Abordagem vídeo-toracoscópica, sem sutura, das perfurações do esôfago torácico diagnosticadas tardiamente / Video-thoracoscopic approach, without suture, of late thoracic esophageal perforations

RESUMO Objetivos: avaliar a utilização da vídeo-toracoscopia, no tratamento das perfurações tardias do esôfago torácico, sem sutura ou ressecção do órgão. Métodos: análise retrospectiva de pacientes com diagnóstico tardio (>12 horas) de perfuração do esôfago torácico tratados por vídeo-toracoscopia, sem sutura ou ressecção do órgão, num período de 15 anos. Resultados: foram operados 16 pacientes, sendo dez homens e seis mulheres, com idades entre 48 e 66 anos e com tempo entre o diagnóstico da perfuração e a cirurgia variando entre 16 e 26 horas. Todos os pacientes foram submetidos a vídeo-toracoscopia, com decorticação pulmonar, abordagem das loculações pleurais, abertura da pleura mediastinal junto ao local da perfuração e desbridamento dos tecidos desvitalizados, seguido por dupla drenagem da cavidade pleural. Não foi realizada sutura ou ressecção esofagiana, e os pacientes evoluíram com fechamento completo das lesões, sem óbitos. Conclusão: a abordagem cirúrgica vídeo-toracoscópica mostrou-se capaz de controlar a infecção pleural, a expansão pulmonar e possibilitar a completa regeneração do esôfago com perfuração diagnosticada tardiamente.

ABSTRACT Objectives: to evaluate the use of video-thoracoscopy, in the treatment of late perforations of the thoracic esophagus, without suture or organ resection. Methods: retrospective analysis of patients with late diagnosis (> 12 hours) of thoracic esophageal perforation treated by video-thoracoscopy, without suture or organ resection, over a 15-year period. Results: sixteen patients were operated on, ten men and six women, aged between 48 and 66 years, with time between the diagnosis of the perforation and the surgery ranging from 16 to 26 hours. All patients underwent video-thoracoscopy, with pulmonary decortication, pleural loculations approach, opening of the mediastinal pleura near the perforation site and debridement of the devitalized tissues, followed by double drainage of the pleural cavity. No esophageal suture or resection was performed, and the patients evolved with complete closure of the lesions, without deaths. Conclusion: the video-thoracoscopic surgical approach was able to control pleural infection, pulmonary expansion and enable complete regeneration of the esophagus with late-diagnosed perforation.

Boerhaave syndrome - case report / Síndrome de Boerhaave - relato de caso

ABSTRACT CONTEXT: Boerhaave syndrome consists of spontaneous longitudinal transmural rupture of the esophagus, usually in its distal part. It generally develops during or after persistent vomiting as a consequence of a sudden increase in intraluminal pressure in the esophagus. It is extremely rare in clinical practice. In 50% of the cases, it is manifested by Mackler's triad: vomiting, lower thoracic pain and subcutaneous emphysema. Hematemesis is an uncommon yet challenging presentation of Boerhaave's syndrome. Compared with ruptures of other parts of the digestive tract, spontaneous rupture is characterized by a higher mortality rate. CASE REPORT: This paper presents a 64-year-old female patient whose vomit was black four days before examination and became bloody on the day of the examination. Her symptoms included epigastric pain and suffocation. Physical examination showed hypotension, tachycardia, dyspnea and a swollen and painful abdomen. Auscultation showed lateral crackling sounds on inspiration. Ultrasound examination showed a distended stomach filled with fluid. Over 1000 ml of fresh blood was extracted by means of nasogastric suction. Esophagogastroduodenoscopy was discontinued immediately upon entering the proximal esophagus, where a large amount of fresh blood was observed. The patient was sent for emergency abdominal surgery, during which she died. An autopsy established a diagnosis of Boerhaave syndrome and ulceration in the duodenal bulb. CONCLUSION: Boerhaave syndrome should be considered in all cases with a combination of gastrointestinal symptoms (especially epigastric pain and vomiting) and pulmonary signs and symptoms (especially suffocation).

RESUMO CONTEXTO: A síndrome de Boerhaave é uma ruptura longitudinal transmural espontânea do esôfago, normalmente da parte distal. Ela geralmente se desenvolve durante ou após vômitos persistentes como consequência do aumento repentino da pressão intraluminal no esôfago. É extremamente rara na prática clínica. Em 50% dos casos, manifesta-se pela tríade de Mackler: vômitos, dor torácica inferior, enfisema subcutâneo. Hematêmese é uma apresentação incomum porém desafiadora da síndrome de Boerhaave. Em comparação com rupturas de outras partes do tubo digestivo, a ruptura espontânea é caracterizada pela taxa de mortalidade mais elevada. RELATO DO CASO: O artigo apresenta uma paciente do sexo feminino de 64 anos de idade, cujo vômito era preto, quatro dias antes do exame, e continha sangue no dia do exame. Os sintomas incluíam dor epigástrica e sufocação. No exame físico, foi verificada hipotensão, taquicardia, dispneia e abdômen inchado e doloroso. Ausculta revelou estertores laterais na inspiração. A ultrassonografia mostrou estômago dilatado, preenchido com conteúdo líquido. Sucção nasogástrica evacuou mais de 1.000 ml de sangue fresco. Esofagogastroduodenoscopia foi abortada imediatamente ao se entrar no esôfago proximal, onde foi observada grande quantidade de sangue fresco. A paciente foi encaminhada com urgência para cirurgia abdominal, durante a qual faleceu. Autópsia estabeleceu diagnóstico de síndrome de Boerhaave e úlcera no bulbo-duodenal. CONCLUSÃO: A síndrome Boerhaave deve ser considerada em todos os casos com uma combinação de sintomas gastrointestinais (especialmente dor epigástrica e vómitos) e sintomas e sinais pulmonares (especialmente sufocação).

Incidence and Clinical Features of Esophageal Perforation Caused by Ingested Foreign Body / 대한소화기학회지

BACKGROUND/AIMS: Esophageal perforation is a rare but often a life-threatening condition. However, the incidence and clinical features of esophageal perforation caused by ingested foreign body are unknown. This study investigated the incidence of esophageal perforation caused by ingested foreign body and evaluated the clinical features and outcome of patients with esophageal perforation. METHODS: Among a total of 196 adult patients with confirmed esophageal foreign body and complained of at least one of the related symptoms at the emergency department between January 2000 and July 2008, 18 patients with esophageal perforation due to esophageal foreign body ingestion were included in the study. Data were collected by retrospectively reviewing the electric medical records. RESULTS: The incidence of esophageal foreign body and esophageal perforation in adults was 19.4% (196/1,009) and 1.8% (18/1,009), respectively. Chest pain was the most common symptom and fishbone was the most common foreign body causing esophageal perforation. Mediastinitis or mediastinal abscess occurred in 13 patients (13/18, 72.2%). About half (8/18) of the patients were admitted to the intensive care unit but there was no in-hospital mortality. CONCLUSIONS: The incidence of esophageal perforation in patients with foreign body ingestion was low but it increased up to 9.2% in patients with esophageal foreign body. However, prognosis was favorable with timely proper treatment. Chest pain can be an ominous sign indicating the presence of esophageal perforation in patients with esophageal foreign body.

Prótesis esofágica autoexpansible para tratamiento de síndrome de Boerhaave: a propósito de un caso / Self-expanding esophageal stent for treatment of Boerhaave syndrome: report of a case

La perforación esofágica espontánea (PEE) o síndrome de Boerhaave es una entidad poco frecuente, consiste en la ruptura del esófago no relacionada con traumatismos, exploraciones invasivas, patología esofágica previa o cuerpos extraños. Independientemente de su mecanismo de producción, la perforación esofágica se considera como la más grave del tracto digestivo. Si su diagnóstico y reparación quirúrgica se retrasan, el pronóstico se ensombrece de forma notable. Presentamos un caso de paciente masculino de 37 años, sin antecedentes de interés que consulta a emergencia por cuadro brusco de dolor epigástrico irradiado a región retroesternal, posterior a vómito de contenido alimentario. El paciente presenta progresivamente deterioro de sus condiciones ventilatorias, que ameritan traslado a UCI y 72 horas posterior a ingreso a UCI se realizó esofagograma con bario evidenciándose extravasación de medio de contraste en tercio distal esofágico, aproximadamente 3 cm por encima de hemidiafragma izquierdo, por lo que de inmediato se decide colocación de stent metálico parcialmente cubierto Wilson-Cook (Evolution) bajo visión endoscópica y fluoroscópica, con resolución completa de la sintomatología

Spontaneous esophageal perforation (SEP) or Boerhaave syndrome is a rare entity that consists in the rupture of the esophagus unrelated to trauma, invasive examinations, previous esophageal disease or the presence of foreign bodies. Regardless of its mechanism, esophageal perforation is considered the most serious of the digestive tract. If diagnosis and surgical repair are delayed the outlook worsens considerably. We present the case of a 37-year-old male patient in good health, who attends the emergency room because of sudden onset of epigastric pain radiating to the retrosternal region after vomiting. The patient´s ventilatory condition deteriorated progressively meriting transfer to the intensive care unit; 72 hours after admission, a barium esophagram showed dye extravasation in the distal esophagus, approx 3 cm above the left diaphragm. We immediately decided to place a Wilson-Cook partially covered metal stent (Evolution) through endoscopic and fluoroscopic guidance with complete resolution of symptoms

Boerhaave's syndrome: a differential diagnosis of acute chest pain following a vomiting illness / Síndrome de Boerhaave: un diagnóstico diferencial de dolor torácico, agudo tras enfermedad acompañada de vómitos

Spontaneous oesophageal rupture (Boerhaave's syndrome) is extremely rare in children. Presentation is usually in middle aged men as a result of vomiting following heavy food or alcohol consumption. We describe an unusual case of a 12-year old boy without significant past medical history presenting with acute chest pain following gastroenteritis.

La ruptura esofágica espontánea (síndrome de Boerhaave) es extremadamente rara en niños. Por lo general se presenta en hombres de mediana edad como resultado vómitos tras la ingestión de alcohol o alimentos pesados. Describimos un caso inusual de un niño de 12 años de edad sin antecedentes clínicos significativos, que acudió con dolor torácico agudo tras una gastroenteritis.

Ruptura espontânea do esôfago: síndrome de Boerhaave / Spontaneous rupture of the esophagus: boerhaave's syndrome

Boerhaave's syndrome, the spontaneous rupture of the esophagus, is associated with a 35% death rate. Perforated esophagus is a surgical emergency; it is the most serious, and frequently the most rapidly lethal, perforation of the gastro-intestinal tract. Three cases of Boerhaave's syndrome are presented, with their variants and resolutions. Treatment and outcome are largely determined by the time of presentation. We reviewed our experience with esophageal perforations to determine the overall mortality and whether the time of presentation should influence management strategy.

Tracheoesophageal perforation following external blunt trauma

External trauma accounts for less than 10% of all esophageal perforations, the major resulting from penetrating trauma. External blunt trauma with tracheoesophageal perforation is an unusual and potentially catastrophic event. The diagnosis of esophageal perforations following blunt trauma presents a diagnostic dilemma as it may be obscured by more obvious injuries. We hereby report a case of a child of road traffic accident who sustained external blunt trauma to cervical and upper thoracic region which resulted into a tracheoesophageal perforation

Rupture spontanee de l'oesophage. A propos de quatre observations

La rupture spontanee de l'oesophage (RSO) represente une urgence chirurgicale rare et grave. Nous en rapportons quatre cas observes et traites au Centre Hospitalier de Pau de janvier 1986 a janvier 2007. L'objectif est de montrer les difficultes diagnostiques et therapeutiques. Si le diagnostic est facile dans sa forme classique; il doit etre evoque dans sa forme atypique devant l'association d'une symptomatologie abdominale et pleuro-pulmonaire; d'une douleur basithoracique et de vomissements. La radiographie thoracique; l'oesophagographie et la tomodensitometrie constituent la cle du diagnostic. Quant a la prise en charge chirurgicale; une suture associee a une fistulisation dirigee et une exclusion oesophagienne semblent etre les gestes les mieux adaptes

Endoscopic examination of the upper esophagus by withdrawal of endoscope over guide wire.

Upper gastrointestinal (UGI) endoscopy is an important diagnostic modality in evaluation of patients with upper gastrointestinal (GI) disorders. However, lesions located in the cricopharyngeal area and upper esophagus can be missed, as this area may not be well visualized during endoscopy. This study was conducted to study the utility of a new technique of endoscopic examination of the upper esophagus by withdrawal of endoscope over guide wire in diagnosing esophageal disorders. Patients with suspected upper esophageal disorders on history and radiological investigations were assessed using guide wire assisted endoscopic examination during withdrawal of the endoscope. In this technique, endoscope is inserted into the esophagus under vision and thereafter the whole of esophagus, stomach and proximal duodenum is examined. The endoscope is then withdrawn into the mid-esophagus, a guide wire is fed into the biopsy channel, and thereafter inserted into the esophagus. Once guide wire has been advanced into the esophagus, the endoscope is withdrawn gently over the guide wire into esophagus carefully examining for lesions in upper esophagus and cricopharyngeal area. Twenty cases of various abnormalities localized to the upper esophagus were studied. The final diagnosis in these patients was cervical esophageal web (10), post transhiatal esophagectomy leak (4), heterotopic gastric mucosa (3), posttraumatic esophageal perforation (2), and Zenker's diverticulum (1). Intact web was detected in 2 patients and in 8 patients fractured web was seen. Guide wire assisted examination of upper esophagus improved the ability to visualize and characterize these lesions and no complications were encountered as a result of this procedure. Endoscopic examination of the upper esophagus by withdrawal of endoscope over guide wire is safe and effective in diagnosing anatomical abnormalities of the upper esophagus that may be missed or poorly characterized during standard endoscopy.

Successful closure of spontaneous esophageal perforation (Boerhaave's syndrome) by endoscopic clipping.

Endoscopic clips have been used mainly for control of gastrointestinal (GI) bleeding and occasionally for closure of GI perforations. However, closure of spontaneous esophageal perforation (Boerhaave's syndrome) by clipping has not been reported. We described successful non-surgical closure of spontaneous esophageal perforation by endoscopic clipping in a patient with bilateral pyopneumothorax and septicemia.

Carmi syndrome complicated by pharyngo-esophageal perforation.

We describe a neonate having congenital pyloric atresia (CPA) associated with epidermolysis bullosa (EB), also known as Carmi syndrome. The case is unusual as it was complicated with pharyngo-esophageal perforation (PEP) and a definite family history of EB in pervious generations could be recorded.

Surgical treatment of traumatic esophageal perforations: analysis of 10 cases

PROPÓSITO: Perfurações esofágicas não são freqüentes. Representam um dilema cirúrgico, especialmente se o diagnóstico é tardio. Relato recente dá conta que a mortalidade devida a perfuração esofágica apresenta redução independentemente de seu tempo de evolução. A experiência com perfurações esofágicas traumáticas é aqui revista para determinar a relação morbi-mortalidade e como esta é afetada pelo tempo. MÉTODOS: Uma revisão retrospectiva clínica foi realizada para todos os pacientes com diagnóstico de perfuração esofágica traumática tratados pelo autor. Registraram-se 10 pacientes, todos do sexo masculino. I idade média foi de 32 anos (17 a 63). As causas foram arma de fogo (7), trauma contuso (1) e corpo estranho (2). Quatro pacientes foram tratados até 24 horas após o trauma (tratamento precoce), enquanto os outros 6 foram tratados 56 a 168 horas pós trauma (tratamento tardio). RESULTADOS: Os pacientes tratados precocemente evoluíram com reparo primário. Os pacientes em tratamento tardio incluíram: reparo primário (n=1), tubo-T (n=2), drenagem de abscesso cervical e decorticação pulmonar (n=2), tratamento conservador (n=1). Foi registrado 1 óbito no grupo tardio (16,6%). Um paciente no grupo precoce (25%) e 4 (66%) no grupo tardio registraram complicações. O tempo médio de permanência hospitalar pós-operatória foi de 20.5 dias para o grupo precoce e de 38 dias para grupo tardio. CONCLUSIONS: A mortalidade resultante de perfurações esofágicas traumáticas reduziu-se significativamente. A morbidade permanece elevada, especialmente em pacientes tratados tardiamente, com cirurgia múltipla e períodos prolongados de hospitalização em unidades de terapia intensiva e enfermarias cirúrgicas, do que resultam elevados custos hospitalares. Aparentemente, o principal fator responsável pela morbi-mortalidade é o tempo de diagnóstico. Todos os esforços deveriam ser investidos no diagnóstico precoce. Uma vez feito o diagnóstico, o tratamento deve ser urgente e agressivo.

Perforación esofágica: experiencia clínica y actualización del tema / An update on esophageal perforation

Esophageal perforation is a complicated clinical entity that demands a high level of diagnostic and therapeutic skills. The management alternatives vary from conservative treatment to esophagectomy, including primary suture and esophageal exclusion. This paper is a review of the literature and personal experience with this condition, focusing on etiology, clinical presentation, diagnostic workout, treatment, complications and mortality. Finally, we propose a management algorithm.

Manejo conservador de la perforación esofágica / Conservative management of esophageal perforation

La perforación esofágica es la más grave de todas las perforaciones del tubo digestivo, con una morbilidad y mortalidad muy elevada. El enfrentamiento diagnóstico y terapéutico es complejo y controversial. Un diagnóstico precoz mejoraría los resultados y permitiría un manejo conservador. Se presenta el caso clínico de un paciente de 17 años que presenta una perforación esofágica secundaria a dilatación, debido a una estenosis producida por caústicos. Es manejado mediante tratamiento conservador en forma satisfactoria. Se realiza una revisión del tema dirigido principalmente hacia la orientación terapéutica de la perforación esofágica, en donde se concluye que ésta va a depender principalmente de un diagnóstico precoz y de las condiciones locales y generales de cada paciente. Se debe preconizar por un manejo conservador de cada caso que cumpla con los criterios para realizarlo.

Resultados actuales del manejo de la perforación esofágica / Current results of the management of esophageal perforation

Introducción: la perforación esofágica (PE) es una entidad clínica que se asocia a alta morbimortalidad y su pronóstico depende básicamente de la etiología y momento del diagnóstico. Objetivo: analizar la presentación clínica, etiología, tratamiento y evolución de los pacientes con PE en el Departamento de Cirugía del Hospital Clínico de la Universidad de Chile. Pacientes y método: se realiza una revisión retrospectiva, entre los años 1986 y 2003 de pacientes con perforación esofágica. La serie está constituida por 34 casos, 16 hombres y 18 mujeres, con una edad promedio de 59 años. Resultados: el diagnóstico fue hecho en un 59 por ciento antes de las 24 hrs. de evolución. La etiología fue en un 35 por ciento de los casos secundaria a ingestión de cuerpo extraño, en un 32 por ciento secundaria a procedimientos endoscópicos, un 27 por ciento corresponden a rotura espontánea y en un 6 por ciento por uso de sonda de Sengstaken. Un 38 por ciento presentó perforación en esófago cervical, un 35 por ciento esófago torácico y un 27 por ciento en esófago abdominal. El manejo fue exclusivamente médico en 8 pacientes (24 por ciento) y quirúrgico en 26 (76 por ciento). Los procedimientos quirúrgicos realizados fueron: esofagectomía en 6 pacientes, esofagorrafia primaria en 9 y desfuncionalización con sutura primaria en 11. La tasa de mortalidad global fue de 21 por ciento. Analizando por sub-grupos se encontró una mortalidad de 15 por ciento en el grupo con <24 hrs. y de 28 por ciento en la de >24 hrs. de evolución. Con respecto al nivel de perforación, la tasa de mortalidad fue de 0 por ciento en las perforaciones de esófago cervical, 42 por ciento en las de esófago torácico y de un 22 por ciento en esófago abdominal. Respecto a la etiología, los pacientes que presentaron rotura espontánea tuvieron una tasa de mortalidad de un 56 por ciento, una tasa de 9 por ciento los pacientes que presentaron PE secundario a procedimientos endoscópicos y ningún paciente falleció por cuerpo extraño. Conclusión: la PE se asocia a alta mortalidad y ésta a su vez se relaciona, en esta serie, con el nivel de la perforación, la etiología y el tiempo de diagnóstico.

Perfurações traumáticas do esôfago / Traumatic esophageal perforation

As perfurações esofágicas ainda representam um desafio quanto ao diagnóstico e tratamento. Objetivo - Descrever a experiência do serviço no tratamento das perfurações de esôfago...

Perforation of the esophagus remains a diagnostic and therapeutic challenger. Aim - To review our experience in the management of esophageal perforation...