip, Peter. I forgot that we do taper those so that it does go in there. It makes it much easier when we've done that.
Nothing about that sounds easy, but sure. And then the other thing that we've learned from Dr. Hofstetter, who is one of Dr. White's mentors, is sometimes you can... Put an endoscopic stent in with the sponge pushed over. So if you have a hard time seeding the sponge into the defect, the stent pushes that sponge into the defect for you. The stent holds it there. The stent holds it there.
tubing is coming up along the side between the esophageal wall and the stretch. Yeah, so lots of options, but it still remains a labor of love if you're going to do it that way. Sure. Wow. So to close out, we're going to revisit everyone's favorite topic, which is nutrition. Every case can be a little different, so it's important to remember all of the options available. How about for the very unstable patient?
Right. So if we're in a case where the patient becomes unstable during the operation... Or that's one that you have to essentially convert to a damage control esophagectomy. It's better to just leave feeding access for another time. I know everyone wants to feed the gut. but your patient has to be alive for them to get feed. So control the soilage.
get them cleaned out, get them to the unit quickly and resuscitated. And then once they've survived, you have a few options. You can bring them back to the operating room and place a feeding degenostomy tube, which is our preferred option. Or Brian, what else can we do?
Well, you know, Peter, in the short term, TPN is always an option for these folks. If the patient has a stent or a primary T-tube where the patient has continuity, You can also endoscopically put a dauboff tube through those and feed the stomach through the dauboff tube, although we would obviously want to try to get that post-pyloric if we could. Certainly once they're more stable, the J-tube for us, as you've outlined, is one of our favorite feeding tubes. What about a G-tube?
Yeah. I mean, for us, it's got a much more limited role. If you think long-term venting in the stomach is necessary, maybe a G-tube could be helpful, but they really don't drain the stomach very well, as you described. Good for gas, not as good for fluid. So an NG tube is actually a much better option for that. It's just not as well tolerated. So I wouldn't really place a G tube at the time of the index operation, but some patients might need one later on, which you could always do if necessary.
If the stomach is very dilated, something like a laparoscopic-assisted push G-tube may be useful in that situation. But you've mentioned before in the past using a G-tube for feeds if the patient required an esophagectomy with diversion. Can you elaborate on that? You know, Peter, I don't have any data for this, but once they're diverted, there's no, and we know that there is a long-term plan for reconstruction.
I like to try to feed the stomach because I think it helps maintain the size. If you're doing bolus feeds with breakfast, lunch, and dinner, that stomach does... get stretched out, and we have seen some folks, particularly in the bariatric population, where that stomach remnant is not used, and it becomes small and a little atrophic, and so I'm not sure it works as well.
I like the idea of a G-tube for bolus feeds if I can get the patient, if I can get the tube in and get the patient to tolerate it. Perfect. There's clearly a lot of nuance, but it goes back to what Dr. White was saying in the beginning, which is there are four main elements of managing esophageal perforations, controlling sepsis and resuscitation, controlling the source.
washing out existing contamination and coming up with your nutrition plan. So thanks Dr. Louis and Dr. White for this absolute blast. And thank you all for joining us on this episode of Behind the Knife. Be sure to check out our website at www.behindthenife.org for more great content. You can also follow us on Twitter at Behind the Knife and Instagram at Behind the Knife Podcast. If you like what you hear, please take a minute to leave us a review.
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