Spontaneous rupture of the esophagus:
report of two cases
Serviço de Cirurgia de Tórax do Hospital do Servidor Público Estadual-
São Paulo, Brazil
O bjective - To study the diagnosis, prognosis and m anagem ent of spontaneous rupture of the esophagus. D esign: This is a
retrospective study through the analysis of tw o cases w ith delayed diagnosis and subsequent treatm ent at the Track S urgery S ervice. Locale: The study w as perform ed at the Thoracic S urgery U nit of the H ospital do S ervidor P úblico E stadual Francisco M orato de
O liveira in the city of S ão P aulo. This is a specialized service. P articipants: The tw o patients reported on had suffered spontaneous
rupture of the esophagus. They w ere transferred to the Thoracic S urgery U nit because of the w orsening of their condition in the
previous institution w hich they had been adm itted into. M easurem ent: The tw o patients w ith esophagus pleural fistula received
sim ilar treatm ent, initially advocated by K anashin in R ussia and H auer-S antos in the U nited S tates, w hich consists of w ashing the
fistula and using continuous pleural aspiration. R esults: A lthough both patients had to spend a long period of tim e in hospital, their
evolution w as satisfactory w ith the treatm ent adopted, and the fistula closed. C onclusion: The authors conclude that the m ethod of
lavage of the m ediastinum and continuous pleural aspiration, in patients w ho after spontaneous rupture of the esophagus developed a pleural esophagus fistula due to belated diagnosis, is an alternative and satisfactory therapy. Furtherm ore, in order to have the best
outcom e, an early diagnosis is recom m ended and thoracostom y as the surgical procedure, w ith prim ary suture.
U N ITE R M S : B oerhaave S yndrom e. S pontaneous rupture ofthe esophagus. P ost-em etic rupture ofthe esophagus. E sophageal pleural fistula.
IN TR O D U C TIO N
S
reportedpontaneousin 1784 by H erm ann B oerhaave.rupture of the esophagus w as firstI T hisprofessor of m edicine at L eyden w as called to attend to B aron Johann V an W assenaer - G reat A dm iraI of the D utch Fleet - w ho presented a severe gastric disorder after having taken part in a banquet.
T o ease the B aron's m alaise B oerhaave gave him an em etic. T he B aron, after forceful vom iting, had severe pains in the chest. H is cli~ical condition quickly w orsened and he him self stated that the upper part of his stom ach had ruptured and th~t, given the intensity of pain his dem ise w as unavoidable. T he B aron's prognosis w as correct: he
A d d r e s s fo r c o r r e s p o n d e n c e : R . P e d r o d e T o le d o , 1 8 0 0
1 0 º A n d a r - A la C e n tr a l V .C le m e n tin o S ã o P a u lo /S P - B r a s il- C E P 0 4 0 3 9 - 0 0 1
died 18 hours later. T he autopsy, perform ed by B oerhaave him self, disclosed an ulceration on the distaI third of the esophagus and food residues in the pleural cavity.
A lthough the B oerhaave Syndrom e is quite rare, it cannot be forgotten in the presence of a sev~re pain in the chest after a sudden increase of intraesophageal pressure, as is the case in the vom iting m echanism .
T o delay diagnosisand treatm ent w illlead to a h~gh rate of m orbidity' and m ortality.
T he tw o cases m anaged recently at our T horacic Surgery U nit describe the severity of this syndrom e.
C A S E
1
A .T .S.F., m ale, C aucasiaIi, 52 years of age, w as adm itted into the E m ergency W ard of the hospital at 9.00 am on O ctober, 15, 1994, com ing from the southem coastal region of the State.
1 5 1 7
H e re p o rte d th a t a t 2 :0 0 p .m . o f th e p re v io u s d a y ,
a fte r h a v in g in g e s te d a la rg e a m o u n t o f fo o d a n d a lc o h o lic
b e v e ra g e s , h e p re s e n te d in te n s e v o m itin g a n d , a fte rw a rd s
a s e v e re p a in in th e c h e s t.
H e w a s ta k e n to th e lo c a l h o s p ita l w h e re , in s p ite o f
a n a lg e s ic s a d m in is te re d , p a in w a s n o t s u p p re s s e d , a n d
u p o n w o rs e n in g o f th e c lin ic a I p ic tu re h e w a s tra n s fe rre d
to S ã o P a u lo .
A t th e a d m is s io n a l e x a m in a tio n , th e p a tie n t
p re s e n te d ta c h y p n e a a n d ta c h y c a rd ia (f 2 4 p m , F C 9 6 p m ,
A P 1 1 x 7 ). H e h a d a n e m p h y s e m a in th e le ft
s u p ra c la v ic u la r c o m p a rtm e n t. A re d u c e d v e s ic u la r m u rm u r
in th e le ft h e m ith o ra x w a s n o te d a t a u s c u lta tio n .
A g a s o m e try w a s ta k e n a n d in d ic a te d n o rm a l. T h e .
b lo o d te s t m e a s u re d H b 1 4 g /% ; H tc 4 4 ; G B : 3 ,5 0 0 w ith a
d e fle c tio n to th e le ft.
S im p le X -ra y o fth e c h e s t in a n te ro p o s te rio r p o s itio n
s h o w e d a h a z y s h a d o w o n th e le ft h e m ith o ra x .
O n e o f th e h y p o th e s e s w a s th a t o f e s o p h a g ic ru p tu re ,
a n d a n e n d o s c o p y w a s im m e d ia te ly re q u e s te d w h ic h c o n fm n e d
a la c e ra tio n in th e le ft d is ta I th ird w ith p re s e n c e o f fo o d re s id u e s .
T h e p a tie n t w a s im m e d ia te ly fo rw a rd e d to th e
S u rg e ry R o o m a n d s u b m itte d to a le ft p o s te ro la te ra l
th o ra c o s to m y . In v e n to ry o f th e c a v ity d is c lo s e d 3 0 0 m l o f
y e llo w is h flu id w ith d e b ris o f fib rin . H o w e v e r, th e
m e d ia s tin u m p le u ra p re s e n te d in ta c t, w ith o u tp o u c h in g ,
s w o lle n a n d c o v e re d b y fib rin . It w a s o p e n e d a n d le t o u t a
la rg e q u a n tity o f fo o d re s id u e s , th a t o n c e re m o v e d
d is c lo s e d a p o s te ro la te ra l e s o p h a g ic la c e ra tio n , e x te n d in g
fo r a b o u t 6 c m fro m th e c a rd ia .
A fte r c le a n in g o f th e s ite , th e le s io n w a s c lo s e d w ith
fo u r s im p le c o tto n 4 .0 s u tu re s o n a s in g le p la n e , e s s e n tia lly
in te n d e d to o rie n t c ic a triz a tio n a lo n g th e s u tu re lin e , a s
F ig u re 1 - E s o p h a g ra m o f p a tie n t A .T .S .F o n 6 th R O .
N o te th e e x tra v a s a tio n in th e m e d ia s tin u m c o n tra s t a n d in th e p le u ra l c a v ity d u e to s u tu re d e h is c e n c e .
th e w o u n d w a s p o te n tia lly in fe c te d . T h e p le u ra l c a v ity w a s
w a s h e d a n d a m u ltip e rfo ra te d d ra in w a s a tta c h e d to th e
rib -v e rte b ra e g u tte r, n e x t to th e le s io n . A fte r th is , th e p a tie n t
w a s s e n t to th e IC U .
O n th e fifth P .O . a n e s o p h a g o g ra m w a s p e rfo rm e d ,
u s in g lo d a te c o n tra s t, w h ic h d is c lo s e d a n e s o p h a g e a l fis tu la
in th e d is ta I e s o p h a g u s .
A lth o u g h th e p a tie n t w a s n o t u n s ta b le , a t th is m o m e n t
h e p re s e n te d p le u ra l-e s o p h a g e a l fis tu la a n d b ila te ra l
e m p y e m a (F ig . 2 ), b e a rin g e v id e n c e o f s e v e re m e d ia s tin a l
in fe c tio n .
T h e c h o s e n tre a tm e n t w a s th a t p ro p o s e d b y H a u e
r-S a n to s (2 ) w h ic h c o n s is ts o f a n e n te ra l p ro b e , w ith its d is ta I
e n d c lo s e to th e fis tu la , in fu s in g p h y s io lo g ic a l s a lin e
s o lu tio n to w h ic h w a s a d d e d a c h lo ra n p h e n ic o l s o lu tio n .
T h e p le u ra l d ra in a g e tu b e w a s k e p t u n d e r c o n tin u o u s
s u c tio n , a llo w in g fo r c o n s ta n t re m o v a l o f th e w a s h o u t o f
th e w h o le in fe c te d a re a .
S im u lta n e o u s ly a je ju n o s to m y w a s p e rfo rm e d to
m a in ta in ' th e n u tritio n a l c o n d itio n .
T h e p a tie n t p re s e n te d 'p ro g re s s iv e im p ro v e m e n t.
O n N o v e m b e r 2 2 , h e w a s s u b m itte d to a n o th e r
e s o p h a g o g ra m w h ic h d is c lo s e d c lo s u re o f th e fis tu la
(F ig .4 ).
F ig u re 2 - C o m p u te riz e d to m o g ra p h y o f th e th o ra x o f p a tie n tA :r.S .
F o n th e 1 4 th P .O . N o te th e b ila te ra l p le u ra l e tfu s io n (e m p h y e m a ) a s a c o n s e q u e n c e o f th e m e d ia s tin itis .
E S G A IS , A .S .; IM A E D A , C .J .; O L IV E IR A ,. R .I.; G H E F T E R , M .C .; R .M .; G U ID U G L I, R .S .; O L IV E IR A J R ., N .R .R . - S p o n ta n e o u rs ru p tu re o f th e e s o p h a g u s : re p o rt o f tw o c a s e s
H e w a s r e l e a s e d o n D e c e m b e r , 9 , 1 9 9 4 , i n g o o d
p h y s i c a l c o n d i t i o n . H i s c l i n i c a I a n d r a d i o l o g i c a l p u l m o n a r y
c o n d i t i o n w a s p r a c t i c a l l y " n o r m a l ( F i g . 5 ) .
C A S E 2
H . B . 6 8 y e a r s o l d , m a l e , A d v e n t i s t , w a s a d m i t t e d o n
J u n e 1 0 , 1 9 9 4 , r n e n t i o n i n g t h a t o n t h e d a y b e f o r e , a f t e r a n
a b u n d a n t r n e a l h e h a d f o r c e f u l v o m i t i n g , f o l l o w e d b y
s e v e r e r e t r o s t e r n a l p a i n s p r e a d i n g o u t t o e b a c k . H e w e n t
t o a n e r n e r g e n c y d a y - c a r e w a r d w h e r e a n a n g i n a p e c t o r i s
o r a r n y o c a r d i a l i n f a r c t i o n w e r e s u s p e c t e d , a l t h o u g h n o t
c o n f i r m e d , a f t e r w h i c h t h e p a t i e n t w a s d i s m i s s e d .
B e c a u s e o f t h e p e r s i s t e n t a n d i n c r e a s i n g l y s e v e r e
p a i n s , h e c a r n e t o t h e E r n e r g e n c y A t t e n d a n c e o f t h e
H o s p i t a l . A c h e s t x - r a y d i s c l o s e d a n e f f u s i o n i n t h e p l e u r a
o n t h e r i g h t s i d e w i t h c h a r a c t e r i s t i c s o f p o s t e r i o r s e p s i s .
A n e s o p h a g e a l r u p t u r e w a s s u s p e c t e d : a n e s o p h a g o s c o p y
w a s r e q u e s t e d , w h i c h c o n f i r m e d a t e a r o f a b o u t 4 c m a t
t h e d i s t a I t h i r d . T h e p a t i e n t w a s t h e n s u b m i t t e d t o s u r g e r y ,
p h a r y n g o s t o m y , b l o c k o f d i s t a I t r a n s i t w i t h a F o l e y p r o b e ,
p l e u r a l d r a i n a g e o n t h e r i g h t s i d e a n d j e j u n o s t o m y f o r
p a r e n t e r a l n u t r i t i o n .
T h i s t r e a t m e n t w a s c o n t i n u e d f o r 2 0 d a y s . T h e r e w a s ,
h o w e v e r , a p r o g r e s s i v e w o r s e n i n g o f t h e o v e r a l l c o n d i t i o n
w i t h a n i n t e n s e t o x e m i c p i c t u r e , a n d i t w a s d e c i d e d t o p e r f o r m
a t h o r a c o s t o m y , d e b r i d e r n e n t o f t h e p l e u r a l s p a c e a n d d r a i n a g e
o f t h e r n e d i a s t i n u r n . A w i d e - b o r e p l e u r a l d r a i n a g e t u b e w a s
i n t r o d u c e d n e a r t o t h e e s o p h a g e a l f i s t u l a u n d e r c o n t i n u o u s
F ig u r e 3 - P a t ie n t A . T . S . F . o n t h e 1 5 t h R O . T h o r a c ic d r a in a g e w it h c o n t in u o u s a s p ir a t io n , e n t e r a l p r o b e f o r w a s h in g o u t o f f is t u la a n d je ju n o t o m y .
F ig u r e 4 - E s o p h a g r a m o f p a t ie n t A . T . S . F . o n t h e 2 8 t h . R O . T h e r e is n o c o n t r a s t o v e r f lo w in g . F is t u la is c lo s e d .
F ig u r e 5 - P la in X - r a y o f t h o r a x o f p a t ie n t A . T . S . F . o n t h e 3 0 t h R O . a f t e r f is t u la h a d c lo s e d . A lm o s t f u I ! r e s o lv a b ilit y o f t h e b ila t e r a l
e m p h y e m a .
1519
asp iratio n . T h e m arg in s o f th e scar w ere b ro u g h t to g eth er b y fo u r stitch es o f n o n ab so rb ab le su tu res to o rien t cicatrizatio n .
T h e F o ley p ro b e w as in tro d u ced ag ain , ro u g h ly o v er th e p o sitio n o f th e fistu la, fo r in fu sio n o f th e p h y sio lo g ical salin e so lu tio n .
A s after 1 0 d ay s th e w ash in g o u t liq u id w as still p u ru len t, ch lo ran p h en ico l w as ad d ed to th e p h y sio lo g ical salin e so lu tio n ( 1 9 / 1 ,0 0 0 m l) d rip p in g in to th e v ein at
1 2 0 m llh o u r.
A fter an o th er ten d ay s, th e clin icaI p ictu re h ad im p ro v ed w ith a sig n ifican t red u ctio n o f o u tp u t d ep o sits in th e co llectin g b o ttle, sh o w in g a p referen tial flo w to th e sto m ach . A n en d o sco p y u n d ertak en at th at tim e, ev in ced th at th e fistu la h ad b een red u ced fro m 4 to 1 .2 cm .
T reatm en t w as co n tin u ed fo r an o th er 1 8 d ay s an d a n ew en d o sco p ic ex am in atio n d isclo sed an ev en g reater red u ctio n o f th e fistu la's size, n o w d o w n to 0 .2 cm . O n th e 3 0 th d ay o f treatm en t th e fistu la w as fu lly clo sed .
D I S C U S S I O N
S p o n tan eo u s ru p tu re o f th e eso p h ag u s co n sists o f th e fu ll ru p tu re o f a seg m en t o f its w all, as a resu lt o f a su d d en in crease o f th e en d o -Iu m in al p ressu re. T h e o th er cau ses o f ru p tu re, su ch as th o se p ro v o k ed b y su rg ical in stru m en tatio n o r p erfo ra,tin g w o u n d s o n th e ch est w o u ld b e ex clu d ed b y d efin itio n .
P o st-p ran d ial v o m itin g h as b een m o st freq u en tly h eld resp o n sib le fo r th is ru p tu re, b u t n ev erth eless, th e literatu re also m en tio n s o th er ru lin g facto rs fo r th e rap id in crease o f ab d o m in al p ressu re su ch as co u g h in g , lab o r an d d efecatio n .3 ,4 .5
C u rren tly , it is b eliev ed th at th e m o st lik ely m ech an ism in v o lv ed is a m alfu n ctio n o f th e o v erall v o m itin g reflex o T h e co o rd in ated relax atio n o f th e crico p h ary n g eal m u scles w ill n o t tak e p lace, b rin g in g ab o u t a h ig h p ressu re ch am b er in sid e its lu m en , m ain ly in th e d istaI th ird w h ere ru p tu re u su ally tak es p lace.
M o stly , th e ru p tu re is lo cated in th e left p o stero lateral co m p artm en t o f th e eso p h ag u s, n ex t to . th e card ia, an d can reach u p to 6 cm in len g th .3 , 4
O ccu rren ce o f laceratio n in th is site h as b een attrib u ted , am o n g o th er an ato m ical cau ses, to th e en tran ce o f v essels an d n erv es, to th e an g u latio n o f th e o rg an an d to th e ab sen ce o f su p p o rtiv e tissu e.4 A cco rd in g to F ab er,6 th e su d d en in crease o f p ressu re w o u ld b e an ev en m o re sig n ifican t facto r th an th e rate o f in crease itself.
O f th e d am ag es cau sed to th e eso p h ag u s b y su ch m ech an ism s, co m p lete ru p tu re o rB o erh aav e S y n d ro m e
is th e m o st d ram atic, alth o u g h so m e o f lesser sev erity h av e b een d escrib ed .
M allo ry &W eiss, in 1 9 2 9 ,7 rep o rted a g astro in testin al b leed in g asso ciated w ith v o m itin g . T h e an ato m o p ath o lo g ical su b strate co n sisted o f sh red s o f th e m u co sa in th e p ro x im ity o f th e card ia.
W illiam s in 1 9 5 7 ,8 rep o rted in tram u ral d issectio n o f p o st -em etic cau se th at d id n o t lead to to tal ru p tu re o f th e , eso p h ag ean w all, fo rm in g a h em ato m a w ith in th e m u scle
b u n d les (F ig . 6 ).
U n til th e m id -1 9 th C en tu ry , th e B o erh aav e S y n d ro m e w as ex clu siv ely a fin d in g at au to p sies. In 1 8 5 8 , M ay er9
w o u ld h av e b een th e first to reach a d iag n o sis p rio r to d eath . D erb es &M itch e1 l4 attrib u te th e first su rg ical treatm en t to O v erh o lt in th e U n ited S tates, in 1 9 4 3 . H o w ev er, it w as B arrett in E n g lan d , in 1 9 4 7 ,1 0 w h o first p u b lish ed a p ap er o n th e th erap eu tical su ccess o f a su rg ical ap p ro ach .
B o erh aav e S y n d ro m e h as a h ig h er in cid en ce in th e m al e g en d er, at an av erag e o f 5 0 y ears o f ag e. I I
Its p red isp o sin g facto rs w o u ld b e alco h o lism , a n eu ro lo g ical d isease, a p ep tic u lcer, a h iatal h em ia o r arterial h y p erten sio n .1 2 H o w ev er, m an y sick in d iv id u aIs d o n o t p resen t an y ' o f th ese d iso rd ers. T h e classic clin icaI triad in clu d es: v o m itin g , p ain in th e ch est an d su b cu tan eo u s em p h y sem a.1 3
O th er ab n o rm alities ex h ib itin g p ain in th e ch est o r th e u p p er ab d o m en an d v o m itin g m ay b e co n fo u n d ed w ith th e sy n d ro m e; am o n g th em , w e can co n sid er m y o card iac isch em ia, p erfo rated p ep tic u lcer an d acu te p an creatitis, d issectin g ao rtal an eu ry sm an d asp iratio n p n eu m o n ia.
X -ray s are an essen tial to0 1fo r co rrect d iag n o sis. C h est x -ray s m ay sh o w w id en in g an d em p h y sem a o f th e m ed iastin u m , h id ro th o rax , p n eu m o th o rax an d lu n g co n d en satio n s. N aclerio l4 d escrib ed th e "V " sig n w h ich co n sists o f an irreg u lar in crease in p u lm o n ary d en sity o n th e left sid e o f th e card iac co n to u r, stressin g ch em ical p n eu m o n ia n ex t to th e eso p h ag eal area. T o ascertain th e p resen ce o f a ru p tu re, sw allo w in g Io d ate co n trast w ill sh o w th e effu sio n . In case o f d o u b t an en d o sco p ic ex am in atio n w ill co n firm th e h y p o th esis.
B arrett 1 2 ,1 0after h is ex p erien ce w ith th e first case o f su rg ical treatm en t b y p rim ary su tu re o f th e tear, claim ed th at o n ly su rg ery w o u ld g u aran tee th e p atien t's su rv iv al.
H o w ev er, it h as b een .o b serv ed th at, to o b tain p o sitiv e resu lts in th is ty p e o f treatm en t, an early d iag n o sis is req u ired . Its d elay d ram atically in creases m o rtality rates. A cco rd in g to so m e au th o rs, 1 5 ,1 6after th e first 2 4 h o u rs, th is rate w o u ld ran g e fro m 2 0 % to 5 0 % . T issu e friab ility , as a resu lt o f n ecro tizin g en zy m es an d in fectio u s ag en ts, w o u ld h am p er cicatrizatio n .
E S G A I B , A . S . ; I M A E D A , C . J . ; O L I V E I R A , . R . I . ; G H E F T E R , M . C . ; R . M . ;G U I D U G L I , R . B . ; O L I V E I R A J R . , N . R . R . - S p o n t a n e o u r s r u p t u r e o f t h e e s o p h a g u s : r e p o r t o f t w oc a s e s
L a c e ra ç ã o d e m u c o s a e s a n g ra m e n to
(M a llo ry e W e is s - 1 9 2 9 )
D is s e c ç ã o in tra m u ra l c o m fo rm a ç ã o d e h e m a to m a
(W illia m s - 1 9 5 7 )
R o tu ra to ta l
(B o e r~ a Q v e - 1 7 2 4 )
F ig u re 6 - E s o p h a g e a lle s io n s d u e to in tra m u ra l p re s s u re in c re a s e . (P o s t E m e tic ) L a c e ra tio n o f m u c o s a a n d in tra m u ra l d is s e c tio n w ith to ta l ru p tu re b le e d in g h e m a to m a (M a llo ry & W e is s - 1 9 2 9 ) (W illia m s - 1 9 5 7 ) (B o e rh a a v e - 1 7 2 4 )
H o w e v e r, in m e d ic a I lite ra tu re th e re h a s b e e n n o a g re e m e n t re g a rd in g th e tim e s p a n fo r th e p e rfo rm a n c e o f th e p rim a ry s u tu re . A c c o rd in g to S a m s o n 1 7th e m a x im u m d e la y fo r a rh a p h y c o u ld n o t b e fo r m o re th a n 1 5 h o u rs .
In v ie w o f th e a b o v e s ta te m e n ts , v a rio u s m o re c o m p le x p ro c e d u re s h a v e b e e n d e s c rib e d in te n d in g to . re d u c e th e p o s s ib ility o f d e h is c e n c e : re p a irs o f s u tu re s w ith s y n th e tic fla p s 3 o r w ith liv e tis s u e s , s u c h a s th e in te rc o s ta l p e d ic le 1 8 o f th e p e ric a rd iu m ,1 9 o f th e p le u ra ,2 o a s w e ll a s p ro te c tio n o f th e g a ~ tric s tu m p .2 1
J o h n s o n , S c h e n e g ra n & K im b y 1 5re c o m m e n d e d th e fu n c tio n a l e x c lu s io n o f th e e s o p h a g u s th ro u g h a c e rv ic o s to m y a n d lig a tu re o f th e d is ta I s p h in c te r. M o re d ra s tic s u rg e rie s , in c lu d in g e s o p h a g o s to m y 2 2 w e re a ls o re c o m m e n d e d .
N e v e rth e le s s , s o fa r n o c o n c lu s io n h a s b e e n re a c h e d a b o u t h o w b e n e fic ia I fo r th e s e v e re ly im p a ire d p a tie n t th o s e m a jo r s u rg ic a l p ro c e d u re s in d e e d a re .
T h e e s s e n tia l m a n a g e m e n t fo r ru p tu re o f th e e s o p h a g u s c o n s is ts o f re v e rs a l o f th e c h a in o f e v e n ts trig g e re d b y th e e n tra n c e o f b a c te ria a n d a c tiv e c h e m ic a l m a tte r in s id e th e m e d ia s tin u m , th a t m a y le a d to a n u n c o n tro lla b le s e p s is .2 3 A s in fe c tio n is n o t c o n tro lla b le , th e la c e ra tio n w ill n o t c lo s e .
A th e ra p e u tic a p p ro a c h , w ith c o n tin u o u s la v a g e o f th e ru p tu re s ite , in itia lly d e s c rib e d in R u s s ia n lite ra tu re 2 4 -2 6w a s a c c e p te d b y o th e r a u th o rs -2 , -2 7a s a ra th e r e ffic ie n t th e ra p y fo r th e c lo s u re o f th e fis tu la . T h e o n g o in g re m o v a l o f th e n e c ro tic m a tte r a n d o f th e b a c te ria l c o n s titu e n t u s in g p h y s io lo g ic a l s a lin e s o lu tio n a n d
F ig u re 7 - T re a tm e n t o f e s o p h a g u s rU p tu re b y w a s h in g o u t o f fis tu la . A n e n te ra l p ro b e is lo c a te d a little a b o v e th e s ite o f ru p tu re , c o n tin u a lly in s tillin g p h y s io lo g ic a l s a lin e s o lu tio n w ith a n tib io tic s . A m u ltio p e n in g p le u ra l d ra in a g e tu b e is fix e d n e x t to th e fis tu la w ith c o n s ta n t a s p ira tio n .
1521
continued suction, evinced positive results in ruptures at
alI esophageallevels.
In our service, w e have therefore system atized the
procedures for the spontaneous rupture of the esophagus:
thoracotom y, cleansing of the site, suture of the laceration
(even m any hours after the rupture), drainage of the cavity,
and
parenteral
nutrition
by jejunostom y.
Should
cicatrization not be successful, the pleuralesophagic fistula
w ill be treated according to the w ork of H auer Santos
2:I. Placing. of a nasogastric probe (D obbhoft) a little
above the fistula;
2. Transpleural drainage of the m ediastinum by a
w ide gauge drain, m ultiperforated and attached
riext to the fistula;
3. Continuous dripping of physiologic serum w ith
chloranphenicol
(lg/IO O O m l) at a 120m l/hour
rate;
4. Continuous aspiration of the pleural cavity at a
pressure of 25m m lh20 (Fig. 7).
This procedure aim s to avoid that the contam inated
m atter of the oropharynx, the active enzym es and the
necrotic tissue retain m ediastinal infection, w hich w ould
deter closing of the fistula.
The final objective ofthese tw o reports is to enhance
surgeons' aw areness of the need for im m ediate repair of
the lesion and, should an early. diagnosis not have been
reached, introduce a sim ple altem ative treatm ent w ith a
positive outcom e.
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