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Ruptured esophagus after Ruptured esophagus after

Ruptured esophagus after - PowerPoint Presentation

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Ruptured esophagus after - PPT Presentation

resection of thoraco abdominal aorta aneurysm 23910 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 ID: 393565

aneurysm graft left aortic graft aneurysm aortic left esophagus aneurysmal post space sac day showed operative omental infection chest

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Slide1

Ruptured esophagus after resection of thoraco abdominal aorta aneurysm

23/9/10Slide2

Case presentationA 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.Slide3

CT angiogram was done after surgery, it showed large thoraco abdominal aortic aneurysm – Crawford type 5

CAG was done, it was normal.Slide4

Chest X ray admission daySlide5

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.Slide6
Slide7

Chest CT scan showed presence of air in aneurysmal sac surrounding the graftEmergency left thoracotomy was done.A large amount of pus and food particles surrounding the graft.

Longituidinal

necrosis of lower esophagus about 2 cm long.Slide8
Slide9
Slide10

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.Slide11

cultureAortic wall Streptococcal

fecalis

Pus

Steptococcus

fecalis

Yeast cell

lactobacilli.Slide12

CT scan after chest re thoracotomySlide13
Slide14
Slide15
Slide16

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.Slide17

CT after re laparotomySlide18
Slide19

Near complete disappearance of perigraft fluid before esophageal bypassSlide20
Slide21

2nd admission3 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.Slide22

There was superficial abdominal wound infection. His post operative course was uneventful otherwise.Oral diet was resumed on 8

th

post operative

day after contrast study showed no leakage no obstruction.Slide23

discussionEsophageal 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

necrosisSlide24

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 hemorrhageSlide25

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