Tokushukai Medical Group

Treatment of disorder

medical treatment

Digestive System Surgery: Spontaneous Rupture of Esophagus

Life-saving rate is drastically down by delayed diagnosis.

Disease where all layer of esophageal wall is raptured, or perforation is developed by sudden internal pressure raise on normal esophagus with no psychogenic pain. This is reported firstly by Boerhaave in 1724, and this disease is relatively rare case. Early diagnosis and early treatment is extremely crucial for this disease, and by delayed initial diagnosis, infectious complicating disease (thoracic empyema, longitudinal abscess) lead to serious condition and prognosis is getting worse. It is necessary to always bear in mind that this is the important disease in Emergency Surgical region. Life-saving rate exceeds more than 90% by early diagnosis and active surgery, but in case it has taken more than 12 hours to the treatment due to the delayed diagnosis by the lower recognition, death rate rises up to 50%.

Vomiting after alcohol drinking set up rupture.

Vomiting after alcoholic drink is considered as contributing factor and common among 30s to 50s male. Esophagus is longitudinally ruptured with having pressure from normal gastric and esophageal junction area to lower esophagus. Favorite site is lower esophagus left wall. This is because, muscle layer at lower esophagus wall is thin compared with stomach muscle layer, pectinate defect on ring-shaped muscle can be seen occasionally, so that congenitally brittle part is developed due to the progression of nerve vessel from outside of wall. Also, anatomical aspect can be considered as a cause where only lower esophagus left wall lacks the supportive organs like heart, large intestine, and body of vertebra.

Esophagography is effective.

Earliest symptoms are; severe pain at upper abdominal and chest pain, breathing difficulty, shock, aerodermectasia, cyanosis (chest pain :53%, Abdominal pain:51%). Distorted noise (Hamman’s sign) corresponded to heart beat heard by auscultation is recognized at 20%.

From these symptoms, it is sometimes miss-diagnosed as acute cardiac disease or upper digestive tract disorder, so that it is important to first treat with a skepticism. Aerodermectasia, mediastinal emphysema, pleural effusion, aero thorax is seen as symptom. Esophagography is an extremely effective assured diagnosis method, and leakage of contrast agent is recognized in approximately 90% of them. Position of perforation part, size, perforation direction, and with or without intrathoracic perforation can be determined. And it can get much information about treatment plan, like whether conservative medical management is possible, or thoracolaparotomy approach method for surgery.

When mild symptom conservative medical management is one of selection.

The selection of treatment method is depending upon the size of perforation part and time passed to diagnosis, but there are conservative medical management, surgical treatment and endoscopic treatment.

Contamination by vomitus is bad at mediastinum and chest cavity, and contents flew out from both side of vertebra body via mediastinum, then become an abscess at outside of parietal pleura. Therefore, contents must be aspirated and discharged in specifying definite position, with using CT or Echo in drainage method. Washable tube is fixed at the back of mediastinum.

Conservative Medical Management
  • Rapture is limited to inside of mediastinum.
  • Contents is drained inside of esophagus.
  • Symptom is mild.
  • There is no serious infection.
  • Impossible to make surgical operation due to extremely bad entire body condition.
From above reasons, conservative medical management is selected.
Drain inside of esophagus, inside of mediastinum and inside of chest cavity, then administer antibiotics agent, total parenteral nutrition or tubal feeding is performed.
Surgical Treatment
This operation is to make, closure and restoration of raptured part, addition by coating method, cleaning and drainage and gastrostomy and enterotomy for nutrition management. Right thoracotomy for middle esophagus perforation, left thoracotomy for lower esophagus perforation is desirable. There is also transabdominal approach. Perform debridement (take debris out) around lesion site, thoroughly check damaged mucosal area up and down, then perform double layer suture using absorbent thread. As a back-up, several kinds of patch are applied, to bottom of stomach, to omental, to diaphragm, to latissimus dorsa muscle valve and to rhomboid muscle valve. There is a method without doing primary closure, but targeting for external fistula by tube indwelling.
In case contamination inside of chest cavity is in high level, select secondary surgery so that performs esophagus cut-off, then perform cervical enterotomy and gastrostomy. There is a method to perform re-building method when entire body condition is improved and after intrathoracic inflammation is calm down
Endoscopic Treatment
There is a report showing clipping at raptured part, and esophagus stent indwelling