TWilliam2019
Guru
Procedure:
1. EGD with placement of esophageal stent (Boston Scientific wall flex 18 mm x 103 mm)
2. Endoscopic distal esophageal biopsies
3. Right open thoracostomy tube placement with evacuation of pleural effusion (32 French right angle chest tube)
Specimens:
-Right pleural fluid for cultures
-Esophageal biopsies from 36 cm, 34 cm, and 30 cm
Estimated blood loss: Minimal
Blood replaced: None drains: 32 French chest tube as described
Implants: Esophageal stent as described
Complications: None
Condition at the completion of the procedure: Stable
Indication:
77-year-old male presenting with chest pain and dysphagia. He was found to have a leukocytosis and pneumomediastinum upon initial work-up. Esophagram confirmed a contained esophageal leak in the distal mediastinum. CT scan of the chest also identified a newly developed right pleural effusion. He presents for definitive management.
Intraoperative findings:
-Chest tube: 950 mL of turbid serous fluid was evacuated from the right pleural space
-EGD: Perforation identified at 34 cm and extending to 35.5 cm. No overt masses were identified in the distal esophagus. There was some hypertrophic appearing esophageal mucosa which was biopsied. The edge of the perforation was also biopsied. Gastric chamber appeared anatomically normal with no ulcerations, active bleeding, or other pathology.
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table where he underwent general anesthesia with endotracheal intubation. Monitoring devices were placed by anesthesia. The patient is on broad-spectrum antibiotics for his esophageal perforation. The right chest was prepped and draped in the usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed.
Once the timeout was completed, a small 10 mm incision was made at the mid axillary line, roughly the sixth intercostal space. The soft tissues had already been injected with 1% Xylocaine for local anesthesia. Using blunt dissection, the hemostat was then used to access the right pleural cavity. The thoracostomy incision was then enlarged with a Kelly forcep. Digital sweeping of the pleural space was performed with some minor adhesions taken down. A 32 French right angle chest tube was then inserted with a large rush of turbid pleural fluid. A total of 950 mL of fluid was removed and a portion of it was submitted for routine cultures as described. The chest tube was secured with 0 silk and dressings were placed.
EGD was then performed. The scope was passed beyond the upper esophageal sphincter with some maneuvering. The cervical esophagus was anatomically normal. The thoracic esophagus at 30 cm had an eschar extending to approximately 36 cm. There were no masses within the region. The scope was advanced beyond this and into the stomach without difficulty. There were no strictures or masses identified. There was no gastric pathology identified. The scope was then retracted into the distal esophagus and it was flushed with saline. Multiple attempts were made to identify the perforation, but it appeared that it may have spontaneously sealed. Therefore, an NG tube was placed. When the NG tube was placed, a portion of the esophageal wall was retracted which identified the perforation extending from 34 to 35.5 cm. The NG tube was removed. At this point, esophageal biopsies were taken from 36 cm, 34 cm, and 30 cm from the incisors. These were submitted as permanent specimens.
Once the biopsies were completed, fluoroscopy was brought in. The perforation was marked at 34 cm. The scope was then advanced 5 cm distally to the perforation with a second marker placed. The scope was then advanced into the gastric chamber and the Jagwire was placed under fluoroscopic guidance. The endoscope was then removed. The Boston Scientific wall flex stent was then placed over wire and advanced under fluoroscopic guidance. Once at the distal marker, the stent was unsheathed and steadily released with excellent coverage of the perforation, with the perforation marker being identified at the midportion of the stent. Endoscope and wire were then removed.
This is not my specialty but one of our doctors decided to do this type of surgery. I need help. Any advce on learning these would be greatly appreciated.
?43266 Is this correct
1. EGD with placement of esophageal stent (Boston Scientific wall flex 18 mm x 103 mm)
2. Endoscopic distal esophageal biopsies
3. Right open thoracostomy tube placement with evacuation of pleural effusion (32 French right angle chest tube)
Specimens:
-Right pleural fluid for cultures
-Esophageal biopsies from 36 cm, 34 cm, and 30 cm
Estimated blood loss: Minimal
Blood replaced: None drains: 32 French chest tube as described
Implants: Esophageal stent as described
Complications: None
Condition at the completion of the procedure: Stable
Indication:
77-year-old male presenting with chest pain and dysphagia. He was found to have a leukocytosis and pneumomediastinum upon initial work-up. Esophagram confirmed a contained esophageal leak in the distal mediastinum. CT scan of the chest also identified a newly developed right pleural effusion. He presents for definitive management.
Intraoperative findings:
-Chest tube: 950 mL of turbid serous fluid was evacuated from the right pleural space
-EGD: Perforation identified at 34 cm and extending to 35.5 cm. No overt masses were identified in the distal esophagus. There was some hypertrophic appearing esophageal mucosa which was biopsied. The edge of the perforation was also biopsied. Gastric chamber appeared anatomically normal with no ulcerations, active bleeding, or other pathology.
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table where he underwent general anesthesia with endotracheal intubation. Monitoring devices were placed by anesthesia. The patient is on broad-spectrum antibiotics for his esophageal perforation. The right chest was prepped and draped in the usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed.
Once the timeout was completed, a small 10 mm incision was made at the mid axillary line, roughly the sixth intercostal space. The soft tissues had already been injected with 1% Xylocaine for local anesthesia. Using blunt dissection, the hemostat was then used to access the right pleural cavity. The thoracostomy incision was then enlarged with a Kelly forcep. Digital sweeping of the pleural space was performed with some minor adhesions taken down. A 32 French right angle chest tube was then inserted with a large rush of turbid pleural fluid. A total of 950 mL of fluid was removed and a portion of it was submitted for routine cultures as described. The chest tube was secured with 0 silk and dressings were placed.
EGD was then performed. The scope was passed beyond the upper esophageal sphincter with some maneuvering. The cervical esophagus was anatomically normal. The thoracic esophagus at 30 cm had an eschar extending to approximately 36 cm. There were no masses within the region. The scope was advanced beyond this and into the stomach without difficulty. There were no strictures or masses identified. There was no gastric pathology identified. The scope was then retracted into the distal esophagus and it was flushed with saline. Multiple attempts were made to identify the perforation, but it appeared that it may have spontaneously sealed. Therefore, an NG tube was placed. When the NG tube was placed, a portion of the esophageal wall was retracted which identified the perforation extending from 34 to 35.5 cm. The NG tube was removed. At this point, esophageal biopsies were taken from 36 cm, 34 cm, and 30 cm from the incisors. These were submitted as permanent specimens.
Once the biopsies were completed, fluoroscopy was brought in. The perforation was marked at 34 cm. The scope was then advanced 5 cm distally to the perforation with a second marker placed. The scope was then advanced into the gastric chamber and the Jagwire was placed under fluoroscopic guidance. The endoscope was then removed. The Boston Scientific wall flex stent was then placed over wire and advanced under fluoroscopic guidance. Once at the distal marker, the stent was unsheathed and steadily released with excellent coverage of the perforation, with the perforation marker being identified at the midportion of the stent. Endoscope and wire were then removed.
This is not my specialty but one of our doctors decided to do this type of surgery. I need help. Any advce on learning these would be greatly appreciated.
?43266 Is this correct