Question 19

You are called to review an 86-year-old female, with severe pleuritic chest pain and difficulty breathing following dilation of an oesophageal stricture. Her CT thorax scan confirms an oesophageal perforation.

Outline your management of this problem, including the options for definitive treatment.

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College answer

Not available.

Discussion

This question is virtually identical to Question 16 from the second paper of 2016.

Immediate management

  • Attention to ABCs and correction of immediately identified life-threatening 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 placement
  • 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)

References

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.

Patton, Anthony S., et al. "Reevaluation of the Boerhaave syndrome: A review of fourteen cases." The American Journal of Surgery 137.4 (1979): 560-565.

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.