[Spontaneous rupture of the esophagus]

Conservative surgical management of Boerhaave's syndrome: experience of two tertiary referral centers

BACKGROUND

Surgery is generally proposed for Boerhaave's syndrome, spontaneous rupture of the esophagus. But diagnosis can be difficult, delaying appropriate management. The purpose of the present study was to evaluate outcome of conservative surgery for primary or T-tube repair performed in two tertiary referral centers.

METHODS

From June 1985 to November 2010, among 53 patients presenting with Boerhaave's syndrome treated surgically, 39 underwent a conservative procedure. These patients were retrospectively divided into two groups by type of repair: primary suture (group 1, n = 25) or suture on a T-tube (group 2, n = 14). Patients in group 1 were further stratified into two subgroups depending on whether the primary suture was made with reinforcement (subgroup rS) or not (subgroup S).

RESULTS

Length of stays in hospital and intensive care were shorter in patients in group 1 (p = 0.037), but after a shorter delay before therapeutic management (p = 0.003) compared with group 2. For the other variables studied, outcome was more favorable in group 1, but the differences were not significant. Comparing subgroups rS and S showed that the rate of persistent leakage was significantly lower after reinforced suture (p = 0.021).

CONCLUSIONS

These findings from the largest reported cohort of Boerhaave's syndrome patients undergoing conservative surgery showed that primary and T-tube repair provide at least equivalent results. Reinforced sutures appear to provide better outcomes by reducing postoperative leakage.

Surgical treatment of esophageal perforations: the importance of a primary repair

PURPOSE

The aim of the current study was to evaluate the outcome after primary repair in comparison to other surgical treatments and the advantage of reinforcing the sutures with an absorbable polyglactin 910 prosthesis.

METHODS

All esophageal perforations surgically managed in this institution from January 1985 through April 2009 (n = 40) were retrospectively analyzed. Patients that underwent surgery with primary sutures (group A, n = 24) were compared with patients that received other surgical procedures (group B, n = 16). The time to initiate treatment (within or after the first 24 h) and if the suture was reinforced with a polyglactin 910 mesh were also analyzed in group A patients.

RESULTS

The outcome was more favorable in group A than group B in terms of time in the intensive care unit (p = 0.005), and rate of reoperation (p = 0.005). There was no difference in the outcome after the primary suture with or without mesh reinforcement, although the rate of fistulization was lower in patients with a mesh (17 vs. 50 %, p = 0.19).

CONCLUSIONS

Primary repair has a better outcome than other surgical treatment, even when performed more than 24 h after symptom onset, but not later than 48 h. Reinforcing the sutures with an absorbable polyglactin 910 mesh therefore seems to improve the outcome.

[Acute mediastinitis except in a context of cardiac surgery]

Acute mediastinitis is a life-threatening complication (20 to 40 % of mortality) secondary to oropharyngeal abscesses, neck infections or oesophageal leak spreading into the mediastium. Early diagnosis and optimal therapeutic approach are crucial for patient survival. CT scanning of the cervical and thoracic area is a useful tool for diagnosis and follow-up. Treatment is based on broad-spectrum antibiotherapy, adequate surgery, mediastinal drainage, and treatment of possible organ failure. There is no surgical standardized attitude. Mini-invasive approach could be satisfactory when prompt diagnosis is established and the thoracic drainage is effective. Repeated postoperative CT scanning and close clinical and laboratory monitoring could make an additional thoracotomy a second-line procedure.

[Misleading diagnosis of a migratory epigastric pain in mobile emergency units: spontaneous rupture of the oesophagus]

The local mobile emergency unit took charge of a patient who suffered from a sudden migratory epigastric pain in the back. The clinical picture led to an initial diagnosis of an aorta dissection. Admitted to Grenoble UH's emergency unit, the radiological examination ruled out a cardiovascular pathology. Emergency surgery, performed only a few hours after the symptoms began, allowed to correctly diagnose a spontaneous rupture of the oesophagus. Fast and specialised medical treatment avoided the risk of an unfavourable development of the Boerhaave's syndrome. It is essential that mobile emergency units personnel are made aware of this rare pathology, even though it remains particularly difficult to diagnose due to its rather non-specific symptoms.

Oesophageal perforation: primary suture repair reinforced with absorbable mesh and fibrin glue

Despite major advances in the management of intrathoracic oesophageal perforation, morbidity and mortality rates remain high1,2. Currently accepted management3 includes early thoracotomy, cleansing of the mediastinum, oesophageal suture and pleural space drainage. Even when performed at an early stage, primary oesophageal suture repair remains precarious, however. Experience of oesophageal primary suture reinforced with absorbable mesh and fibrin glue is reported.