Oesophageal perforation was discussed in Question 3 from the first paper of 2011, Question 16 from the second paper of 2016 and the identical Question 19 from the first paper of 2021. Specifically, Boerhaave's syndrome is the oesophageal perforation that one sustains in the course of vomiting. The classical case, I suppose, is that of gross gluttony followed by forced vomiting, as was the case which claimed the life of Baron von Wassenaer, Grand Admiral of the Dutch Fleet. All other forms of non-vomit-induced oesophageal perforation appear to be non-eponymous.
In one retrospective audit, the following features were commonly noted:
That's right, subcutaneous emphysema was one of the presenting complaints in over 1/3rd of patients. The pain is usualy retrosternal or pleuritic.
Back in my day, the only options were surgical. Any sort of conservative management has come on the menu only since TPN became available.
Thus, the options of definitive treatment are surgical, endoscopic and conservative.
There are a few little details about the perforated oesophagus which must be considered:
Presumably to reduce the incidence of horrendoplasty, Biancari et al published on the "Treatment of esophageal perforation in octogenarians" in 2014. Surprisingly, this small scale (33 patient) observational study did not reveal much of a mortality difference between surgical, conservative and endoscopic approaches. The mortality at 30 days was approximately 40%. These were not randomised patients, suggesting that those (11 of them) who were operated on were probably reasonably fit in order to be even considered.
This hideous and fortunately extremely rare complication was the topic of Question 23 from the second paper of 2019, which discussed the "principles and priorities in the management" of a patient who, after intubation, has a massive air leak through a hole in their left main bronchus which communicates directly with their oesophago-gastric anastomosis. It is extremely unlikely that any intensivist (let alone an end-stage trainee) have ever come directly in contact with such a beast, and so it is rather surprising and encouraging that the pass rate for that SAQ was 43.9%.
In terms of published recommendations, one could do no better than the article by Shamji & Inculet (2018), which is unfortnately paywalled. As much of the content of this article as possible has been integrated into the management options below.
Management priorities:
As usual, the management can be divided into "supportive" and "specific".
Supportive management:
Specific management resembles the oesophageal perforation options mentioned above, with the exception of all the bronchoscopic stuff:
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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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