Question 26

College answer

Not available.

Discussion

This question is identical to Question 23 from the second paper of 2019.

Management priorities:

1. Stabilise the patient (control ABCD)
2. Organise definitive management, which will be surgical, bronchoscopic or endoscopic
3. Prepare the family for the worse

As usual, the management can be divided into "supportive" and "specific".

Supportive management:

• Airway management:
  • Intubate the patient with a right-sided  double lumen tube
  • Ideally do this in theatre, with an upper GI and thoracic surgen present. The risk here is that potentially, you will place the tube in such a violently stupid way that the bronchio-oesophageal tear is extended. The  consequence may be massive pneumomediastinum and an unventilatable patient with rapidly falling blood pressure due to greater vessel compression. 
• Ventilator management
  • With a single lumen tube:
    • Account for large leak: use a pressure-control mode
  • With a double lumen tube:
    • Use differential lung ventilation
    • Ventilate the "good" lung with normal one-lung ventilation
    • Ventilate the "bad" lung with some modest  PEEP (~ 5-8) and zero inspiratory pressure (i.e. CPAP)
• Sedation and analgesia
  • ​​​​With a double lumen tube, ideally the patient should be paralysed and sedated to prevent tube dislodgement and to facilitate differential lung ventilation
  • With a single lumen tube, spontaneous respiratory activity should be encouraged and sedation should be minimised
• Gastrointestinal/nutritional management:
  • If this is feasible,place an NGT endoscopically and allow it to vent freely or place it on low wall suction
  • Most likely, this is not feasible, and the whole anastomotic site should be left well alone  
  • Feed the patient parenterally 
  • Use liberal PPI  therapy (perhaps an infusion of pantoprazole)
• Management of infection
  • One can almost guarrantee that some infectious process will take place, 
    • in the lung (aspirtation)
    • in the chest cavity (collection)
    • in the abdominal cavity
  • Thus, empiric antibiotics should probably be commenced, and these should ideally be broad enough to cover upper GI anaerobes. You can always stop them again in a couple of days, when the antimicrobial stewardship people start mocking you openly in the corridors.
• Management of family expectations
  • The outcome for these scenarios is almost uniformly bad, particularrly wherre a malignancy is involved

Specific management resembles the oesophageal perforation options mentioned above, with the exception of all the bronchoscopic stuff:

• Bronchoscopic repair
  • Bronchial stent
• Gastroscopic repair options
  • self-expanding esophageal stainless steel-covered metal stents (SEM)
• Surgical repair options
  • Resection and diversion (i.e. oesophagus is externalised in the neck; one essentially disconnects the upper GI tract from the lower)
  • Resection and re-anastomosis (the latter is risky)
  • Conservative management (i.e. after having a look and the placement of a NG tube, the patient returns to ICU for conservative and palliative management)