Boerhaave's syndrome - Forum

Chirurgia

Boerhaave's syndrome - Ärzteforum

Post#1 »

A good drainage of the mediastinum and pleural spaces, buttressed suture and exclusion plus yeyunostomy have been claimed by some as the standard method for the treatment of Boerhaave's syndrome.

We have recently treated a patient suffering from an utterly necrotic fungal mediastinitis by the means of the Grillo's technique, after dissecting and draining both pleural and mediastinal spaces. An exclusion was made by using both nasoesophageal and gastrostomy tubes.
During three weeks sepsis was under control and CT scan did not show any sign of mediastinitis.
Despite this a leak was demonstrated after a distressing attempt to replace the Foley's gastrostomy tube. The radiologist said: "the balloon seems to have been inflated into the esophagus (!)". Moreover a split in the chest wound led us to reoperate on the patient.
The graft was alive but far from a non-healed esophageal lesion. The mediastinum was locked but without any sign of infection. A subpulmonary residual cavity was filled with dorsal muscle after resuturing and buttressing the lesion. As it was occurring a relentless sinergystic pneumonia brought about patient's death.
Would have been the outcome different if we had taken the esophagus out during the first operation? What do you think?


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Re: Boerhaave's syndrome - Ärzteforum

Post#2 »

I am not a lover or a hater but had some experience with this condition. Before responding to your most interesting case could you update us on what is exactly Grillo's technique; what muscle flap has been used? In addition: how "old" was the perforation?

forceps

Re: Boerhaave's syndrome - Ärzteforum

Post#3 »

Grillo's technique (pleural flap) and Dooling and Zick's technique (pedicled intercostal muscle) are well described in Pearson's Esophageal Surgery. On the other hand, we thought that the perforation would have been at least 24-48 hours before surgery, based on the necrotic aspect of the mediastinum.

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Re: Boerhaave's syndrome - Ärzteforum

Post#4 »

As you well know all studies on this syndrome represent short retrospective series or case reports. In the absence of solid evidence we can only speculate what is the "best" therapy .

The principle of management here is ofcourse SOURCE CONTROL- i.e.- exclude the perforation from the mediastinum. This can be achieved in numerous ways. The literature mentions large spectrum of possibilities: on one side of the spectrum there is non-operative RX, on the other side-total esophageal exclusion. In between, various buttress-flaps, tubes, pipes, and even simple drainage of the perforation through the bed of the 10th rib(on te left).

Obviously, in selected cases non-operative Rx is successful, but the success is defined post-factum and cannot be predicted. I have seen a patient such treated suddenly dying 3 days after admission.

So how you treat theses cases depends on how sick they are- the sicker-the more aggressive surgery should be, how late are they diagnosed, and what is the condition of the tissues.

In late- diagnosed, critically ill patients, with severe mediastinitis I would go for total exclusion with end cervical esophagistomy, stapling of the GEJ, and pleural drainage. Lesser procedures, ofcourse, may be as effective but in the individual patient-who knows?

As a flap to close the perforation I would prefer the mobilized gastric fundus.

Some late diagnosed patients are non-salvageable whatever you do- your patient?

As a junior Intern in Jerusalem I diagnosed my first Boerhaave's syn- presenting with chest pain, Homman's (Spelling?) crunch, pleural effusion- high in amylase. On the morning after admission, on Grand Rounds I presenetd this case to the local Chairman of Medicine (the local "God") mentioing the possibility of Boerhaave's syn. The "god" smiled, diagnosed "some sort of "pericarditis" and ordered cardiac echo. When the patient deteriorated gastrografin demonstrated the obvious diagnosis. I have learned then : a. this syndorme is often missed. b. always carefully listen to what your juniors have to say.

Hans

Re: Boerhaave's syndrome - Ärzteforum

Post#5 »

I remember the first time I met with Boerhaave's syndrome was the first solo laparotomy I ever did. I thought the patient had acute perf DU, but the lap was negative. I called my boss, but he refused to come and told me to close up the patient (this was in the UK). The next day the patient was much sicker, and the diagnosis became clear - he eventually died on ICU. He was an otherwise fit young man of around 30 yrs. Since then I have always treated oesophageal injury with the greatest of respect. Despite this the battle is often lost. Some may feel surgeon's suggestion of cervical oesophagostomy and stapling to the GE junction is overkill, but by the time you have failed with a lesser procedure it will be too late for anything to succeed.

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