Boerhaave syndrome surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Boerhaave syndrome}} | {{Boerhaave syndrome}} | ||
{{CMG}} {{AE}} {{DM}} {{FT}} | {{CMG}} {{AE}} {{DM}}, {{FT}}, {{Ajay}} | ||
==Overview== | ==Overview== | ||
Most physicians advice surgical intervention if the diagnosis is made within the first 24 hours after [[perforation]]. | Most physicians advice surgical [[Intervention (counseling)|intervention]] if the diagnosis is made within the first 24 hours after [[perforation]]. The main objectives of surgical management in patients undergoing primary repair are [[debridement]] of non-viable [[esophagus]] and repair of the [[perforation]]. The surgical procedure opted depends on the general condition of the patient, level of [[intrathoracic]] [[contamination]] and eligibility of the [[esophagus]] for primary repair. | ||
==Surgery== | ==Surgery== | ||
===Objectives of surgical management=== | ===Objectives of surgical management=== | ||
The main objectives of surgical management in patients undergoing primary | The main objectives of surgical management in patients undergoing primary repair are as follows:<ref name="pmid10217689">{{cite journal| author=Morales-Angulo C, Rodríguez Iglesias J, Mazón Gutiérrez A, Rubio Suárez A, Rama J| title=[Diagnosis and treatment of cervical esophageal perforation in adults]. | journal=Acta Otorrinolaringol Esp | year= 1999 | volume= 50 | issue= 2 | pages= 142-6 | pmid=10217689 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10217689 }} </ref><ref name="pmid8246543">{{cite journal| author=Salo JA, Isolauri JO, Heikkilä LJ, Markkula HT, Heikkinen LO, Kivilaakso EO et al.| title=Management of delayed esophageal perforation with mediastinal sepsis. Esophagectomy or primary repair? | journal=J Thorac Cardiovasc Surg | year= 1993 | volume= 106 | issue= 6 | pages= 1088-91 | pmid=8246543 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8246543 }} </ref><ref name="pmid19328338">{{cite journal| author=Mao JC, Kayali FM, Dworkin JP, Stachler RJ, Mathog RH| title=Conservative management of iatrogenic esophageal perforation in head and neck cancer patients with esophageal stricture. | journal=Otolaryngol Head Neck Surg | year= 2009 | volume= 140 | issue= 4 | pages= 505-11 | pmid=19328338 | doi=10.1016/j.otohns.2008.12.052 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19328338 }} </ref> | ||
*Debridement of | *[[Debridement]] of non-viable esophagus | ||
*Repair of perforation | *Repair of [[perforation]] | ||
*Drainage of pleural and mediastinal spaces | *Drainage of [[pleural]] and [[mediastinal]] spaces | ||
*Pleural and mediastinal decontamination | *[[Pleural]] and [[mediastinal]] [[decontamination]] | ||
*Gastric decompression | *[[Gastric]] [[decompression]] | ||
*Enteral feeding access | *[[Enteral feeding]] access | ||
===Surgical techniques=== | ===Surgical techniques=== | ||
The operative procedure opted for the repair of [[esophagus]] is influenced by the following factors: | |||
*General condition of the patient | |||
*Level of [[intrathoracic]] contamination | |||
*Eligibility of the [[esophagus]] for primary repair | |||
The following | The following surgical techniques are used to perform a repair of a [[perforation]] of the [[esophagus]]: | ||
* Devitalized tissue is debrided from the perforation. | * Devitalized tissue is debrided from the perforation. | ||
* Longitudinal incision of the muscular layer and along the muscle fibers superior and inferior to the perforation to expose the entire extent of the mucosal injury. | * Longitudinal incision of the [[muscular]] layer and along the muscle fibers superior and inferior to the perforation to expose the entire extent of the [[mucosal]] [[injury]]. | ||
* The mucosa is closed with absorbable sutures and the muscularis layer is closed with | * The [[Mucosal|mucosa]] is closed with absorbable [[Suture|sutures]] and the [[Muscularis|muscularis layer]] is closed with non-absorbable [[sutures]]. | ||
# '''Primary repair''' | |||
# '''Repair over T-tube''' | |||
# '''Debridement and drainage''' | |||
# '''Esophageal exclusion''' ([[cervical]] esophagostomy, [[distal]] esophageal [[transection]] ± esophagectomy). | |||
* Large-bore apical and [[Basal cell|basal]] [[intercostal]] [[Chest drain|chest drains]] are inserted in all patients at the initial operation | |||
* A trans-hiatal drain is inserted in patients undergoing a pure trans-hiatal approach without [[thoracotomy]] | |||
===Video=== | |||
The following videos demonstrate the step by step procedure of surgical management of boerhaave syndrome. | |||
{{#ev:youtube|GkJnyGvFxU8}} | |||
===E-Vac therapy=== | |||
{{#ev:youtube|ZxWSQPqN734}} | |||
=== Postoperative management === | === Postoperative management === | ||
* Nutritional support until oral feedings can be initiated and sustained | * [[Nutritional]] support until oral feedings can be initiated and sustained | ||
* IV broad spectrum antibiotics typically for 7 to 10 days | * IV [[Broad-spectrum antibiotic|broad spectrum antibiotics]] typically for 7 to 10 days | ||
* A contrast esophagram is done on postoperative day seven if the patient is stable | * A contrast [[esophagram]] is done on postoperative day seven if the patient is stable | ||
* Drains remain in place until the patient is tolerating oral feedings and without evidence of a leak | * Drains remain in place until the patient is tolerating oral feedings and without evidence of a leak | ||
=== Endoscopy === | === Endoscopy === | ||
Endoscopic treatment for an esophageal perforation should be considered in patients who are unlikely to tolerate surgery | [[Endoscopic]] treatment for an [[esophageal perforation]] should be considered in patients who are unlikely to tolerate surgery<ref name="pmid23711276">{{cite journal |vauthors=Schweigert M, Beattie R, Solymosi N, Booth K, Dubecz A, Muir A, Moskorz K, Stadlhuber RJ, Ofner D, McGuigan J, Stein HJ |title=Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): an international study comparing the outcome |journal=Am Surg |volume=79 |issue=6 |pages=634–40 |year=2013 |pmid=23711276 |doi= |url=}}</ref> | ||
==References== | ==References== | ||
Latest revision as of 20:20, 17 February 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamed Diab, MD [2], Feham Tariq, MD [3], Ajay Gade MD[4]]
Overview
Most physicians advice surgical intervention if the diagnosis is made within the first 24 hours after perforation. The main objectives of surgical management in patients undergoing primary repair are debridement of non-viable esophagus and repair of the perforation. The surgical procedure opted depends on the general condition of the patient, level of intrathoracic contamination and eligibility of the esophagus for primary repair.
Surgery
Objectives of surgical management
The main objectives of surgical management in patients undergoing primary repair are as follows:[1][2][3]
- Debridement of non-viable esophagus
- Repair of perforation
- Drainage of pleural and mediastinal spaces
- Pleural and mediastinal decontamination
- Gastric decompression
- Enteral feeding access
Surgical techniques
The operative procedure opted for the repair of esophagus is influenced by the following factors:
- General condition of the patient
- Level of intrathoracic contamination
- Eligibility of the esophagus for primary repair
The following surgical techniques are used to perform a repair of a perforation of the esophagus:
- Devitalized tissue is debrided from the perforation.
- Longitudinal incision of the muscular layer and along the muscle fibers superior and inferior to the perforation to expose the entire extent of the mucosal injury.
- The mucosa is closed with absorbable sutures and the muscularis layer is closed with non-absorbable sutures.
- Primary repair
- Repair over T-tube
- Debridement and drainage
- Esophageal exclusion (cervical esophagostomy, distal esophageal transection ± esophagectomy).
- Large-bore apical and basal intercostal chest drains are inserted in all patients at the initial operation
- A trans-hiatal drain is inserted in patients undergoing a pure trans-hiatal approach without thoracotomy
Video
The following videos demonstrate the step by step procedure of surgical management of boerhaave syndrome. {{#ev:youtube|GkJnyGvFxU8}}
E-Vac therapy
{{#ev:youtube|ZxWSQPqN734}}
Postoperative management
- Nutritional support until oral feedings can be initiated and sustained
- IV broad spectrum antibiotics typically for 7 to 10 days
- A contrast esophagram is done on postoperative day seven if the patient is stable
- Drains remain in place until the patient is tolerating oral feedings and without evidence of a leak
Endoscopy
Endoscopic treatment for an esophageal perforation should be considered in patients who are unlikely to tolerate surgery[4]
References
- ↑ Morales-Angulo C, Rodríguez Iglesias J, Mazón Gutiérrez A, Rubio Suárez A, Rama J (1999). "[Diagnosis and treatment of cervical esophageal perforation in adults]". Acta Otorrinolaringol Esp. 50 (2): 142–6. PMID 10217689.
- ↑ Salo JA, Isolauri JO, Heikkilä LJ, Markkula HT, Heikkinen LO, Kivilaakso EO; et al. (1993). "Management of delayed esophageal perforation with mediastinal sepsis. Esophagectomy or primary repair?". J Thorac Cardiovasc Surg. 106 (6): 1088–91. PMID 8246543.
- ↑ Mao JC, Kayali FM, Dworkin JP, Stachler RJ, Mathog RH (2009). "Conservative management of iatrogenic esophageal perforation in head and neck cancer patients with esophageal stricture". Otolaryngol Head Neck Surg. 140 (4): 505–11. doi:10.1016/j.otohns.2008.12.052. PMID 19328338.
- ↑ Schweigert M, Beattie R, Solymosi N, Booth K, Dubecz A, Muir A, Moskorz K, Stadlhuber RJ, Ofner D, McGuigan J, Stein HJ (2013). "Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): an international study comparing the outcome". Am Surg. 79 (6): 634–40. PMID 23711276.