Boerhaave's Syndrome - USarpel

Boerhaave's Syndrome - USarpel - Team IV Surgery Conference...

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Unformatted text preview: Team IV Surgery Conference Conference Pallavi Patri, MSIII Umut Sarpel, MD June 14th 2005 Patient R.E. Patient CC: sudden onset epigastric pain, hematemesis HPI: 36 y/o male with Crohn’s disease s/p ileocolic 36 resection 6/04 and hx of pSBO in 7/04 presenting with three episodes of hematemesis. three At dinner, a piece of steak became stuck in pt’s throat Pt tried to cough up the bolus but felt it relodge. Self-induced vomiting –3 episodes of bloody vomiting Self-induced – mod amount of serosanginous material. mod Episodes were followed by development of severe Episodes burning epigastric pain, no radiation, unrelieved by pain medications. pain Denied any fever/chills/cough/dysuria. PMH: CD s/p ileocolic resection 6/04 On Pentosa 500mg BID Partial SBO 7/04 – treated conservatively Partial GERD MVP PSH: Ileocolic resection 6/04 Meds: Allergies: Unknown Social Hx: NKDA FH: Pentosa 500mg BID Pepcid MVI Denies ETOH, tobacco, drug use ROS: Otherwise unremarkable PE: Gen: lying in fetal position, holding abdomen. VS: 133/97 35.5 72 18 97%RA Heent: no frank blood in oropharynx CV: RRR, S1, S2, +Hamman’s sign Pulm/chest: lungs CTA b/l, no respiratory Pulm/chest: distress, no crepitus distress, Abd: soft, +BS, ND, mod mid-epigastric tenderness with mild voluntary guarding tenderness Labs 144 102 18 4.0 26 0.9 13.8 16.4 48.6 S 81.7% 198 252 aPTT: 27 PT: 12.8 INR: 1.0 OBS: Single dilated loop of small bowel with air-fluid Single level in the right mid-abdomen likely the duodenum. Relative paucity of gas. duodenum. CXR CXR CT chest/abd CT CT chest/abd IV/oral contrast IV/oral Esophagus diffusely thick-walled. Air in the wall of the Esophagus esophagus involving the prox-mid segment. Pneumomediastinum noted. Findings suspicious for esophageal perforation. Fluid within the mediastinum adjacent to the esophagus. Mediastinitis cannot be excluded. excluded. Multiple hepatic lesions. DDx include septic Multiple foci/abscesses, metastases, and complex cysts. foci/abscesses, Esophagram No evidence of esophageal leak. No Streaky densities at the left lung base, which Streaky may represent infiltrate vs. atelectasis. may Diagnosis Diagnosis Contained perforated esophagus with Contained possible mediastinitis: likely Boerhaave’s syndrome Plan: Admit to Surgery NPO with IVFs Monitor urine output Follow H/H Abx: zosyn Hospital Course Hospital Labs: 5/26 5/27 5/27 5/27 5/28 5/29 WBC 13.8 21.5 15.2 10.4 9.8 6.7 Temp AVSS Tmax=37.8 AVSS Tmax=38.5 Blood Cx: No growth at 5 days Urine: negative Outcome Outcome Pt managed conservatively CT chest (5/30) NPO, IVFs, Abxs Mild thickening of wall of mid and distal esophagus. Pneumomediastinum resolved. No extravasation of contrast from esophageal lumen. Improvement in left pleural effusion. D/c’d home with resolution of symptoms on PO D/c’d augmentin augmentin Boerhaave’s Syndrome Boerhaave’s Syndrome • Hermann Boerhaave (1668-1738) • 1724: described postmortem findings of Baron J van Wassenaer, the Grand Admiral of the Dutch Fleet Causes of perforation Brinster et al, Ann Thorac Surg 77: 2004 Meta-analysis of 559 cases of perforation • Iatrogenic: 59% Increasing frequency Endocopic procedures: variceal banding, dilation, etc. • Spontaneous: 15% Boerhaave’s syndrome • • Foreign body: 12% Trauma: 9% Caustic ingestion, blunt injury History Non-localizing symptoms, frequent atypical Non-localizing presentations: presentations: • • • Chest / epigastric pain 83% Emesis 79% Dyspnea 39% • History of alcoholism 40% • GERD 41% History Frequent delay due to misdiagnosis: • • • AMI Pancreatitis Perforated peptic ulcer Physical Exam • Subcutaneous emphysema • Hamman’s sign: audible crepitus w/ heartbeats • Pleural effusion on CXR Diagnosis • Gastrograffin swallow up to 25% false negative rate if suspicion high, follow w/ barium swallow • CT scan • Likely no role for endoscopy Insufflation of air and mechanical forces may worsen perforation and contamination Location of Perforation • Cervical • Thoracic Rupture usually along left supradiaphragmatic portion of esophagus due to anterior portion angulation at left crura (80%) angulation • Abdominal Etiology of perforation suggests site of injury Brinster et al, Ann Thorac Surg 77: 2004 Brinster Outcome • • • Historically highly fatal process >50% No serosal lining to esophagus Now mortality ranges from 6-30% Outcome: factors 1) Time delay to diagnosis - most important 2) Etiology of perforation Iatrogenic injuries with immediate diagnosis Patients are usually NPO 1) Underlying esophageal disease 2) Location of perforation Cervical less likely to have contamination Mortality 6% (cervical) vs. 21% (thoracic) Time to Dx Time to Dx # pts Deaths Mortality Immediate 37 2 5% Early 22 3 14% (<24hrs) Late 16 7 44% (>24 hrs) Muir et al, Eur J of Cardiothoracic Surg 23: 2003 Treatment • Operative • Non-operative • Endoscopic Operative Interventions • • • • • Primary closure Esophageal resection Drainage alone T-tube drainage Exclusion / diversion Operative Intervention Location of injury determines approach • Cervical: drainage by cervical incision • Mid-thoracic: right thoracotomy • Low-thoracic: left thoracotomy • Abdominal: midline laparotomy Primary Repair Remains current standard in healthy esophagus: • Vertical esophagomyotomy to fully expose Vertical mucosal defect mucosal • Debridement of necrotic tissue • Double layer interrupted sutures w/ absorbable • +/- pleural patch • Wide drainage of mediastinum / pleura Resection/Diversion • Primary repair should not be attempted in Primary esophagus with underlying disease esophagus • Esophageal resection and diversion w/ cervical Esophageal esophagostomy esophagostomy • -/+ restoration of GI continuity at same time • Severe fibrosis from mediastinitis may make Severe prohibit future reconnection prohibit Non-operative Management Conservative treatment is a viable option, but remains controversial: • Early diagnosis / iatrogenic injury • Contained leak w/o systemic sxs • No obstruction, or underlying malignancy • Late diagnosis (> 24hrs) • Some advocate liberal use of nonoperative management Non-operative Management • Vogel et al, Annals of Surgery June 2005 • Series of 47 patients, attempted Series conservative management conservative • 13 pts condition deteriorated, to OR • 34 successfully underwent non-operative 34 management, w/ 0% mortality management, • Overall mortality 4.2% Endoscopic Landen et al, Surg Endoscopy May 2002 • Stenting w/ flexible coated device • Still in trials • Unclear indications at present • For persistent fistula? • Complimentary to operative repair? Gupta et al, Am J of Surgery 187: 2002 ...
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This note was uploaded on 12/21/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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