Ruptured oesopahgus and Boerhaave's syndrome
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Associated with a high mortality usually secondary to delayed diagnosis and inadequate resuscitation and treatment. 60 % occur in thoracic oesophagus, 24 % in cervical and 16 % in abdominal oesophagus.
Instrumentation eg scopes
Operative
Blunt
Foreign body
Caustic injury
Postemetic (Boerhaaves Syndrome)
Thoracic tumours
Depends on level, duration of perforation, and whether complications have started.
Cervical oesopahgus - Severe pain and subcutaneous emphysema
Thoracic and abdominal oesophagus - Pain radiating to back, subcutaneous emphysema, peritonitis, dullness and reduced air entry on side of leak.
It should not be forgotten about the anatomical planes that can allow spread within the neck and mediastinum
A high index of suspicion
CXR - Air in the mediastinum and soft tissue of the neck. Pleural effusions and pneumothorax. An air fluid level may be seen.
Contrast study - To demonstrate site of perforation and associated pathology. If this is normal consideration should be given to a dilute barium examination as the higher density may demonstrate the hole if their is one.
CT scan - This can help, as it is more sensitive at detecting mediastinal air than a plain CXR.
OGD - Useful at time of operation in identifying the site of the hole, associated pathology. May also help intra operatively in finding the exact location of the hole as it can be difficult intra operatively secondary to the adhesions.
Unless the patient has excessive comorbid medical conditions or is so sick that an operation would be inhumane an operation is warranted. In very sick patients the use of a covered stent with drainage of any collection with large drains may be a temporising measure. A very well patient with say a guide wire perforation, with no systemic symptoms, no emphysema or effusion could probably be managed with NBM and iv antibiotics.
Adequate pre operative resuscitation can not be over emphasised.
If any associated pathology has been demonstrated the operation should be tailed to fix this if possible, eg oesophageal cancer or achalasia or stricture.
Cervical oesophageal perforation
Exploration via a neck incision parallel to sternocleidomastoid with extensive drainage of the retropharngeal space and upper mediastinum
Thoracic oesophageal perforation
Upper and mid thoracic perforations are best approached from the right. Lower ones are usually best approached from the left, but depends on which side the hole is and the amount of pleural involvement.
At thoracotomy but before rib spreading the decision to take an intercostal muscle flap should be taken as spreading can damage its vascular supply.
The perforation is found with the help of the light in the scope and the help of a Maloney bougie in the oesophagus. The entire length of the mucosal perforation should be visualised by dissecting the overlying muscle layers.
Primary repair over a bougie is performed if possible, which can be buttressed by the intercostal flap (pleura, pericardium and diaphragm can also be utilised).
The entire thoracic cavity should be cleaned and debrided including the visceral pleural surface.
Chest tubes are inserted, one of which should be adjacent to the repair, to maintain position the drain may need to be sutured in position.
Abdominal oesophageal perforation
Similar to above.
Upper midline laparotomy, all collections are evacuated.
Primary repair is buttressed by utilising ome3ntum or gastric fundus.
ALL PATIENTS SHOULD HAVE A
CONTRAST SWALLOW ON DAY 5 TO 7
BEFORE BEING ALLOWED TO COMMENCE ON FLUIDS.
Controversial points
Gastrostomy placement for the prevention of reflux of gastric contents up to the area of repair.
Feeding jejunostomy / TPN / Double lumen nasogastroduodenal tube ( you drain the proximal port in the stomach and feed into the distal port which is placed distal to the pylorus endoscopically)