View source for WBR0263

 {{WBRQuestion
|QuestionAuthor=Vendhan Ramanujam
|ExamType=USMLE Step 3
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|MainCategory=Inpatient Facilities
|MainCategory=Inpatient Facilities
|SubCategory=Gastrointestinal, Surgery
|Prompt=A 54 year old male was admitted following complaints of epigastric abdominal pain and dysphagia. Upon admission he looked pale and underweight.  He was then followed by an upper gastrointestinal endoscopy for a possible distal esophageal cancer.  After the procedure, he complains of significant new substernal pain.  Palpation reveals subcutaneous emphysema.  His temperature is 38 C, blood pressure is 110/68 mm Hg, respiratory rate is 20/min and heart rate is 112/min.  Perforation of the esophagus is suspected. An immediate chest film reveals air in the mediastinum.  Which of the following management is most recommended?
|Explanation=Perforation of the esophagus requires aggressive intervention in virtually all circumstances.  While that intervention can usually consist of efforts to patch the perforation and drain the [[mediastinum]], concomitant obstructive esophageal disease, whether inflammatory stenosis or cancer, mandates removal or bypass of the obstruction if control of the leak and its consequent persisting mediastinal and pleural contamination is to be accomplished.  For distal esophageal cancers, many thoracic surgeons would use the classic Ivor-Lewis operation, which consists of mobilizing the stomach in the abdomen and then performing a right [[thoracotomy]] with mediastinal drainage, [[esophagectomy]], and esophagogastrostomy. 

'''Educational Objective:'''
The most recommended management approach in esophageal perforation with concomitant obstructive esophageal disease and signs of sepsis is esophagectomy and esophagogastrostomy via laparotomy and right thoracotomy.  Left thoracotomy approach can be done in more distal perforations close to the gastroesophageal junction. Conservative approaches are only for treating small perforations with a diameter of few millimeters without any diagnostic delay or septic symptoms.

|AnswerA=Placement of a nasogastric tube to the level of perforation, intravenous antibiotics, close observation and repeated esophagograms to confirm healing
 

|AnswerAExp='''Incorrect'''-Placement of a nasogastric tube to the level of perforation, intravenous antibiotics, close observation and repeated esophagograms to confirm healing are conservative approaches for treating small perforations with a diameter of few millimeters without any diagnostic delay or septic symptoms.
|AnswerB=Gastrostomy
|AnswerBExp='''Incorrect'''-[[Gastrostomy]] is a controversial approach and is never recommended. 
|AnswerC=Esophagectomy and esophagogastrostomy via laparotomy and left thoracotomy 
|AnswerCExp='''Incorrect'''-Only in distal perforations that are close to the gastroesophageal junction, a left thoracotomy approach is recommended.
|AnswerD=Esophagectomy and esophagogastrostomy via laparotomy and right thoracotomy
|AnswerDExp='''Correct'''-Perforation of the esophagus requires aggressive intervention in virtually all circumstances. While that intervention can usually consist of efforts to patch the perforation and drain the mediastinum, concomitant obstructive esophageal disease, whether inflammatory stenosis or cancer, mandates removal or bypass of the obstruction if control of the leak and its consequent persisting mediastinal and pleural contamination is to be accomplished. For distal esophageal cancers, many thoracic surgeons would use the classic Ivor-Lewis operation, which consists of mobilizing the stomach in the abdomen and then performing a right thoracotomy with mediastinal drainage, esophagectomy, and esophagogastrostomy. 
|AnswerE=Transhiatal esophagogastrectomy 
|AnswerEExp='''Incorrect'''-The transhiatal approach would probably be avoided in this situation where an unknown amount of mediastinal contamination has taken place.
|RightAnswer=D
|Approved=Yes
}}