Boerhaave’s SyndromeIs Esophagostomy needed?

Dr Derek TL Tam

United Christian Hospital

Boerhaave’s Syndrome

1st descriped by Hermann Boerhaave in 1724

Mortality rate 8-60%

Spontaneous transmural perforation of the esophagus

Commonly at lower 1/3 of esophagus, involving left thoracic cavity

Hill 2003 ANZ J Surg

Diagnosis

High index of suspicion

Vomiting

Sudden onset chest / epigastric pain

+/- Respiratory symptoms (dyspnea / cough)

Investigations

CXR– Hydrothorax, Hydropneumothroax– Mediastinal emphysema

Contrast study– Water soluble contrast– Barium study if inconclusive

CT– Difficulty to Dx or locate perforation– Contrast study not a/v

Investigations

Flexible endoscopy (OGD)– Rarely – Direct visualization of perforation site

Thoracentesis– Presence of undigested food– Low pH– ↑Salivary amylase

Management

Prompt recognition

Immediate action

Initial phase– Resuscitation and close monitoring– NPO– Broad-spectrum antibiotic therapy– NG decompression Whyte 2005 Surg Clin N Am

Subsequent phase depends on – Time course– Location, cause, extent of injury– Presence of intrinsic disease (eg. carcinoma /

distal obstruction)– Age and general health of patient

Whyte 2005 Surg Clin N Am

Surgical Objectives

Repair of perforation and restore gastrointestinal integrity

Eliminate infection and contamination

Nutritional support

Brinster 2004 Ann Thorac Surg

Surgical Plan

Infection and contamination:– Thoracotomy– Mediastinal and pleural drainage– Broad-spectrum antibiotics

Surgical Plan

Perforation:– Primary repair +/- reinforced primary repair +/-

T-tube OR– T-tube alone OR– Esophagectomy with immediate or interval

reconstruction OR – Endoscopic means

Whyte Surg Clin N Am 2005, Davies Ann Thorac Surg 1999

Repair of Perforation

Primary repair– 2 layer repair– Meticulous exposure and repair of mucosa – Repair of muscular tear– Debridement of necrotic tissue

Perforations with underlying distal obstruction requires additional evaluation

Whyte 2005 Surg Clin N Am, Brinster 2004 Ann Thorac Surg, Zwischenberger 2001 Am J Respir Crit Care Med

Repair of Perforation

Reinforced primary repair– Pleural flap– Diaphragmatic flap– Pericaridal flap– Intercostal muscle flap– Ometum– Fundus of stomach

Whyte 2005 Surg Clin N Am, Brinster 2004 Ann Thorac Surg, Zwischenberger 2001 Am J Respir Crit Care Med

Injuries beyond repair

Esophageal T-tube– Controlled fistula– Problem of chronic fistula

Esophagectomy +/- immediate or interval reconstruction

Brinster 2004 Ann Thorac Surg

Determinants of Success

Interval between perforation and treatment

Age and general health of patient

Severity of contamination

Controversy

? Esophagostomy

Our experience

Recent 3 consecutive patients

Esophagostomy – 2 patients

Without esophagostomy – 1 patient

Patient 1 Patient 2 Patient 3

Esophagostomy Yes Yes No

ICU stay (days) 11 10 49

Thoracic contamination

Well after first thoractomy

Well after first thoractomy

Requires second thoracotomy

Hospital stay (days)

45 55 78

Vocal cord palsy Nil Left VC palsy Nil

Literature review

MEDLINE database– Esophageal perforation– Boerhaave’s syndrome– Diversion– Esophagostomy

“Can be extremely helpful in controlling ongoing thoracic contamination and sepsis”

“Employed when the patient is too unstable to tolerate definitive repair or resection”

Koniaris 2004 American College of Surgeons

Whyte 2005 Surg Clin N Am

Esophagostomy

Described many decades ago

Possible role of contamination by oral secretions

Form of esophageal diversion

Whyte 2005 Surg Clin N Am, Koniaris 2004 American College of Surgeons

Originally an end-cervical esophagostomy plus division and closure of esophagus proximal and distal to site of injury

Later a side cervical esophagostomy plus placement of either a staple line or removable ligature distally

Advantages:– Role of controlling oral secretions is critical– Risk or ability to tolerate ongoing sepsis is

impaired

Disadvantages:– Needs second operation– Increase risk of morbidity– May result in subsequent leak or late stricture

Koniaris 2004 American College of Surgeons

Surgical Management

No golden standard or guidelines because few surgeons have managed enough patients

Conclusion

Boerhaave’s syndrome requires prompt recognition and aggressive management

Individualized approach to every patient

Use of cervical esophagostomy carries its own risk of morbidity

Thank You

Koniaris 2004 American College of Surgeons

Koniaris 2004 American College of Surgeons