Role of Primary Repair in Spontaneous Esophageal Rupture Management: Decades of Experience from a Single Center
Spontaneous esophageal rupture, also known as Boerhaave syndrome, is a rare but life-threatening condition with a reported mortality rate ranging from 20% to 30%. The incidence of this condition is particularly low in some European countries, with fewer than 3 to 6 cases per 1,000,000 persons. Despite advancements in medical science, the management of Boerhaave syndrome remains challenging due to its variable clinical presentations and the lack of standardized treatment guidelines. This study aims to provide a comprehensive overview of the role of primary repair in the management of spontaneous esophageal rupture, based on decades of experience from a single center.
The study retrospectively analyzed the medical records of 73 consecutive patients diagnosed with spontaneous esophageal rupture at the Fourth Hospital of Hebei Medical University between April 1983 and June 2013. The diagnosis was confirmed through a combination of clinical history, physical examination, radiographic imaging, thoracentesis, and thoracic drainage. Treatment options were categorized into surgical procedures (operative group) and aggressive conservative therapy (non-operative group). Surgical treatment involved primary esophageal repair, extensive pleural and mediastinal lavage, and complete drainage of the mediastinum and pleural cavity. Post-operative measures included cessation of oral intake, drainage of the upper digestive tract and pleural cavity, and administration of broad-spectrum antibiotics. Patients with severe sepsis, respiratory failure, or multiple-organ dysfunction syndrome (MODS) were transferred to the intensive care unit for further management. Nutritional support, either enteral or parenteral, was provided to all patients until the rupture was confirmed to be healed.
The study population consisted of 65 males and eight females, with a median age of 53 years (range: 22–84 years). The most common etiology was vomiting induced by alcohol consumption, accounting for 56.2% of cases, followed by vomiting caused by improper diet in 24.7% of cases. The time from symptom onset to diagnosis varied widely, ranging from 4 hours to 21 days. The most frequent presenting symptom was chest pain or upper abdominal pain following vomiting. Radiographic findings indicated that the right pleural cavity was the most commonly affected site, with 54.8% of patients exhibiting ruptures on the right side. The definitive diagnosis was often confirmed by the presence of gastrointestinal fluid or orally administered methylene blue in pleural effusions, which was observed in 72.6% of cases.
Primary surgical repair was performed in 51 patients who were diagnosed early and had relatively good general health. In contrast, 22 patients with poorer health status received aggressive conservative therapy. The time from symptom onset to treatment in the surgical group ranged from 4 hours to 6 days, with a median of 16 hours, while in the non-operative group, it ranged from 12 hours to 21 days, with a median of 72 hours. Early diagnosis (within 24 hours) was significantly more common in the surgical group (70.6%) compared to the non-operative group (18.2%). Additionally, a higher proportion of patients in the surgical group resumed oral food intake within 15 days (33.3% vs. 4.5%). The rate of persistent fistula (lasting more than 30 days) did not differ significantly between the two groups (49.0% vs. 68.2%).
The overall in-hospital mortality rate for the entire cohort was 12.3%, with nine deaths attributed to MODS and sepsis. The mortality rate in the surgical group was 9.8%, compared to 18.2% in the non-operative group. Although the survival rate appeared better in the surgical group, the difference was not statistically significant. Similarly, there were no significant differences in 30-day mortality or mortality rates before and after 1992 between the two groups.
The study highlights the importance of early diagnosis and primary surgical repair in the management of spontaneous esophageal rupture. The findings suggest that surgical intervention can facilitate the healing process and enable earlier resumption of oral food intake, which is a critical function of the esophagus. Despite the higher mortality rate in the non-operative group, the difference was not statistically significant, indicating that aggressive conservative therapy remains a viable option for patients with poor health status. The study underscores the need for complete nutritional support and critical care services in the management of Boerhaave syndrome.
In conclusion, primary esophageal repair is recommended for patients with early diagnosis and good general health. However, further research is necessary to confirm the role of surgery in the treatment of this condition. The study provides valuable insights into the management of spontaneous esophageal rupture and emphasizes the importance of individualized treatment strategies based on patient-specific factors.
doi.org/10.1097/CM9.0000000000001153
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