Surgical Unit 1
CASE 1
DR. SAJID MAHMOOD
 Name: Najma Shaheen W/O Asif
 Age: 30 Years
 Sex: Female
 Occupation: House Wife
 Address: Dhok Farman Ali Rwp.
 DOA: 26-12-14
 MOA: Referred from MU II
Presenting Complaints
 History of corrosive intake ….5 months back.
 Difficulty in swallowing………..5 months
History of presenting complaints
 My 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 history
 History of C section 9 years back
Family history
 No family history of psychiatric illness
 No family history of DM , HTN , TB, any malignancy
Personal history
 Non smoker
 Non addict
 Normal sleep habits
Drug history
No H/O any drug allergy.
Obstetric history
 3 sons and 1 daughter
 Age of eldest child is 13 years
 Age of youngest child is 7 years
Socio economic status
 Belongs to middle class family
General physical examination
 A 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/min
 BP=100/60
 Temp=A/F
 R/R=14/min
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
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Pallor
absent
Jaundice
absent
Cyanosis
absent
Clubbing
absent
Koilonychia
absent
Pedal edema
absent
JVP not raised
Skin - normal
Thyroid not enlarged
No lymph nodes palpable
Body weight : 48 kg
Height
: 156cm
BMI=19.7 kg/m2
Systemic examination
GASTROINTESTINAL 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 SYSTEM
 Normal vesicular breathing
 No added sounds
CARDIOVASCULAR SYSTEM
 S1 + S2 +no added sounds
CENTRAL NERVOUS SYSTEM
 Higher mental functions……..intact
 Sensory system……intact
 Motor system:
power 5/5 on both sides
reflexes normal
 Cranial nerves…..intact
SUMMARY
 A 30 years female , normotensive and normoglycemic ,
presented to surgical floor ,being referred from mu2 after
failure of endoscopic esophageal dilatation.
Provisional Diagnosis
Esophageal stricture secondary to corrosive intake
INVESTIGATION
Endoscopy findings
 Tight stricture 30 cm from incisors.
 For 4 consecutive times the dilatation not possible beyond
9 Fr.
 HB=11.3 g/dl
 WBC=3400/ul
 PLT=204000/ul
 S/Urea=28 mg/dl
 S/Creat=0.7mg/dl
 T/bilirubin=.8mg/dl
 S/ALT=33u/l
 S/ALP=186UL
 Serum albumin 4.5 g/ dl
 ECG : Normal
 CXR : Normal
DIAGNOSIS
 Benign Esophageal Stricture secondary to corrosive
intake.
Plan
Definitive surgical intervention was planned
Pre-operative preparation
 Calculate BMI
 Nutritional Assessment & Diet Charting.
 Counseling Of Patient & Attendants about the Operative
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Procedure and Prognosis
Pre op psychiatric consultation
Availability of Bed/Vent in SICU.
Informed consent.
Anesthesia fitness.
Arrange Blood & Blood Products.
Pass CVP
PROCEDURE
 Upper mid line abdominal incision given , abdomen opened
 Stomach 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 THORACOTOMY
 Right sided thoracotomy done
 Per op Findings :
Middle and lower esophageal stricture with very
narrow lumen.
 Azygous vein ligated between ligatures
 Thoracic part of esophagus mobilized under vision
 Stomach pulled up through the diaphragm.
 Haemostasis secured
 Chest tube placed
 Thoracotomy wound closed in layers.
NECK DISSECTION
 Neck 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
transfused
 Patient was successfully extubated.
 Then shifted to surgical ICU for monitoring.
Post op orders
 NPO till further order
 Oxygen at 4L/min via face mask.
 I/V fluids x TDS with K+ replacement.
 Inj. Omeprazole 40 mg I/V BD
 Inj. imipenum 1g I/V TDS
 Inj. Vancomycin 1 g i/v BD
 Epidural top up QID
 Esophagectomy sample for H/P
Post operative course
 Patient had fits and Oxygen saturation dropped on first
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POD, was put on mechanical ventilation.
Work up done for fits which showed hypocalcemia
Calcium replacement done.
Extubated after 12 hours
Nutrition according to standard protocol was started in
feeding jejunostomy.
Remained in SICU for 3 days
Shifted to HDU on 3rd POD
Post operative course
 NGT 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 ZULFIKAR
 Name :Adnan
 Age :18 years
 Sex: Male
 Occupation: student
 Address :kot P/O Abbasspur
 Date of admission:13-01-2015
 Mode 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 complaints
 My 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 weeks
Liquids well tolerated ( till esophageal perforation)
No history of vomiting
No h/o odynophagia, retrosternal burning pain, dyspepsia ,
acid or water brash
No h/o cough, choking sensation, chest pain present
 He underwent endoscopy 2 weeks after corrosive intake
and lower esophageal stricture was noted, dilatation was
done
 Symptoms relieved temporarily
 Later he had 3 sessions of upper GI endoscopies and
dilatation of strictured part of esophagus was attempted
 During the 4th session he developed iatrogenic esophageal
perforation
 Esophageal exclusion procedure was done which consists of
1. Cervical oesophagostomy
2. Closure of oesophagogastric junction
3. Feeding jejunostomy
 Bilateral Chest intubation for drainage
 Remained 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 -01-2015
 Complete work up done and patient was prepared 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 history
 Not significant
Family history
 No family history of psychiatric illness
 No family history of DM +HTN +TB +malignancy
Personal history
 Non smoker
 Non addict
 Normal sleep habits
Drug history
 No h/o any drug allergy.
Socio economic status
 Belong to lower class family
General physical examination
 A young male of average built sitting comfortably on the




bed well oriented in time place and person with following
vitals
Pulse=70/min
BP=120/80
Temp=A/F
R/R=14/min




Pallor
Jaundice
Cyanosis
Clubbing




Pedal edema -ve
JVP not raised
Thyroid not enlarged
No lymph nodes palpable
-ve
-ve
-ve
-ve
body wt =51 kg
height= 160 cm
BMI= 19.92
Koilonychia -ve
Skin normal
Systemic examination
GASTROINTESTINAL SYSTEM
 Oral 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 resonant
 Bowel sounds audible
RESPIRATORY SYSTEM
 Normal vesicular breathing
 No added sounds
CARDIOVASCULAR SYSTEM
 S1 + S2 +no added sounds
CENTRAL NERVOUS SYSTEM
 Higher mental Functions……..intact
 Sensory system……intact
 Motor system:
power 5/5 on both sides
reflexes normal
 Cranial nerves…..intact
summary
 18years male having esophageal exclusion done after
iatrogenic esophageal perforation.
 Now admitted for definitive surgical management
investigations
 WBC : 9.4/ul
 Hb : 14.9mg/dl
 Plt : 253/ul
 Urea: 46mg/dl
 s/creat :1.4 mg/dl
 S/E : WNL
 S/Albumin : 4.1g/dl
 CXR : N
 ECG : N
Pre operative preparation
 Calculate BMI
 Nutritional Assessment & Diet Charting.
 Counseling Of Patient & Attendants about the Operative






Procedure and Prognosis
Pre op psychiatric consultation
Availability of Bed/Vent in SICU.
Informed consent.
Anesthesia fitness.
Arrange Blood & Blood Products.
Pass CVP
Operation
 Mckeown esophagectomy
Per op findings
 Inflammed middle and lower esophagus
 Normal stomach
Post op orders
 NPO till further order
 I/V fluids x TDS with K+ replacement.
 Inj Omeprazole 40 mg I/V BD
 Inj . imipenum 1g I/V TDS
 Inj. vancomycin 1 g i/v BD
 Epidural top up QID
 Esophagectomy sample for H/P
Post operative course
 Shifted to ICU
 Remained on ventilatory support for 1day
 Extubated after 24 hours
 Nutrition started in feeding jejunostomy according to
standard protocol
 Remained in SICU for 3 days
 Shifted to HDU on 3rd POD
Post operative course
 NGT 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 INTAKE
DR GOHAR RASHEED
AP SU1
OBJECTIVES
 Mechanism of injury
 Initial management
 Later management
 Surgical management
TYPES OF CORROSIVES
 Typically 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 injury
3 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 &
Pharynx
Esophagus
Stomach
Perforation
Stridor
Dysphagia
Epigastric
Pain
Hypotension
Hoarseness
Odynophagia
Hematemesis
Fever
Chest Pain
Laryngitis
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Peritonitis
ALGORITHM
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 Carcinoma
 Rare occurrence.
 Tracheo-esophageal Fistula:
*Update on diagnosis and treatment of caustic ingestion, Michael Lupa, Jacqueline
Management 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 stent
Indications of Surgical
Interventions
 Complete stenosis in which all attempts have failed to
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establish patent lumen
Marked irregularity and pocketing on barium swallow
Inability to dilate or maintain the lumen above 40 Fr
bougie
Development of severe peri-esophageal reaction or
mediastinitis with dilatation
Fistula Formation
Patient who is unwilling or unable to prolong period of
dilation
SURGICAL MANAGEMENT OF STRICTURE
ESOPHAGUS
 Damaged 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 SURGERY
 Mainly 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
strictures
Stomach--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 resection
Stomach Tube
The 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 good
Jejunal 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.
Advantages:
 Peristaltic tube
 No acid/alkaline reflux (Roux–en-Y).
 Free graft
Disadvantage:
 Limited length.
 Size.
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