Oesophageal Rupture


DEFINITION
Oesophageal rupture or perforation, including Boerhaave's
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INCIDENCE
No racial predominance
28-43 years mean, but 1-80 recorded
M>F
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AETIOLOGY

Congenital structural lack of muscularis mucosa predisposes (very rare)
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 aneurysm resection).
Heimlich maneuver
Mechanical spontaneously from vomiting
  (Boerhaave's Syndrome)
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BIOLOGICAL BEHAVIOUR

Pathogenesis

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

Complications
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. pneumothorax
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 bilateral.
Sepsis rapidly established if not diagnosed and treated
--> mediastinal abscess and pleuropulmonary suppuration.

Size dependency
Smaller ruptures may allow only air out
- presentation may be delayed for days or even weeks after the rupture.

Factors influencing mortality
Age
Comorbidities
Location of perf
Cause
Intrinsic oesophageal disease.
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MANIFESTATIONS

Symptoms
Local
History of vomiting in Boerhaave's
50% are asymptomatic for 8 hours
- lapsed time before diagnosis impacts on morbidity / mortality.
Machler's triad
- 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
Perhaps haematemesis
Hoarseness and difficulty speaking
- may be high pitched if air around larynx
Abdo pain
- in distal rupture

Complications
Rapid deterioration.

Signs
Observe
Subcutaneous emphysema if pneumomediastum
May note reduced chest wall movements
Gastric contents on chest drainage
Look for fever and sepsis

Palpate
Subcutaneous emphysema
- 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.

Percuss
Stoney dullness

Auscultate
Pleural fluid.
Crepitance of chest
Hamman's Crunch
C
runching, rasping, grasping sound synchronous with pulse and heard over praecordium
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INVESTIGATIONS

CXR

Mediastinal air
Pneumothorax
Pleural fluid
Dissection of air along subcutaneous planes and into mediastinum is a hallmark.

CT

More sensitive for mediastinal air, abscess, and inflammation.

Contrast Swallow

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 hours.

Endoscopy
Helps to evaluate associated pathology that may have caused the problem.
- fears of worsening the injury outweighed by the information gained if careful.
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MANAGEMENT

General Measures
NG suction
- careful! pass during esophagram to prevent further injury.
Cardiorespiratory support
Chest tube for drainage
Parenteral broad spectrum ABs rapidly.
- including fungi, gram +ves and gram -ves.
Treat sepsis
Nutritional support

Approach
Depends on cause and location of injury.

Conservative management
Selective cases and with very close monitoring (e.g. in ICU)
- minor holes in well patients, often after procedures (i.e. little contamination).
- 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 diet.


Surgical
Generally, early aggressive surgical management.
Surgical drainage and primary closure of tear for large tears / septic patients ASAP

Cervical Perf
L neck incision over anterior SCM.
Retract carotid sheath and IJV laterally and trachea and esophagus medially.
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).

Thoracic Perf
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 together longitudinally.
--> 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.

Abdominal Perf
Similar to above: debridement, drainage, two-layer closure and buttress repair
Closure and fundoplication, essentially.
Address any intrinsic oesophageal disorders.



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References
Hill, J.  Surgical Emergencies - an on the spot guide.
Cameron 10th