Oesophageal rupture or perforation, including Boerhaave's
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No racial predominance
28-43 years mean, but 1-80 recorded
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Congenital structural lack of muscularis mucosa predisposes (very
Corrosive oesophagitis (TB, AIDS)
Tumours causing necrotic rupture (esophagus, lung, mediastinum)
Trauma (eg steering wheel)
Foreign bodies, caustic ingestion.
Barrett's ulcer perforation
Iatrogenic instruments (endoscopes, balloons, nasogastrics)
Surgical injury (thyroid / parathyroid surgery, antireflux, thoracic
Mechanical spontaneously from vomiting
Commonly a predisposing factor is identified
- but can be spontaneous
Increased intraoesophageal pressure precipitates the event
- e.g. vomiting, coughing, retching, lifting, straining.
--> in Boerhaave's, typically at left posterolateral wall of
lower third of esophagus, 2-3cm proximal to the GEJ.
(this wall is strcturally and inherently weak as longitudinal muscle
fibers taper out before passing onto stomach wall.
May be due to instrumentation
Free air & contents enter mediastinum
- encouraged by relatively negative intrathoracic pressure
- passage tract depends on rupture site; inferior / posterior perf
--> descent into post mediastinum, cervical perf can -->
anterior mediastinum as well.
- spreads to neck and chest; subcutaneous emphysema and poss.
Gastric contents may be dumped into mediastinum if post-prandial
--> mediastinitis and severe illness
Mediastinal pleura then ruptures
--> typically L sided pleural effusion / collection; can be
Sepsis rapidly established if not diagnosed and treated
--> mediastinal abscess and pleuropulmonary suppuration.
Smaller ruptures may allow only air out
- presentation may be delayed for days or even weeks after the
Factors influencing mortality
Location of perf
Intrinsic oesophageal disease.
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History of vomiting in Boerhaave's
50% are asymptomatic for 8 hours
- lapsed time before diagnosis impacts on morbidity / mortality.
- vomiting, chest pain and subcutaneous emphysema in 1/3
- especially if upper oesophagus
Severe retrosternal chest +/- epigastric pain
- worse on breathing
- can be mild in elderly
Dysphagia, odynophagia, nausea, retching, vomiting
Hoarseness and difficulty speaking
- may be high pitched if air around larynx
- in distal rupture
Subcutaneous emphysema if pneumomediastum
May note reduced chest wall movements
Gastric contents on chest drainage
Look for fever and sepsis
- crepitus is early and reliable
- look for this if worried about gastroscopy perforation.
Heart and trachea displacement
Abdomen is often very tender
- can confuse diagnosis.
Crepitance of chest
Crunching, rasping, grasping sound synchronous with pulse and
heard over praecordium
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Dissection of air along subcutaneous planes and into mediastinum
is a hallmark.
More sensitive for mediastinal air, abscess, and inflammation.
Most advise an urgent formal esophagogram
Radio-opaque contrast swallow can confirm location of a hole.
- and avoids unnecessary exploration.
- options are thin barium or gastrografin; water soluble agents have
a risk of aspiration with chemical pneumonitis.
If negative, but high clinical suspicion, can repeat after several
Helps to evaluate associated pathology that may have caused the
- fears of worsening the injury outweighed by the information gained
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- careful! pass during esophagram to prevent further injury.
Chest tube for drainage
Parenteral broad spectrum ABs rapidly.
- including fungi, gram +ves and gram -ves.
Depends on cause and location of injury.
Selective cases and with very close monitoring (e.g. in ICU)
- minor holes in well patients, often after procedures (i.e. little
- criteria: intraluminal dissection, transmural that drains back
into oesophagus, no distal obstruction, not in abdo cavity, no
sepsis, no cancer.
If signs of sepsis, needs urgent operative intervention (20%+)
NBM at least 3 days, place a covered stent, and then slowly advance
Generally, early aggressive surgical management.
Surgical drainage and primary closure of tear for large tears /
septic patients ASAP
L neck incision over anterior SCM.
Retract carotid sheath and IJV laterally and trachea and esophagus
Bluntly enter retroesophageal space, along prevertebral fascia
- identify and preserve the RLN in the tracheo-esophageal groove.
Finger dissection to posterior mediastinum to drain all collections.
Close defect with absorbable sutures and drain.
(If penetrating trauma, with tracheal concomitant injury, must have
a pedicled muscle flat to separate two repairs).
Upper 2/3rds: R thoracotomy in 4th or 5th intercostal space.
Lower 1/3: through 6th or 7th intercostal space.
Options are primary repair, diversion or esophagectomy.
- utmost importance to know if there is intrinsic oesophageal
disease - guides operative intervention.
Primary repair is preferred
- open layers above and below to visualize mucosa; usually injury
here is more extensive than muscle injury.
- two layered closure
--> can use a GIA to grab the mucosal edges and staple them back
--> then absorbable suture closure of muscle layer
--> buttressed via pleura, or muscle from intercostals.
Irrigate pleural cavities and place chest drains.
If Ca, or injury proximal to a long stricture
- oesophagectomy and immediate reconstruction
--> must not have obstruction distal to repair.
Similar to above: debridement, drainage, two-layer closure and
Closure and fundoplication, essentially.
Address any intrinsic oesophageal disorders.
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Hill, J. Surgical Emergencies - an on the spot guide.