The Diagnosis And Treatment Of Spontaneous Esophageal Rupture

Background: Spontaneous esophageal rupture was first described byBoerhaave in 1724 and is known as Boerhaave 's syndrome. Spontaneousesophageal rupture is extremely rare,and early symptoms of the disease are similarto those of emergency diseases of the chest and badomen.The diagnosis andtreatment are often delayed, resulting in an unfavorable outcome in some cases. Objective: To study the clinical characteristics about the diagnosis,treatment of spontaneous esophageal rupture,in order to improve the veracity ofdiagnosis and efficiency of treatment.Methods: Eight cases with spontaneous esophageal rupture admittedin our hospital sice 2000 were retrospectively studied.The diagnosis was made byiodolography of esophagus,esophagoscopy and teleroentyenogram of chest.Clinical data:The whole group involve 8 patients, including 7 males,1female.Age 17-65 years old. Spontaneous esophageal rupture is traditionallyassociated with the triad of vomiting , pain in the lower thorax, and subcutaneousemphysema, as described by Mackler. However ,these signs are often absent, asreflected by more than 40% of patients being referred more than 24 hours after theoriginal injury.Only 3 cases of 8 were with theses signs, and 3 cases of 8 werewith special clinical findings.The treatment of spontaneous esophageal rupture depends upon the clinicalstatus of the patient and the extent of contamination as determined by radiologicfindings.Cameron et al suggest that nonoperative management is acceptable onlyin case of small leaks without pleura contamination.2 cases of 8 were withnonoperative management.Therefore ,as soon as a patient shows signs of systemicinfection or worsening radiographic findings,surgery is recommended.The surgicalprocedure is as follows: primary suture and external drainage;primary suture andexterna drainage and covering of the laceration with a pedicle omentum pad , orfundic patch;transthoracic esophagectomy;esophagostomy and secondaryreconstruction.Results:There were 3 cases misdiagnosed. Among them,only 4 cases werediagnosed within 24h. 3 cases were diagnosed within 24h-72h. X-ray examinationwere performed for all cases. 2 cases of 8 showed cervical and chest wallsubcutaneous emphysema.5 cases of 8 showed hydropnermothorax ,and thedensity of 2 cases pleurorrhea was not uniform.The length of the rupture rangedfrom 3cm to 12cm,and the rupture occurred in all parts of esophagus.7 cases werein the left wall and the other one in the right.Six cases underwent surgicaltreatment.Repair of esophagus was performed in 4 cases and esophagectomy in 2cases .Three underwent primary repair within 24h of onset.Primary repair wasperformed in 2 cases and 1 failed.Two cases received operation 2-3 days afteronset.Transthoracic esophagectomy was performed in 1 case and wascured.Conservative therapy with close drainage of thoracic cavity and nutritionalsupport in 2 cases,1 patient was cured and the other one died.Conclusion: 1. A rapid but complete and accurate grasp of history,remaininghigh alert on the disease is the key to avoid misdiagnosis.The diagnosis can beconfirmed or excluded by a chest film,a contrast study of the esophagus orcharacteristic contents in thoracic fluid.2. Early diagnosis and appropriate surgical treatments are the key to increasethe curative effect and reduce the mortality rate .Suffici-ent drainage and esophageal repair is effective and reliable therapy. 24h is not thedemarcation line to determine whether primary repair should be done.Primaryrepair is the first choice if the condition of horizontal tear and thoraciccavity permit.