Zusammenfassung
Einleitung
Operative sowie auch interventionelle Therapien des Boerhaave-Syndroms beinhalten zum einen den Verschluss des Ösophagusdefektes zum anderen die Sanierung des septischen Fokus. Erste Berichte über den Einsatz der endoskopischen Vakuumtherapie (EVT) beim Boerhaave-Syndrom liegen vor. Anhand zweier Falldarstellungen wird über die Erfahrungen in der klinischen Anwendung dieses neuen chirurgischen Verfahrens berichtet. Die aktuelle Literatur zur Behandlung des Boerhaave-Syndroms mit EVT wird dargestellt.Material und Methode
Offenporige Drainagen werden endoskopisch ösophageal entweder durch den transmuralen Defekt hindurch in die extraluminale Wundhöhle (intrakavitäre EVT) oder den Defekt überdeckend im Ösophaguslumen (intraluminale EVT) platziert. Die Anlage eines Unterdrucks an der Drainage führt zu einer aktiven nach luminal gerichteten Drainage und gleichzeitig zum Defektverschluss. Durch diese Maßnahmen kann sowohl der Perforationsdefekt als auch der septische Fokus zur Ausheilung gebracht werden. Offenporige Drainagen werden aus Drainageschläuchen und offenporigen Schäumen oder einer offenporigen Folie hergestellt.Ergebnisse
Bei beiden Patienten wurden die im distalen Ösophagus gelegenen Perforationsdefekte mit der EVT zur kompletten Abheilung gebracht. Beim ersten Patienten war die alleinige Behandlung mit einer 8 Tage dauernden EVT ausreichend. Bei dem zweiten Patienten wurde die EVT mit einer offenen Thorakotomie zur Dekortikation eines Pleuraempyems kombiniert. Die Therapiedauer der EVT betrug 23 Tage, ein Therapiezyklus wurde mit einem offenporigen Drainageschlauch durchgeführt. Ein operativer Defektverschluss oder eine Ösophagusresektion waren bei keinem der beiden Patienten erforderlich.In der aktuellen Literatur wird in mehreren Studien und Einzelfalldarstellungen über die EVT beim Boerhaave-Syndrom an insgesamt 13 Patienten berichtet, 11 Patienten (84 %) konnten erfolgreich behandelt werden.
Fazit
Erste klinische Erfahrungen zeigen, dass mit der EVT sowohl die Drainage des septischen Fokus als auch der Verschluss des Boerhaave-Defektes im gastroösophagealen Übergang gelingt. EVT ist eine organerhaltene endoskopische chirurgische Therapie, die eine Alternative und Ergänzung zu operativen Eingriffen darstellen kann.Boerhaave syndrome
From Wikipedia, the free encyclopedia
| Boerhaave syndrome | |
|---|---|
| Classification and external resources | |
| Specialty | gastroenterology |
| ICD-10 | K22.3 |
| ICD-9-CM | 530.4 |
| DiseasesDB | 9168 |
| MedlinePlus | 000231 |
| eMedicine | med/233 |
| MeSH | D004939 |
Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery.[1] In contrast, the term Boerhaave's syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting.[2]
Spontaneous perforation of the esophagus most commonly results from a full-thickness tear in the esophageal wall due to a sudden increase in intraesophageal pressure combined with relatively negative intrathoracic pressure caused by straining or vomiting (effort rupture of the esophagus or Boerhaave's syndrome). Other causes of spontaneous perforation include caustic ingestion, pill esophagitis, Barrett's esophagus, infectious ulcers in patients with AIDS, and following dilation of esophageal strictures.
In most cases of Boerhaave's syndrome, the tear occurs at the left postero-lateral aspect of the distal esophagus and extends for several centimeters. The condition is associated with high morbidity and mortality and is fatal without treatment. The occasionally nonspecific nature of the symptoms may contribute to a delay in diagnosis and a poor outcome. Spontaneous effort rupture of the cervical esophagus, leading to localized cervical perforation, may be more common than previously recognized and has a generally benign course. Preexisting esophageal disease is not a prerequisite for esophageal perforation but it contributes to increased mortality
This condition was first documented by the 18th-century physician Herman Boerhaave, after whom it is named.[3][4] A related condition is Mallory-Weiss syndrome which is only a mucosal tear. In case of iatrogenic perforation common site is cervical esophagus just above the upper sphincter where as spontaneous rupture as seen in Boerhaave's syndrome perforation commonly occurs in the lower (1/3)rd of esophagus.[5]
Contents
[hide]Signs and symptoms
The classic history of esophageal rupture is one of severe retching and vomiting followed by excruciating retrosternal chest and upper abdominal pain. Odynophagia, tachypnea, dyspnea, cyanosis, fever, andshock develop rapidly thereafter.
Physical examination is usually not helpful, particularly early in the course. Subcutaneous emphysema (crepitation) is an important diagnostic finding but is not very sensitive, being present in only 9 of 34 patients (27 percent) in one series . A pleural effusion may be detected.
Mackler's triad includes chest pain, vomiting, and subcutaneous emphysema, and while it is a classical presentation, it is only present in 14% of people.[6]
Pain can occasionally radiate to the left shoulder, causing physicians to confuse an esophageal perforation with a myocardial infarction.
It may also be audibly recognized as Hamman's sign.
Differential diagnosis
Common misdiagnoses include myocardial infarction, pancreatitis, lung abscess, pericarditis, and spontaneous pneumothorax. If esophageal perforation is suspected, even in the absence of physical findings, contrast radiographic studies of the esophagus and a CT scan should be promptly obtained.
Pathophysiology
Esophageal rupture in Boerhaave syndrome is thought to be the result of a sudden rise in internal esophageal pressure produced during vomiting, as a result of neuromuscular incoordination causing failure of thecricopharyngeus muscle (a sphincter within the esophagus) to relax. The syndrome is commonly associated with the consumption of excessive food and/or alcohol as well as eating disorders such as bulimia.
The most common anatomical location of the tear in Boerhaave syndrome is at left posterolateral wall of the lower third of the esophagus, 2–3 cm before the stomach.[7]
Currently, the most common cause of esophageal perforation is iatrogenic. However, iatrogenic perforations, while still constituting a serious medical condition, are easier to treat and less prone to complications, particularly mediastinitis and sepsis. This is because they usually do not involve contamination of the mediastinum with gastric contents.
Diagnosis
Upright chest radiography showing mediastinal air adjacent to the aorta and tracking cephalad adjacent to the left common carotid artery. This patient presented to the Emergency department with severe chest pain after eating.
Axial CT image through the upper chest showing extraluminal air(pneumediastinum) surrounding the trachea and esophagus
Sagittal remormatted CT image showing discontinutity in the wall of the posterolateral aspect of the distal esophagus
The diagnosis of Boerhaave's syndrome is suggested on the plain chest radiography and confirmed by chest CT scan. The initial plain chest radiograph is almost always abnormal in patients with Boerhaave's syndrome and usually reveals mediastinal or free peritoneal air as the initial radiologic manifestation. With cervical esophageal perforations, plain films of the neck show air in the soft tissues of the prevertebral space.
Hours to days later, pleural effusion(s) with or without pneumothorax, widened mediastinum, and subcutaneous emphysema are typically seen. CT scan may show esophageal wall edema and thickening, extraesophageal air, periesophageal fluid with or without gas bubbles, mediastinal widening, and air and fluid in the pleural spaces, retroperitoneum or lesser sac.
The diagnosis of esophageal perforation could also be confirmed by water-soluble contrast esophagram (Gastrograffin), which reveals the location and extent of extravasation of contrast material. Although barium is superior in demonstrating small perforations, the spillage of barium sulfate into the mediastinal and pleural cavities can cause an inflammatory response and subsequent fibrosis and is therefore not used as the primary diagnostic study. If, however, the water-soluble study is negative, a barium study should be performed for better definition.
Endoscopy has no role in the diagnosis of spontaneous esophageal perforation. Both the endoscope and insufflation of air can extend the perforation and introduce air into the mediastinum.
Patients may also have a pleural effusion high in amylase (from saliva), low pH, and may contain particles of food.
Treatment
With the exception of few case reports describing survival without surgery,[2] the mortality of untreated Boerhaave syndrome is nearly 100%.[8] Its treatment includes immediate antibiotic therapy to prevent mediastinitis and sepsis, surgical repair of the perforation,[9] and if there is significant fluid loss it should be replaced with IV fluid therapy since oral rehydration is not possible. Even with early surgical intervention (within 24 hours) the risk of death is 25%.[10]
References
- Rosen, Peter; John J. Ratey MD; Marx, John A.; Robert I. Simon MD; Hockberger, Robert S.; Ron Walls MD; Walls, Ron M.; Adams, James L. (2010). Rosen's emergency medicine: concepts and clinical practice 1 (7th ed.). St. Louis, Mo: Mosby/Elsevier. ISBN 0-323-05472-2.
- Boerhaave syndromeat eMedicine
- synd/2800 at Who Named It?
- H. Boerhaave. Atrocis, nec descripti prius, morbis historia: Secundum medicae artis leges conscripta. Lugduni Batavorum; Ex officine Boutesteniana. 1724.
- Bailey & Love 25th/e page 1014
- Woo KM, Schneider JI (November 2009). "High-risk chief complaints I: chest pain--the big three". Emerg. Med. Clin. North Am. 27 (4): 685–712, x.doi:10.1016/j.emc.2009.07.007. PMID 19932401.
- Korn O, Oñate JC, López R (2007). "Anatomy of the Boerhaave syndrome".Surgery 141 (2): 222–8. doi:10.1016/j.surg.2006.06.034. PMID 17263979.
- Curci JJ, Horman MJ (April 1976). "Boerhaave's syndrome: The importance of early diagnosis and treatment". Annals of Surgery 183 (4): 401–8.doi:10.1097/00000658-197604000-00013. PMC 1344212. PMID 1267496.
- Matsuda A, Miyashita M, Sasajima K, et al. (2006). "Boerhaave syndrome treated conservatively following early endoscopic diagnosis: a case report".Journal of Nippon Medical School = Nihon Ika Daigaku zasshi 73 (6): 341–5.doi:10.1272/jnms.73.341. PMID 17220586.
- Jougon J, Mc Bride T, Delcambre F, Minniti A, Velly JF (April 2004). "Primary esophageal repair for Boerhaave's syndrome whatever the free interval between perforation and treatment". Eur J Cardiothorac Surg 25 (4): 475–9.doi:10.1016/j.ejcts.2003.12.029. PMID 15037257.
External links
- Radiology Esophageal rupture
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