The Ruptured Oesophagus

Rob Watson,  Blackburn

Consultant Upper GI Surgeon, The Ruptured Oesophagus

Rupture of the oesophagus is an uncommon condition. The causes are spontaneous (Boerhaave’s syndrome), traumatic, caustic and by far the most common iatrogenic.

Diagnosis should be easy but is often delayed; the common mistakes are poor history taking and misinterpretation of a chest x-ray. This is unfortunate as prompt diagnosis and appropriate treatment is crucial for the successful management of this condition.

Once the diagnosis is considered, contrast imaging is essential. This is to show the side and level of perforation. Spontaneous rupture is fairly consistent, invariably occurring in the lower oesophagus into the left chest. However, with ever increasing endoscopic techniques, perforation at different levels and into different sides of the chest is seen.

Rupture of a normal oesophagus is fairly straight forward, but rupture of a diseased oesophagus can be a challenging event carrying a higher mortality than the considerable mortality associated with this condition overall. The rupture is treated differently depending on the disease process.

Occasionally, in carcinoma and benign oesophageal strictures that perforate during dilatation, the perforation is not full thickness and contrast does not escape into the chest. The patient may well have all the signs of perforation and even have a pleural effusion. These patients can be managed conservatively. In the case of carcinoma, covered stents are of benefit.

The only other place for conservative management of oesophageal rupture is in confined cervical perforations.

In all other situations, surgery is mandatory. For carcinoma, if the tumour is deemed to be operable, then emergency resection is indicated. In most other situations, local repair is feasible. In rupture of the non malignant diseased oesophagus simple repair is preferred to a more complicated procedure, leaving management of the benign condition to a later date in those who survive. However, in bleeding variceal disease it is necessary to attempt to stop the haemorrhage. In this situation ligation of the varices, as described in the Boerema-crile operation, is recommended.

In patients undergoing local repair, there will be a prolonged period of no oral intake and therefore nutrition is an important aspect of their care. In this situation, I perform a gastroscopy and insert a feeding peg gastrostomy just prior to the repair.

Many operations have been described for this condition. I perform a controlled fistula over a large sized T tube, repairing the oesophagus with interrupted sutures. Thorough lavage of the pleural cavity and drainage with 2 large chest drains is necessary. Some can be repaired by thoracoscopic techniques.

Survival from oesophageal rupture depends on prompt diagnosis and rapid appropriate treatment. It is an emergency situation requiring logical steps in a timely fashion. Treatment by committee will impose unnecessary delays. What is required is an appropriate surgeon conducting the event in a controlled way. It is well within the remit of a competent general surgeon to manage this condition and a multi disciplinary team meeting will be of no value to you.

[On October 29th 1723 the baron’s son asked Boerhaave for urgent help because his father was suffering from excruciating pain in the chest. Three days previously the admiral had consumed a heavy meal of duck for which he used an increasing dose of an emetic afterwards. During vomiting the patient experienced a sudden heavy pain in the chest.

Next morning the patient died; from Boerhaave’s description of symptoms and signs we would today diagnose "death from septic shock". At autopsy the opening of the chest revealed a heavy smell of duck meat, three litres of pleural effusion were present and an eight centimetre tear in the oesophagus was found.]