Question 16

College answer

This is an emergency situation. Leakage of oesophageal and gastric contents results in a severe necrotising mediastinitis with sequelae of septic shock, multi-

organ failure and death. Mortality is about 20% and probably higher in this age group.

The principles of management are:

• Resuscitation
• Supportive care including haemodynamic monitoring
• Broad-spectrum antibiotics
• Control of extra-luminal contamination
• Analgesia
• Nil by mouth
• Plan for definitive treatment to close or bypass the perforation
• Nutritional support
• Ensure adequate oxygenation and ventilation
  • NIV and bag-valve-mask assisted ventilation contra-indicated
  • If severely hypoxic or shocked needs intubation (unless palliative approach appropriate)
• Haemodynamic support with fluid resuscitation and vasopressor support as indicated. Cautious fluid replacement in 86-year-old with echo or other haemodynamic monitoring guidance. 
  Monitoring including A-line and CVC and transfer to ICU/HDU
• Early broad-spectrum antimicrobials to cover gram positives, gram negatives and anaerobes, e.g.Tazocin, Meropenem. May need addition of Vancomycin if MRSA likely and consider anti-fungal if immunocompromised or long stay in hospital
• Drainage of pleural and mediastinal collections (source control) with surgical and/or interventional radiology assistance
• Analgesia – opiates and adjuncts as needed
• Strictly nil by mouth
• Surgical opinion
• Treatment options
  • Operative
    • Surgical repair
    • Oesophagectomy
    • Oesophageal diversion
  • Non-operative- Covered oesophageal stent –appropriate if early diagnosis, contained perforation and limited extra-luminal soilage
  • Conservative approach -antibiotics and feeding tube (jejunostomy) ± drains
• Nutrition – likely to need TPN if poor baseline state of nutrition. NJ tube or jejunostomy can be sited at time of stent placement or surgical repair
• Follow-up imaging –CT gastrograffin swallow
• Consider treatment limitations with advanced age if significant co-morbidities, underlying inoperable cancer.

An acceptable answer for a pass mark included the following elements:

Resuscitation
Antimicrobial therapy
Surgical and non-surgical options
Nutrition

Additional Examiners' Comments:
Most  candidates  were  able  to  describe  surgical  and  non-surgical  options  for  definitive  treatment. However  candidates  who  did  not  pass  provided  superficial  answers  with  insufficient  detail.  Most candidates  addressed  the  ABCs  but  did  not  address  the  specific  issues  for  the  case.  For  example, issues  such  as  consideration  of  nutrition,  keeping  the  patient  nil  by  mouth,  analgesia  and  treatment limitations were commonly missed in the answers. Some candidates did not appreciate the need for resuscitation

Discussion

Immediate management

• Attention to ABCs and correction of immediately identified lifethreatening features
• Detailed history and thorough physical examination
• Assessment of airway patency and intubation as needed
• Maintenance of normoxia with supplemental oxygen
• Maintenance of normotension with fluid resuscitation and vasopressors as needed
• Analgesia and sedation
• Attention to broad-spectrum antibiotic cover, including antifungal agents

Investigations:

• CXR looking for pneumomediastinum
• CT chest with contrast
• Gastrograffin swallow (not barium)
• Intercostal catheter to drain pleural effusion and analyse it, looking for acidity (suggestive of gastric contents) and food particles.

Specific Management

• Thoracoscopic or open surgical management;
• alternatively, endoscopic stent placeemnt
• alternatively, conservative antibiotic-based management and supportive care in ICU
• alternatively, palliative care

Supportive management:

• TPN: they won't be eating for a while
• Broad-spectrum antibiotics (tazocin is a fine choice)
• Proton pump inhibitors to encourage the process of oesophageal repair
• Eventually, these people end up having surgery - but it is delayed until the empyema or mediastinal abscess are well-circumscribed.

Idiosyncratic ICU issues

• No positive pressure without intubation: even high flow nasal prongs can blow gas into the mediastinum. Thus, no bag-mask ventilation with intubation. All of these patients should be getting an RSI-like induction.

Social issues

• This is an iatrogenic complication. Full open disclosure must be carried out
• A family discussion of the possible outcome must take place, ideally led by the team of perforators.
• The mortality- irrespective of the management approach - will be in the order of 40% (Biancari et al, 2014)

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Eroǧlu, Atilla, et al. "Esophageal perforation: the importance of early diagnosis and primary repair." Diseases of the Esophagus 17.1 (2004): 91-94.

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Movsas, S. "Spontaneous Rupture of the Oesophagus Is Conservative Treatment Ever Justified?." Thorax 21.2 (1966): 111-114.

Bolooki, H. O. O. S. A. N. G., et al. "Spontaneous rupture of the esophagus: Boerhaave's syndrome." Annals of surgery 174.2 (1971): 319.

Curci, JOSEPH J., and MARC J. Horman. "Boerhaave's syndrome: The importance of early diagnosis and treatment." Annals of surgery 183.4 (1976): 401.

Teh, Elaine, et al. "Boerhaave's syndrome: a review of management and outcome." Interactive cardiovascular and thoracic surgery 6.5 (2007): 640-643.

Eroǧlu, Atilla, et al. "Esophageal perforation: the importance of early diagnosis and primary repair." Diseases of the Esophagus 17.1 (2004): 91-94.

Bhatia, Pankaj, et al. "Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience." The Annals of thoracic surgery 92.1 (2011): 209-215.

Spapen, J., et al. "Boerhaave's Syndrome: Still a Diagnostic and Therapeutic Challenge in the 21st Century." Case reports in critical care 2013 (2013).

Biancari, Fausto, et al. "Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies." World journal of surgery 37.5 (2013): 1051-1059.

Hasan, Shafqat, Ali NA Jilaihawi, and Dhruva Prakash. "Conservative management of iatrogenic oesophageal perforations—a viable option." European journal of cardio-thoracic surgery 28.1 (2005): 7-10.

Biancari, F., et al. "Treatment of esophageal perforation in octogenarians: a multicenter study." Diseases of the Esophagus 27.8 (2014): 715-718.