Spontaneous Rupture Of Esophagus Research Articles

Mediastinitis and septic shock complicating spontaneous esophageal rupture “Boerhaave’s syndrome”: a case report

Boerhaave’s syndrome, also known as spontaneous esophageal rupture, is a rare but life-threatening condition characterized by a tear in the esophagus. It is most commonly caused by a sudden increase in intraesophageal pressure, often due to severe vomiting or retching.Early diagnosis of Boerhaave’s syndrome is crucial for improving patient outcomes. The classic triad of symptoms includes severe chest pain, vomiting, and subcutaneous emphysema (air under the skin). However, not all patients present with this triad, and the diagnosis can be challenging, especially in patients without the typical symptoms.In this case report, we present the clinical details of a 52-year-old male patient who presented to the emergency department (ED) with severe abdominal pain and vomiting for several days. The patient had a history of chronic alcohol abuse and a recent episode of vigorous vomiting.

Surgical treatment of Boerhaave syndrome in the past, present and future: updated results of a specialised surgical unit.

Boerhaave syndrome is a rare clinical entity associated with high rates of morbidity and mortality. Early recognition of the symptoms, and identification of the site and extension of the injury are key in improving the prognosis. This study presents data on the mortality, morbidity and length of hospital stay in patients diagnosed with Boerhaave syndrome. The data were retrieved from a prospectively collected database in a single surgical unit between 2012 and 2022. The study makes a comparison with the surgical outcomes of the previous decade. Some 33 patients were diagnosed with Boerhaave syndrome and were treated surgically between 2012 and 2022 in a specialist upper gastrointestinal surgical unit. All patients underwent standard surgical repair (in-theatre diagnostic endoscopy, T-tube placement through thoracotomy and feeding jejunostomy through laparotomy). The mean size of the defects in the oesophageal lumen was 3.3cm. Delayed presentation was noted for 13 patients (39%); 8 patients (24%) died in hospital, and 19 patients (58%) developed postoperative complications. Mortality was similar to the rate recorded for the 20 patients from the previous decade (24% vs 20%, respectively). The mean length of hospital stay was 41 days, and was comparable to the 35.7 days reported between 1997 and 2011. Early and aggressive management of spontaneous oesophageal rupture ameliorates the postoperative recovery and prognosis. The surgical results of our unit were found comparable to the previous decade in the population of patients who were treated surgically.

Diagnosis and treatment of spontaneous esophageal rupture (Boerhaave syndrome): A case report and literature review

Abstract We present a case report of spontaneous esophageal rupture (Boerhaave syndrome) has been successfully treated at Viet Duc University Hospital. Through this case report, we reviewed the literatures on this rare disease's pathogenesis, diagnosis, and treatment methods. Keywords: Boerhaave syndrome; Endoscopic Vacuum-Assisted Closure Therapy; Endoscopic Vacuum Therapy

408. COMPARISON OF THE SHORT-TERM EFFICACY OF THORACOSCOPY COMBINED WITH GASTROSCOPY AND TRADITIONAL THORACOTOMY IN THE TREATMENT OF SPONTANEOUS ESOPHAGEAL RUPTURE

Abstract Background Early and thorough intrathoracic debridement，irrigation and catheter drainage are of great significance for the healing of esophageal rupture. This study aims to explore the surgical treatment of spontaneous esophageal rupture, reduce the trauma and improve the cure rate. Methods A total of 21 patients with spontaneous esophageal rupture were selected from June 2010 to June 2022. In the thoracoscopy combined with gastroscopy group, 12 patients were treated with thoracoscopic debridement, esophageal rupture repair, thoracic drainage with closed drainage tube, nasal drainage with gastroscope and nasal duodenal feeding tube placement. In the thoracotomy group, 9 patients performed scheduled thoracotomy. Results Compared with the thoracotomy group, the thoracoscopy combined with gastroscopy group had less incision pain, shorter operation time, less surgical bleeding, and lower incidence of incision infection, pulmonary infection and arrhythmia, with statistical significance (P < 0.05), while the incidence of anastomotic fistula and mortality showed no statistical significance (P > 0.05). Conclusion Spontaneous esophageal rupture is an emergency in thoracic surgery, and the combined operation of thoracoscopy and gastroscopy after early diagnosis has less trauma, faster recovery and good therapeutic effect.

Outcome after stent and endoscopic vacuum therapy-based treatment for postemetic esophageal rupture

Objectives Extent of surgical repair of spontaneous esophageal effort rupture (Boerhaave syndrome) has gradually decreased by the emergence of minimal invasive treatment based on endoscopic stent sealing of the perforation. However, for this diagnosis, use of endoscopic vacuum therapy (EVT) is still in its beginning. We present our results after 7-years with both stent and/or EVT-based treatment. Materials and methods 17 consecutive patients with Boerhaave syndrome from June 2015 to May 2022 were retrospectively registered in a database. The perforation was sealed by stent and/or EVT, and gastric effluent was drained transthoracically by a chest tube or pigtail catheter. Eight out of 14 patients responded to questions on fatigue and dysphagia (Ogilvie’s score). Results Seventeen patients aged median 67 years (range 34–88), had a primary hospital stay of 38 days (7–68). Ninety-day mortality was 6% (n = 1). Perforations were sealed with stent (n = 10), EVT (n = 3) or stent and EVT (n = 4). One patient (6%) needed laparoscopic lavage and transhiatal drainage. Eight patients (47%) were re-stented due to persistent leakage (n = 4) and stent migration (n = 4). Fifteen patients (88%) had complications, including multi-organ failure (n = 9), pleural empyema (n = 8) and esophageal stricture (n = 3). The perforations healed. After 35.5 months (range 2–62) fourteen patients were alive. Eight that responded had no dysphagia and total fatigue score comparable to an age-matched reference population. Conclusion Mortality rate was low after initial stent and EVT-based treatment of Boerhaave syndrome, combined with adequate transthoracic drainage of gastric effluent. Patients required repeated minimal invasive procedures, but with no apparent negative effect on functional outcome.

Spontaneous esophageal rupture visualized by means of transthoracic echocardiography.

Spontaneous esophageal rupture visualized by means of transthoracic echocardiography.

Treatment strategies for advanced spontaneous esophageal rupture.

Treatment strategies for advanced spontaneous esophageal rupture.

Risk factors for the poor prognosis of Benign esophageal perforation: 8-year experience

BackgroundEsophageal perforation (EP) has a high mortality rate and poor prognosis. This single-center retrospective study aims to analyze the related risk factors for benign EP.MethodsWe retrospectively analyzed 135 patients with benign EP admitted to the First Affiliated Hospital of Nanchang University from January 2012 to December 2020. Univariate and multivariate logistic analysis were performed to estimate risk factors for prognosis of esophageal perforation patients.ResultsThere were 118 EP patients with foreign body ingestion and 17 patients with nonforeign body ingestion. Fish bones (78/118) were the most common foreign body and most of the nonforeign EPs were caused by spontaneous esophageal rupture (14/17). Foreign body perforations occurred mostly in the upper thoracic segment (70/118) and middle thoracic segment (31/118), and spontaneous esophageal ruptures occurred mostly in the lower thoracic segment (15/17). Fifteen patients (11.1%) died during hospitalization or within one month of discharge. Multivariable logistic regression analysis showed that high white blood cell (WBC) levels [odds ratio (OR) = 2.229, 95% confidential interval (CI): 0.776–6.403, P = 0.025], chest or mediastinal emphysema (OR = 7.609, 95% CI: 2.418–23.946, P = 0.001), and time to treatment > 72 h (OR = 3.407, 95% CI: 0.674–17.233, P = 0.018) were independent risk factors for poor prognosis.ConclusionForeign body was the major reason for benign EP. High WBC level, chest or mediastinal emphysema and time to treatment > 72 h were risk factors for poor prognosis.

Spontaneous Rupture of Esophageal Diverticulum—A Case Report and Literature Review

The spontaneous rupture of the esophageal diverticulum is a rare condition that occurs without any warning signs. Its incidence is low, but the mortality rate is high. This paper reports a case of spontaneous esophageal diverticulum rupture and analyzes it along with 13 other cases to explore its prevention and treatment measures. When patients suffer from chronic swallowing difficulties and chest pain or vomiting that cannot be explained after meals, they should be suspected to have a possible spontaneous rupture of the esophageal diverticulum, which is critical to the patient's prognosis.

An endoscopic approach to therapy for spontaneous esophageal rupture.

Video.

Outcomes after hybrid minimally invasive treatment of Boerhaave syndrome: a single-institution experience

Background Spontaneous esophageal perforation or Boerhaave syndrome is a life-threatening emergency, associated with significant morbidity and mortality. In this retrospective series we describe our single-center experience with a hybrid minimally invasive treatment approach for the treatment of Boerhaave syndrome. Methods Clinical data of all patients who presented with spontaneous esophageal rupture between January 2009 and December 2019 were analyzed. All patients underwent esophageal endoscopic stenting to seal the perforation and debridement of the contaminated mediastinal and pleural cavity through video-assisted thoracoscopic surgery (VATS). Primary outcome measure was defined as in-hospital death and 30-day mortality. Results Twelve patients were included with a median age of 63 years (interquartile range [IQR] 51–74 years) of whom 58% (n = 7) were male. The median Pittsburg perforation severity score was 6.5 (IQR 6–9). Endoscopic reintervention was required in 8 patients (67%), primarily due to stent dislocation. In addition, 5 patients (42%) required re-VATS due to empyema formation. Thirty-day mortality and in-hospital mortality were respectively 17% (n = 2) and 25% (n = 3). Conclusion Endoscopic stenting in combination with thoracoscopic debridement is an effective and safe minimally invasive hybrid approach for the treatment of Boerhaave syndrome. This is depicted by the relatively low mortality rates, even among patients with high perforation severity scores. The relatively low mortality rates may be attributed to the combined approach of rapidly sealing the defect and decontamination of the thorax. Future studies should aim to corroborate this evidence which is limited by its sample size and retrospective nature.

Subtotal esophagectomy followed by subtotal gastric reconstruction for Boerhaave's syndrome: Case report with literature review.

IntroductionBoerhaave's syndrome, or spontaneous esophageal rupture, is a potentially fatal disease requiring prompt diagnosis and effective treatment. We report Boerhaave's syndrome in a patient who underwent subtotal esophagectomy and temporary cervical esophagostomy for esophageal perforation to the right thoracic cavity, followed by subtotal gastric reconstruction as the second step.Presentation of caseA 70-year-old man with diarrhea and vomiting as chief complaints had underlying disease of reflux esophagitis. He experienced frequent hematemesis. Computed tomography (CT) at another hospital revealed right pleural effusion and abnormal mediastinal air and fluid retention around the esophagus, and he was transferred to our hospital. From the CT findings, he was diagnosed as having Boerhaave's syndrome with esophageal perforation into the right thoracic cavity. He was in shock, and emergency right thoracotomy was performed, revealing a severely purulent thoracic cavity, ruptured parietal pleura, and 5-cm perforation in the right front middle esophageal wall that was surrounded by mucosal necrosis. Subtotal esophagectomy, temporal cervical esophagostomy, and enteral feeding tube insertion were performed. After hospital discharge, he underwent subtotal gastric reconstruction 43 days postoperatively. His course was good, and he was transferred to another hospital for rehabilitation 36 days after reconstruction.DiscussionIn Boerhaave's syndrome, depending on the size of the perforation and fragility of the esophageal wall, subtotal esophagectomy may be feasible.ConclusionTwo-step reconstruction following esophageal rupture is possible after sufficient local infection control, and anastomosis can be performed if the patient's general condition is good, but only under conditions that guarantee no anastomotic leakage.

Improvement of surgical methods for the treatment of spontaneous rupture of the esophagus ­complicated by purulent mediastinitis

Aim. To improve surgical treatment outcomes of patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis.
 Methods. Over the past 30 years, we have experience in the surgical treatment of 31 patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis. Depending on the tactics and techniques of surgical treatment, we identified two groups of patients. The first group (n=8) consisted of patients operated with conventional techniques: thoracotomy, transpleural mediastinotomy according to Dobromyslov, suturing of the esophagus with drainage of the mediastinum and pleural cavities, blind mediastinal drainage. The second group (n=23) consisted of patients treated with programmed re-thoracotomy. Re-thoracotomy was performed along with the postoperative thoracotomy wounds. The delimited foci of purulent mediastinitis were opened and sanitized (necrotic tissues were excised and removed). Preventive hemostatic methods were used in the area of pressure ulcers from drainage tubes. Replacing and changing the position of the drainage tubes in the mediastinum was a strictly compulsory technique. Pus and necrotic soft tissue that appeared in the thoracotomy wound were subsequently eliminated by a device consisting of two titanium brackets connected by a lock embodied in the form of an oval ring during the wound suturing at the stage of programmed re-thoracotomy. The groups were comparable in age and comorbidities. The average diagnosis of spontaneous esophageal rupture took 3.5 days; the maximum time is 10 days. The statistical significance of differences in immune status indicators was assessed by using the Student's t-test and Pearson's 2 test.
 Results. A systematic approach using the tactical and technical surgical techniques developed by us (such as suturing esophageal wall defects regardless of the rupture time, multifunctional nasoesophagogastric tube installation; the imposition of a purse string suture to prevent reflux from the stomach into the esophagus; programmed re-thoracotomy using the method of temporary fixation of the ribs) allowed to reduce the number of complications, such as haemorrhage from the mediastinal vessels, by 3 times, sepsis 1.5 times, mortality almost 2 times.
 Conclusion. The introduction of patented techniques allowed to reduce the number of life-threatening complications and mortality in patients with spontaneous rupture of the esophagus complicated by purulent mediastinitis.

胸部上部食道に生じた特発性食道破裂の1例(A case of spontaneous rupture of the upper esophagus)

要旨特発性食道破裂は胸部下部食道の左壁に好発するが，今回胸部上部食道に生じた特発性食道破裂の1例を経験したので報告する。症例は61歳の男性，肉塊が食道につかえ，吐出努力繰り返すも改善ないことから前医へ搬送された。胸腹部単純CTにて食道第1狭窄部直下に詰まった食道異物と広範な縦隔気腫を認め，当院へ転送された。内視鏡検査にて食道入口部直下に食道を塞ぐ大きな肉塊を認め，それを押し込むと停滞部直下に縦走潰瘍が形成されており，胸部上部食道が穿孔部と判断した。状態は安定しており保存的加療を行い，15日目に退院となった。胸部上部食道における特発性食道破裂は非常に稀ではあるが，本症例は，肉塊が一度食道内に詰まり，吐出しようと努力を繰り返した際に肉塊の下で食道内圧が亢進したことで同部位に穿孔が生じたものと思われた。

S3558 Esophageal Candidiasis Leading to Spontaneous Esophageal Rupture

Introduction: Spontaneous esophageal perforation (SEP) is a rare and potentially life-threatening condition usually caused by esophageal trauma due to instrumentation or prolonged vomiting and retching. SEP due to esophageal candidiasis (EC) is extremely rare. We present a case of SEP in a patient with EC despite treatment with systemic antifungals. Case Description/Methods: A 53-year-old woman with a history of stage IV lung adenocarcinoma treated with chemoradiotherapy and immunotherapy presented with fever, abdominal pain, diarrhea and hematochezia. Her symptoms were consistent with immune-checkpoint inhibitor colitis, similar to a recent episode that improved with corticosteroids. She has a history of radiation esophagitis in the form of superficial ulceration and stenosis affecting the proximal esophagus. High-dose intravenous corticosteroids were initiated. Due to minimal response, infliximab was administered. Colonoscopy was unremarkable and random biopsies were negative for cytomegalovirus (CMV). Upper endoscopy (EGD) revealed resolution of the initially seen ulceration and no evidence of stricture or stenosis. However, a new distal superficial esophageal CMV ulcer was found. CMV viral load was 6,810 IU/mL and was successfully treated with intravenous ganciclovir leading to viral clearance. EGD for ongoing hematochezia revealed severe esophageal candidiasis (EC) confirmed with histopathology (Figure 1). Despite completing a 14-day course of intravenous fluconazole was, she developed septic shock due to SEP leading to a hydropneumothorax (Figure 2 and 3). Pleural fluid culture was positive for C. albicans. At that stage, family decided to enroll her in home hospice where she died a few days later. Discussion: Although, EC is not uncommon in immunocompromised patients, it is usually treated successfully with antifungal agents in 80-90% of cases. Transmural invasive Candida infection, however, is exceptionally rare with only 4 confirmed cases in the literature. It may lead to esophageal perforation and esophageal-pleural fistula formation. A second-look EGD with culture and sensitivity is recommend in symptomatic patients with EC who fail to improve with treatment. However, there are no guidelines recommending a repeat EGD in immunocompromised patients who initially had minimal symptoms. Our case suggests that for those patients a repeat EGD should be done to ensure resolution of EC and discontinuation of immunosuppressive therapy should be considered.Figure 1.: Endoscopic picture showing mucosal yellow-white plaques throughout entire esophagus, consistent with candidiasis.Figure 2.: Non-enhanced CT (axial view) demonstrating right hydropneumothorax with loculated fluid components.Figure 3.: Esophagram with extravasation of contrast from superior upper esophagus extending into right upper chest.

A Rare Cause of Epidural Abscess: Esophageal Perforation After Radiotherapy

Introduction:
 Spinal epidural abscess is a rare neurosurgical emergency that is usually seen invasive interventions to the spinal region, trauma or infection. In our case, anteriorly located spinal epidural abscess, which is caused by spontaneous esophageal rupture as complication of radiotherapy, is described.
 Case report:
 A 60-year-old female patient was admitted to the emergency department with complaints of confusion, high fever and weakness in both legs. The patient had been treated for lung metastasis of breast cancer with radiotherapy. Spinal anterior epidural abscess was observed in the spinal imaging, and it was considered that the abscess developed after esophageal rupture secondary to radiotherapy. After surgery the patient had antibiotic treatment during the postoperative period. Although there are cases of spinal epidural abscess that developed after esophageal rupture in the literature, they were generally observed after interventions to the esophagus or trauma to the chest. In our case, epidural abscess developed after radiotherapy, that caused esophageal rupture, was presented.
 Conclusion:
 Clinicians should consider spinal epidural abscess, which is a rare complication in patients with walking difficulties after radiotherapy, in the differential diagnosis.

Candida Empyema Thoracis at Two Academic Medical Centers: New Insights Into Treatment and Outcomes.

Background Candida empyema thoracis (pleural empyema) is an uncommon manifestation of invasive candidiasis, for which optimal treatment is unknown.MethodsThis is a retrospective study of patients with Candida empyema at 2 academic medical centers from September 2006 through December 2015.ResultsWe identified 81 patients with Candida empyema (median age, 62 years; 68% men). Sixty-five percent of patients underwent surgery or an invasive intervention of the thorax or abdomen within the preceding 90 days. Candida empyema originated from intrathoracic (51%) or intra-abdominal sources (20%), spontaneous esophageal rupture (12%), pleural space manipulation (9%), and pneumonia (6%). Eighty-four percent and 41% of patients were intensive care unit residents and in septic shock, respectively, within 3 days of diagnosis. Causative species were Candida albicans (65%), Candida glabrata (26%), Candida parapsilosis (11%), Candida tropicalis (4%), Candida krusei (2%), and Candida dubliniensis (1%). Bacteria were recovered from empyemas in 51% of patients. Concurrent candidemia was diagnosed in only 2% of patients. Management included pleural drainage and antifungal treatment in 98% and 85% of patients, respectively. Mortality at 100 days was 27%, and it was highest for cases stemming from esophageal rupture (67%). Spontaneous esophageal rupture and echinocandin rather than fluconazole treatment were independent risk factors for death at 100 days (P = .003 and .04, respectively); receipt of antifungal therapy was an independent predictor of survival (P = .046).Conclusions Candida empyema mortality rates were lower than reported previously. Optimal management included pleural drainage and fluconazole treatment. Superiority of fluconazole over echinocandins against Candida empyema needs to be confirmed in future studies.

Spontaneous esophageal rupture following perforated peptic ulcer: a report of two cases

BackgroundSpontaneous esophageal rupture, also called Boerhaave’s syndrome, is relatively uncommon but may result in high morbidity and mortality. Synchronous presentation of spontaneous esophageal rupture and perforated peptic ulcer was rare and may contribute to the difficulty of achieving a correct diagnosis.Case presentationWe reported two patients with spontaneous esophageal rupture following perforated peptic ulcer. Both patients were successfully treated with thoracoscopic primary repair of esophageal rupture. The first patient underwent peptic ulcer repair via laparotomy. The second patient underwent laparoscopic duodenorrhaphy. Both patients resumed oral intake smoothly and were discharged uneventfully.ConclusionMinimally invasive approaches are safe and feasible for both esophageal rupture and perforated peptic ulcer in patients diagnosed within 24 h and without shock.

Enhanced Recovery Protocol for Boerhaave Syndrome: Our Experience

From its first description in 1724, the diagnosis and management of Boerhaave syndrome remain challenging till date. We share our management protocol for enhanced recovery in patients presenting more than 24 h following spontaneous esophageal rupture at a tertiary care center in India. A retrospective review of all patients diagnosed with Boerhaave syndrome and managed by the chief investigator in the Department of General Surgery at our institution in the last 3 years (2016–2019) was performed. After hemodynamic stabilization, an intercostal drainage (ICD) tube was inserted on the side of empyema to drain the collection. This was followed by an upper GI (UGI) endoscopy to confirm the site and size of perforation. No attempt at a therapeutic intervention was made during the procedure. A triple lumen tube was inserted under imaging at the same time for gastric decompression and advanced to the jejunum for enteric feeding. In patients with sepsis and persistent collection, a video-assisted thoracoscopic (VATS) drainage was performed. Twelve patients were admitted for Boerhaave syndrome. ICD was inserted for 9 patients and managed by us as per our enhanced recovery protocol. Three patients referred from other setup came with an ICD in situ showing signs of sepsis. Debridement and drainage by VATS was performed for these patients. No patient required prolonged ventilatory assistance, and there was no mortality. Gastric decompression, adequate and timely drainage of collection/s, and enteral nutrition form the pillars of enhanced recovery protocol for management of Boerhaave syndrome.

[Surgical treatment of spontaneous esophageal rupture: long-term experience of the Sklifosovsky Research Institute for Emergency Care].

To analyze the treatment outcomes in patients with spontaneous esophageal rupture (SER). The study included 106 patients with SER admitted to the Sklifosovsky Research Institute for the period from 1992 to 2015. The sample also included 91 patients who were referred from other hospitals. All patients were divided into 4 groups depending on surgical procedure: surgical drainage (Group I, n=19); suturing the esophageal defect without antireflux surgery (Group II, n=12); esophageal wall repair with fundoplication procedure (Group III, n=62); resection of the thoracic esophagus (Group IV, n=13). In the 1st group, complication rate was 100% and significantly exceeded these values in groups II, III, and IV (66.7%, 71%, and 69.2%, respectively; p=0.0318, p=0.0189, and p=0.0413). The length of hospital-stay was the lowest in group IV (mean 42 days) and group I (mean 55 days). Mortality rate in groups I, III and IV was 15-20% lower than in group II. Pneumonia and pleural empyema were significant predictors of poor outcome. Fundoplication improved postoperative outcomes in group III compared to group II. Resection of the thoracic esophagus performed in accordance with strict indications interrupts infectious process and shortens recovery period. Surgical drainage is followed by persistent contamination of mediastinum and pleural cavities that may quickly result a fatal outcome. A differentiated approach to SER treatment can reduce the risk of complications and mortality.