And so here the question is, what do you do after you have an esophageal perforation? And I go straight to this slide, because first of all, if you recognize the esophageal perforation, you might want to try to close it with an Ovesco or with Eclipse. It's quite difficult, especially if the patient is not on their GA. And please bear in mind that in Europe, in the majority of the hospitals in Europe, we use still conscious sedation. So if this is the case, it's more difficult to place the clip or to close it with an Ovesco. If you fail to close the perforation, and that one that I showed you was quite a large perforation, then you need to perform, to give to the patient straight away antibiotics. So starting on antibiotics, and then if he needs to have an urgent CT scan of his chest with oral contrast, so that you are sure that is a transmural perforation that looked like a transmural perforation, but you might have smaller perforation that you're not sure. So CT scan with transoral contrast and start the patient on a painkiller. So it's like codeine or fentanyl or because I'm afraid, but paracetamol won't be enough. Of course, you need to involve the surgical team as soon as possible. And then you also, but this is very, it varies. So someone plays a nasogastric tube so that all the secretions are aspirated. And also in many hospitals, a nasoesophageal tube is inserted with a continuous aspiration so that all secretion and saliva are sucked. But it's also important that, that's one of the most important thing actually, the patient is too fast. So kneel by mouth, nothing. You might want the patient, if you cannot place a nasoesophageal tube with a continuous aspiration, you can ask the patient to spit out the saliva and try not to swallow the saliva. Bear in mind that this is for the patient a very, very tough situation because the patient will stay in the hospital at least for seven days because he needs to take antibiotic for seven days. And then he needs to have a repeat CT scan with barium, sorry, with oral contrast after seven days to check if the perforation has healed and is closed. So again, we come back here to the best friend rule. So no matter if you're covering the world or not, go back to the world and see the patient every day. And usually in this case, we, he needs to have gram, sorry, a full broad spectrum antibiotic cover. Now, always ask the surgeon to review him every day as well. The other point here for this patient is in some hospital, they place stent after a perforation. In other hospital, the stent is not placed. I think, and the guidelines here are a bit contradictory. So someone suggests the stent to be placed, other guidelines do not recommend the stent. So this is a gray area. I can tell you that, for example, in my hospital, we don't place stent in these cases anymore because the surgeon don't recommend it. But it's always better to double check with that.

esophageal perforation management

Ovesco clip

Eclipse clip

antibiotics

CT scan with oral contrast