SPONTANEOUS RUPTURE OF THE OESOPHAGUS A GROUP OF NINE CASES TREATED SURGICALLY

Abstract

Summary The pathology and clinical picture in typical cases of spontaneous rupture of the oesophagus have been described. The rupture is usually a longitudinal tear in the left lateral wall of the oesophagus commencing just above the diaphragm. Mediastinitis, mediastinal emphysema, and pyopneumothorax develop. Vomiting, pain, dyspnoea, abdominal rigidity, and surgical emphysema in the neck, occurring in that sequence, is the typical clinical picture. Untreated cases usually die in forty-eight hours. Atypical clinical pictures and their causal atypical pathology have been described. Awareness that the condition exists, a knowledge of the symptom sequence, a carefully taken history, the detection of air in the mediastinum or neck, and signs of fluid and air in the pleural cavity, will enable an early correct diagnosis to be made in typical cases. A portable X-ray film which includes the neck, chest and upper abdomen should always be done. Air in the mediastinum and the absence of air under the diaphragm are the two most significant radiological findings. Aids to diagnosis are pleural aspiration, a lipiodol swallow followed by a chest X-ray, and thoracoscopy. When the history is atypical, and when the hydro-pneumothorax is confined to the right pleural cavity, a lipiodol swallow and an oeso-phagoscopy must be done, as such patients may have pre-existing oesophageal disease or a perforation at a level higher than the usual supra-diaphragmatic site. Cases are classified as follows:– “Early”—diagnosed within thirty-six hours of onset. “Intermediate”—diagnosed between thirty-six hours and one month of onset. “Late”—diagnosed more than one month from the onset. The following treatment has been recommended:— (a) “Early” cases — immediate thoracotomy with repair of the oesophagus and drainage of the mediastinum and the pleural cavity should be done. (b) “Intermediate” cases — (i) If a total empyema is present— thoracotomy, decortication, and drainage of the pleural cavity and mediastinum should be done. The oesophageal rent should not be repaired. (ii) If the empyema is small and loculated—drainage of the empyema and the mediastinal abscess is all that is required. (c) “Late” cases—thoracotomy, decortication, excision of the oesophago-pleural fistulous track, and repair of the oesophagus should be done. Management of the post-operative feeding problems in all three groups of cases have been discussed. Nine cases of spontaneous rupture of the oesophagus treated surgically between 1952 and 1957 have been described. Six of these cases have survived.