1. Oesophageal emergencies
Pál Ondrejka
Professor of Surgery

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

3. 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

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

5. 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.

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

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

9. 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

10. 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)

11. 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 hours cardiopulmanary insuffitienty develops

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

13. Plain chest radigraphy

14. Tipical chest radiography findings
Pleural effusion
Pneumomediastinum
Sucutaneous emphysema
Hydropneumothorax
Pneumothorax

15. 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

16. Contrast radiograpy

17. Endoscopic examination

18. CT scan

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

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