Oesophageal emergencies Pál Ondrejka Professor of Surgery

Emergency oeasophageal disorders Perforation Iatrogenic perforation Spontaneous perforation Boerhaave’s syndrome Traumatic perforation Blunt trauma Penetrating injuries Foreign body Caustic injuries Alcalic Acidic

Why the oesophageal injuries are highly problematic? The proximity of vital structures The blood suply The lack of serosal surface arround the organ The injuries are carry high morbidity and mortality Most surgeons has limited experiences with diagnosis and treatment of such cases

Hermann Boerhaave (31 December 1668 – 23 September 1738)[

Boerhaave syndrome Boerhaave first described Boerhaave syndrome, which involves tearing of the oesophagus, usually a consequence of vigorous vomiting. He notoriously described in 1724 the case of Baron Jan van Wassenaer, a Dutch admiral who died of this condition following a gluttonous feast and subsequent regurgitation.[8] This condition was uniformly fatal prior to modern surgical techniques allowing repair of the oesophagus.

Aetiology Sudden rise of intra-abdominal pressure (80-90%) Vomiting or retching Blunt trauma Weightlifting Defecation Heimlich manoeuvre Status epilepticus

Existing underlying oesophageal disorders (10-20%) Malignancy Peptic ulceration Herpes simplex virus (HSV) Human immunodeficiency virus (HIV) Tuberculosis (TB)

Tipical location Just above the diaphragm Left posterolateral position Usually singl, longitudinal, 1-8 cm Men : women = 4 . 1 Median age 64 years Most of tham because of alcoholic intoxication Pleural disruption developes barogenically or from rapid gastric acid erosion

Mackler’s triadof clinical presentation of oesophageal perforation Vomiting or retching Chest pain (Sudden and dramatic) constant, epigastric or retrosternal, exacerbated by movement Subcutaneous emphisema (takes about an hour to develop)

Other symptomes Tachycardia, tachypnoe The patient takes siting position in order to reduce diaphragmatic movements Patients are pale and sweaty Cool peripheries Chemical pleuromediastinitis develops In 24.48 hours cardiopulmanary insuffitienty develops

Diagnostic examinations Plain chest and abdominal radiography Contrast radiography Upper gastrointestinal endoscopy Computed tomography (CT) Other Pleural aspiration Oral blue dyes

Plain chest radigraphy

Tipical chest radiography findings Pleural effusion Pneumomediastinum Sucutaneous emphysema Hydropneumothorax Pneumothorax

Preoperative resustitation Control of airway and administration of O2 Early anaesthetic involvment Stabile central intravenosus access Urethral catether Broad spectrum antibiotic and antifungal agents Intravenosus antisecretory drugs Zero diet Intercostal chest drainage Nasogastric tube

Contrast radiograpy

Endoscopic examination

CT scan

Frequent medical misdiagnoses Myocardial infarction Pericarditis Spontaneous pneumothorax Pneumonia Oesophageal varices/mallory-Weis tear Mesenteric ischaemia

Frequent surgical misdiagnoses Peritonitis Acute pancreatitis Perforated peptic ulcer Renal coloc Aortic aneurism (dissection/rupture) Billiary colic Mesenteric ischaemia