Transcript Historic Background

Joint Hospital Grand Round
- Boerhaave’s Syndrome and
Oesophageal Perforation
NDH
Dr. Samson Tse
Case Presentation
(Boerhaave’s Syndrome)
 WT Lee
 M/69
 Good past health except chronic
duodenal ulcer detected >10 years ago
Case Presentation
 Presented on 21.12.2002 with repeated
vomiting and diarrhoea and epigastric
pain radiating to back
 No history of foreign body ingestion or
trauma
 CXR normal and discharged from A&E
Case Presentation
 Reattended on 24.12.2002 with dysphagia,
SOB and persistent right sided chest and back
pain
 Clinical examination – right anterior chest wall
tenderness and decreased right sided air entry
 CXR – subcutaneous emphysema,
pneumomediastinum and RLZ hazziness
Causes of Pneumomediastinum
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Pulmonary pathology
Tracheal pathology
Oesophageal pathology
Iatrogenic
Idiopathic
Case Presentation
 Water soluble contrast study
performed – extraluminal collection of
contrast near the gastro-oesophageal
junction
 CT – pneumomediastinum and pocket of
air-fluid level in the lower thorax around
the lower thoracic oesophagus
Treatment
 Right sided chest drain insertion, blood stained
fluid with some debris drained
 Drainage and diversion decided - transection of
oesophagus, cervical oesophagostomy,
gastrostomy and feeding jejunostomy 3 days
later
 Laparotomy and presternal gastric
transposition 3½ months later
Historic Background
 Hermann Boerhaave described the clinical
presentation, the progress and the autopsy
finding of this syndrome in 1724
 Boerhaave’s syndrome is synonymous to
barogenic perforation, postemetic perforation
and spontaneous oesophageal rupture
Clinical Presentation
 Depending on the location and size of the
injury and the time course
 Almost always on the left side of the distal
third oesophagus (~90%)
 Most occurs along the longitudinal axis
 Mucosal tear often longer than the serosal tear
Clinical Presentation
 Pain occurs in 80-100% of cases
 Other symptoms including dyspnoea,
dysphagia, facial swelling, proptosis,
dysphonia, polydipsia, haematemasis,
hoarseness and SCM muscle spasm
Clinical Presentation
 Signs including an acutely ill patient with fever,
subcutaneous or mediastinal emphysema,
tachycardia, tachypnea, cyanosis and shock
 Hamman’s sign had been reported
 Mackler’s classic triad of vomiting, chest
pain and subcutaneous emphysema is less
common than originally thought
Diagnosis
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? History
CXR (AP and lateral), erect AXR
Lateral neck XR
Gastrograffin / Barium contrast study
If gastrograffin negative -> follow by Barium
-> will detect 60% of cervical and 90%
surgically confirmed perforations – (Bladergroen MR
1986 & Symbar PN 1972 Ann Thor Surg, Kim-Deobald J 1992, Am J GE)
False negative rate of 10-36%
Diagnosis
 IV and oral contrast CT scan thorax and
abdomen
 Endoscopy’s role is highly questionable but
has high accuracy for perforation secondary to
external injury but not recommended for acute,
non-penetrating perforations(Horwitz 1993 & Kim-Deobald
1992 AJGE, Mengoli 1965 Arch Surg
)
Diagnosis
 Thoracentesis may aid in diagnosis
Acidic pH, elevated salivary amylase,
purulent foul smelling material, or
presence of undigested food are useful
finding (Attar 1990 Ann Thor Surg, Dubost 1979 J Thor
Cadiovas, Roufail 1972 GI Endo)
Pathophysiology
 Mainly due to necrotizing mediastinitis
 Hydropneumothorax and localized
perioesophageal abscess are common finding
 Staphylococcus, Pseudomonas,
Streptococcus and Bacteroides usually
involved
 Natural history is fluid sequestration, sepsis
and death
Medical Management for
Oesophageal Perforation
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Principles of medical treatment consists of :- NPO
- parental alimentation
- nasogastric suction
- board spectrum antibiotics
Good results achieved but only in patients
with instrumentation perforation (Mengoli 1965 Arch
Surg, Wesdorp 1984 Gut, Sarr 1982 JTCVS, Michel 1981 Ann Surg)
Medical Management
 Criteria for conservative management :- clinically stable, minimal sepsis
- elective instrumental perforation
- contained perforation
- absence of crepitus, pneumothorax or
pneumoperitoneum
Medical Management
 Endoprothesis usually reserved for patients
with malignant disease and instrumental
perforation (Wesdorp 1984 Gut, Hine 1986 Dig Dis Sci, Nicholson 1995
Clin Rad)
 Successful use of endoprothesis in
management of Boerhaave’s Syndrome had
also been reported (Chung 2001 Endoscopy, Davies 1999 Ann
Thorac Surg)
Surgical Management
 Surgical techniques include drainage alone,
drainage and repair (direct closure,
omental; diaphragmatic or fundal patch) ,
and drainage and diversion depending on
the location of perforation, time period between
perforation and diagnosis and the presence of
underlying oesophageal disease
Surgical Management
 Open vs minimal invasive technique
 Most suitable operation is usually
“ tailor made” operation for individual
patient
Surgical Management
 Criteria for surgical management :- Boerhaave’s syndrome
- clinically unstable with sepsis, shock, and
respiratory failure
- contaminated mediastinum or pleural space
- perforation with retained foreign bodies
- perforation in oesophageal disease for which
elective surgery is considered
- failed medical therapy
Mortality
 Overall mortality of oesophageal perforations is
15.5% - 29% (range 0-64%)
 Outcome depends on timing of treatment,
location and aetiology of the perforation
Boerhaave’s syndrome has the highest
mortality rate – from 22% - 63%
 Underlying oesophageal disease increases the
mortality rate by six times
Conclusion
 A diagnostic and therapeutic challenge
 High index of suspicion in clinically suspicious
cases even if initial investigations are negative
 Thoracic site, delayed diagnosis and treatment
are the main factors contributing to poor
survival
 If surgery is performed, a 12-24 hour window
is optimal