boerhaave ’ s syndrome is esophagostomy needed? dr derek tl tam united christian hospital
TRANSCRIPT
Boerhaave’s SyndromeIs Esophagostomy needed?
Dr Derek TL Tam
United Christian Hospital
Boerhaave’s Syndrome
1st descriped by Hermann Boerhaave in 1724
Mortality rate 8-60%
Spontaneous transmural perforation of the esophagus
Commonly at lower 1/3 of esophagus, involving left thoracic cavity
Hill 2003 ANZ J Surg
Diagnosis
High index of suspicion
Vomiting
Sudden onset chest / epigastric pain
+/- Respiratory symptoms (dyspnea / cough)
Investigations
CXR– Hydrothorax, Hydropneumothroax– Mediastinal emphysema
Contrast study– Water soluble contrast– Barium study if inconclusive
CT– Difficulty to Dx or locate perforation– Contrast study not a/v
Investigations
Flexible endoscopy (OGD)– Rarely – Direct visualization of perforation site
Thoracentesis– Presence of undigested food– Low pH– ↑Salivary amylase
Management
Prompt recognition
Immediate action
Initial phase– Resuscitation and close monitoring– NPO– Broad-spectrum antibiotic therapy– NG decompression Whyte 2005 Surg Clin N Am
Subsequent phase depends on – Time course– Location, cause, extent of injury– Presence of intrinsic disease (eg. carcinoma /
distal obstruction)– Age and general health of patient
Whyte 2005 Surg Clin N Am
Surgical Objectives
Repair of perforation and restore gastrointestinal integrity
Eliminate infection and contamination
Nutritional support
Brinster 2004 Ann Thorac Surg
Surgical Plan
Infection and contamination:– Thoracotomy– Mediastinal and pleural drainage– Broad-spectrum antibiotics
Surgical Plan
Perforation:– Primary repair +/- reinforced primary repair +/-
T-tube OR– T-tube alone OR– Esophagectomy with immediate or interval
reconstruction OR – Endoscopic means
Whyte Surg Clin N Am 2005, Davies Ann Thorac Surg 1999
Repair of Perforation
Primary repair– 2 layer repair– Meticulous exposure and repair of mucosa – Repair of muscular tear– Debridement of necrotic tissue
Perforations with underlying distal obstruction requires additional evaluation
Whyte 2005 Surg Clin N Am, Brinster 2004 Ann Thorac Surg, Zwischenberger 2001 Am J Respir Crit Care Med
Repair of Perforation
Reinforced primary repair– Pleural flap– Diaphragmatic flap– Pericaridal flap– Intercostal muscle flap– Ometum– Fundus of stomach
Whyte 2005 Surg Clin N Am, Brinster 2004 Ann Thorac Surg, Zwischenberger 2001 Am J Respir Crit Care Med
Injuries beyond repair
Esophageal T-tube– Controlled fistula– Problem of chronic fistula
Esophagectomy +/- immediate or interval reconstruction
Brinster 2004 Ann Thorac Surg
Determinants of Success
Interval between perforation and treatment
Age and general health of patient
Severity of contamination
Controversy
? Esophagostomy
Our experience
Recent 3 consecutive patients
Esophagostomy – 2 patients
Without esophagostomy – 1 patient
Patient 1 Patient 2 Patient 3
Esophagostomy Yes Yes No
ICU stay (days) 11 10 49
Thoracic contamination
Well after first thoractomy
Well after first thoractomy
Requires second thoracotomy
Hospital stay (days)
45 55 78
Vocal cord palsy Nil Left VC palsy Nil
Literature review
MEDLINE database– Esophageal perforation– Boerhaave’s syndrome– Diversion– Esophagostomy
“Can be extremely helpful in controlling ongoing thoracic contamination and sepsis”
“Employed when the patient is too unstable to tolerate definitive repair or resection”
Koniaris 2004 American College of Surgeons
Whyte 2005 Surg Clin N Am
Esophagostomy
Described many decades ago
Possible role of contamination by oral secretions
Form of esophageal diversion
Whyte 2005 Surg Clin N Am, Koniaris 2004 American College of Surgeons
Originally an end-cervical esophagostomy plus division and closure of esophagus proximal and distal to site of injury
Later a side cervical esophagostomy plus placement of either a staple line or removable ligature distally
Advantages:– Role of controlling oral secretions is critical– Risk or ability to tolerate ongoing sepsis is
impaired
Disadvantages:– Needs second operation– Increase risk of morbidity– May result in subsequent leak or late stricture
Koniaris 2004 American College of Surgeons
Surgical Management
No golden standard or guidelines because few surgeons have managed enough patients
Conclusion
Boerhaave’s syndrome requires prompt recognition and aggressive management
Individualized approach to every patient
Use of cervical esophagostomy carries its own risk of morbidity
Thank You
Koniaris 2004 American College of Surgeons
Koniaris 2004 American College of Surgeons