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Management of Boerhaave's Syndrome

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Presentation on theme: "Management of Boerhaave's Syndrome"— Presentation transcript:

1 Management of Boerhaave's Syndrome
Spontaneous Rupture of the Esophagus Joint Hospital Surgical Grand Round 21 April 2012 Dr Lee Wang Fai Frank Princess Margaret Hospital

2 Boerhaave's Syndrome Spontaneous rupture of the esophagus
Rare condition with high mortality rate Originally described in 1724 by Dutch physician Hermann Boerhaave Classical symptoms: Forceful vomiting followed by pain, dyspnoea, shock

3 Pathophysiology 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

4 Pathophysiology 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

5 Diagnosis Mackler's triad (<14% of patients) Common misdiagnosis
Vomiting (~80%) Lower chest pain Subcutaneous emphysema (~25%) Common misdiagnosis PPU Myocardial infarction Pneumonia Pulmonary embolism Aortic dissection Pancreatitis

6 Diagnosis Diagnosis is commonly delayed
CXR: left pleural effusion, pneumomediastinum Contrast esophagiogram CT scan Upper endoscopy

7 Management principles
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

8 Therapeutic options Conservative treatment
Surgical treatment ("Gold standard") Primary closure +/- reinforcement Drainage Exclusion and diversion Esophagectomy Endoscopic treatment Esophageal stenting Endoclip application

9 Factors to consider 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

10 Conservative treatment
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

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

12 Surgical treatment 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

13 Surgical treatment Drainage
When direct repair is thought to have high chance of leakage Drainage alone +/- T-tube Convert into controlled fistula

14 Surgical treatment 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

15 Surgical treatment 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

16 Surgical treatment Additional procedures to consider
Decompressing gastrostomy Drainage of gastric content Feeding jejunostomy Facilitate early enteric feeding Fundoplication Prevention of reflux

17 Endoscopic stenting Endoscopic stenting Effective seal of perforation
Self-expanding metallic stent (SEMS) Fully covered vs Partially covered Self-expanding plastic stent (SEPS) Effective seal of perforation

18 Endoscopic stenting 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

19 Endoscopic stenting 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

20 Endoscopic treatment 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

21 Outcome 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

22 Conclusion 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

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