Joint Hospital Grand Joint Hospital Grand RoundRound

- Boerhaave’s - Boerhaave’s Syndrome and Syndrome and Oesophageal Oesophageal PerforationPerforation

NDHDr. Samson Tse

Case PresentationCase Presentation(Boerhaave’s Syndrome)(Boerhaave’s Syndrome)

WT Lee M/69

Good past health except chronic duodenal ulcer detected >10 years ago

Case PresentationCase 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 PresentationCase 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 PneumomediastinumCauses of Pneumomediastinum

Pulmonary pathology Tracheal pathology Oesophageal pathology Iatrogenic Idiopathic

Case PresentationCase 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

TreatmentTreatment

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 BackgroundHistoric 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 barogenic perforation, postemetic perforation and spontaneous oesophageal ruptureand spontaneous oesophageal rupture

Clinical PresentationClinical Presentation

Depending on the locationocation and sizesize of the injury and the time coursetime course

Almost always on the leftleft side of the distal distal thirdthird oesophagus (~90%)

Most occurs along the longitudinal axis Mucosal tear often longer than the serosal

tear

Clinical PresentationClinical Presentation

PainPain 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 Hamman’s sign had been reported Mackler’s classic triad Mackler’s classic triad of vomiting, chest

pain and subcutaneous emphysema is less common than originally thought

DiagnosisDiagnosis

? 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%

DiagnosisDiagnosis

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, Meng

oli 1965 Arch Surg)

DiagnosisDiagnosis

Thoracentesis may aid in diagnosisAcidic 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)

PathophysiologyPathophysiology

Mainly due to necrotizing mediastinitisnecrotizing mediastinitis Hydropneumothorax and localized

perioesophageal abscess are common finding Staphylococcus, Pseudomonas, Staphylococcus, Pseudomonas,

Streptococcus and Bacteroides Streptococcus and Bacteroides usually involved

Natural history is fluid sequestration, fluid sequestration, sepsis and deathsepsis and death

Medical Management for Medical Management for Oesophageal PerforationOesophageal Perforation

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 ManagementMedical Management

Criteria for conservative management :-- clinically stable, minimal sepsis- elective instrumental perforation- contained perforation- absence of crepitus, pneumothorax or pneumoperitoneum

Medical ManagementMedical 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 ManagementSurgical Management

Surgical techniques include drainage alonedrainage alone, drainage and repair (direct closure, drainage and repair (direct closure, omental; diaphragmatic or fundal patch) omental; diaphragmatic or fundal patch) , and drainage and diversion drainage and diversion depending on the location of perforation, time period between perforation and diagnosis and the presence of underlying oesophageal disease

Surgical ManagementSurgical Management

Open vs minimal invasive technique Most suitable operation is usually “

tailor made” operation for individual patient

Surgical ManagementSurgical 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

MortalityMortality

Overall mortality of oesophageal perforations is 15.5% - 29% (range 0-64%)

Outcome depends on timing of treatment, timing of treatment, location and aetiology of the perforationlocation and aetiology of the perforationBoerhaave’s syndrome has the highest mortality rate – from 22% - 63%

Underlying oesophageal disease increases the mortality rate by sixsix times

ConclusionConclusion

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