Spontaneous Rupture of the Esophagus

Joint Hospital Surgical Grand Round21 April 2012

Dr Lee Wang Fai FrankPrincess Margaret Hospital

Originally described in 1724 by Dutch physician Hermann Boerhaave

Classical symptoms: Forceful vomiting followed by pain, dyspnoea, shock

Spontaneous rupture of the esophagus Rare condition with high mortality rate

Barogenic rupture caused by rapid rise in intraluminal pressure in the distal esophagus

90% at the left lateral position of lower third of esophagus due to anatomic weakness at that point

Esophageal and gastric contents sucked out through the perforation into mediastinum by negative intrathoracic pressure

Chemical burn by gastric juice Super-imposed necrotizing infection due

to digestive enzymes and oral bacteria Rapid tissue destruction and severe

sepsis

Mackler's triad (<14% of patients)• Vomiting (~80%)• Lower chest pain• Subcutaneous emphysema (~25%)

Common misdiagnosis• PPU• Myocardial infarction• Pneumonia• Pulmonary embolism• Aortic dissection• Pancreatitis

Diagnosis is commonly delayed

CXR: left pleural effusion, pneumomediastinum

Contrast esophagiogram

CT scan Upper endoscopy

Resuscitation and stabilization Elimination of infection

• Prevent further spoilage from the perforation

• Control of extraluminal contamination• Appropriate broad-spectrum antibiotics

coverage Enteric access for nutritional support Restoration of gastrointestinal

continuity

Conservative treatment Surgical treatment ("Gold standard")

• Primary closure +/- reinforcement• Drainage• Exclusion and diversion• Esophagectomy

Endoscopic treatment• Esophageal stenting• Endoclip application

Location of perforation Degree of tissue destruction Degree of contamination and sepsis Time interval from injury Presence of underlying esophageal

disorder Patient’s general condition and

comorbidities

In patients present late, with contained perforation

Patient selection• Criteria by Cameron (1970)

Minimal clinical sepsis Disruption contained in mediastinum Drainage of the cavity back into esophagus

Principles:• Restriction of oral intake• Parenteral antibiotics• Gastric acid suppresion• Fluid resuscitation• +/- Percutaneous drainage of abscess• +/- Nasogastric tube insertion

Transthoracic primary repair• “Gold standard”• Best result for patients present within 24

hours• Tension-free apposition of healthy mucosal

and submucosal tissue• +/- Reinforcement with autologous tissue,

e.g. intercostal muscle, pleural or omental flap

• Thoracotomy vs VATS

Drainage• When direct repair is thought to have high

chance of leakage• Drainage alone• +/- T-tube• Convert into controlled fistula

Exclusion and diversion• Repair may be impossible in some patients, who

present late with sepsis, heavy mediastinal contamination and devitalized esophageal tissue

• Exclusion of the esophagus Ligation of the cardia Prevent reflux of gastric content

• Diversion of oral secretions Cervical esophagostomy

• Require a second operation for restoration of gastrointestinal continuity

• Esophagus is preserved for later reconstruction

Esophagectomy• When there is heavy mediastinal

contamination and necrotized esophageal tissue beyond salvage, or when underlying esophageal pathology is suspected

• Transthoracic / transhiatal esophagectomy• Closure of cardia• Formation of cervical esophagostomy• Delayed reconstruction

Additional procedures to consider• Decompressing gastrostomy

Drainage of gastric content• Feeding jejunostomy

Facilitate early enteric feeding• Fundoplication

Prevention of reflux

Endoscopic stenting• Self-expanding metallic stent (SEMS)

Fully covered vs Partially covered• Self-expanding plastic stent (SEPS)

Effective seal of perforation

• High reported success rate (~85%)• Mean time of stent placement: 6-8 weeks• Time delay between rupture and treatment

remains most critical prognostic factor• Require concurrent adequate drainage of

fluid collection in mediastinum / pleural cavity

• Patient selection remains a topic of continued study; no guideline available currently

Complications• Stent migration (25%)

More common in fully covered stent• Tissue in-growth and over-growth

Increased difficulty in removal of stent More common in partially covered stent

No significant differences in efficacy between different types of stents

Endoscopic clipping• Limited to small clean perforations

(<1.5cm) and minimal symptoms of infection

• Early diagnosis and treatment• Reports of successful clipping of late,

mature perforation

Reported mortality varies in the literature (8-60%)

Mortality remains high and seemingly unchanged in recent 20 years

Delayed treatment is associated with higher mortality and complication rate

Multiple treatment options and operative strategies

Limited evidence in the literature on best treatment• Rare disease• Retrospective case series, case reports, expert

opinions• Reporting bias

Treatment should be individualized Early recognition and prompt treatment

are needed to maximize survival