Anatomy of the Boerhaave syndrome

doi:10.1016/j.surg.2006.06.034

Surgery

Volume 141, Issue 2, February 2007, Pages 222-228

https://doi.org/10.1016/j.surg.2006.06.034 Get rights and content

Background

Spontaneous rupture of the esophagus (Boerhaave syndrome) occurs almost invariably at the same anatomic site. A weakness of the distal esophageal wall is suspected but has not been confirmed by anatomic studies. The aim of this work was to determine the existence of a structural abnormality in the esophageal wall.

Material and Methods

In six fresh human cadavers, the left lung was removed and the esophagus was insufflated in situ with air until it burst. The mucosa of the specimens was stripped off, allowing the fibers of the inner muscular coat to be seen. In addition a specimen from a patient who died from this cause was submitted to the same procedure.

Results

The site of the experimental rupture matched the clinical case. The tear was located at the margin of contact between “clasp” and oblique fibers, and extends upwards.

Conclusions

The connective tissue of the junction between clasp and oblique fibers appears to constitute a weak point in the lower esophagus.

Section snippets

Experimental model

We used an experimental model used already by other authors, in which the rupture of the esophagus is achieved by means of the insufflation of air into the esophageal lumen.4, 6 The experiments were carried out in 6 fresh human cadavers, 3 men and 3 women, with a mean age of 43 years (range, 10-66 years), mean height of 1.62 m (range, 1.32-1.80 m), and a mean weight of 67 kg (range, 38-90 kg). The specimens used were in perfect condition without the existence of hiatal hernia or disease or

Results

In the 6 experimental specimens, the esophageal rupture occurred in the lower third of the esophagus immediately above the diaphragmatic hiatus, and in all cases the tears were longitudinal (Fig 1). The phrenoesophageal membrane was not involved. In 5 esophagi, the lesion was oriented to the left side in 4 and to the right side in 1. In 5 esophagi, the rupture occurred as a single lesion, while one esophagus suffered 2 longitudinal wounds separated by a narrow bridge of esophageal wall.

The

Discussion

According to clinical and experimental data, in the spontaneous rupture of the esophagus, or Boerhaave syndrome, it is possible to recognize some characteristic findings.1, 2, 4 The rupture is usually the result of a sudden increase in intraesophageal pressure.3, 4, 6, 7, 8, 9, 10 The rupture is usually longitudinal, from 2 to 6 cm long, and located at the left side of the lower third of the esophagus.2, 3, 11, 12, 13 Rupture of the cervical,¹⁴ middle third,15, 16 or abdominal segment of the

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Boerhaave Syndrome (BS) is a surgical emergency, defined as a spontaneous rupture of the oesophagus occurring after vomiting efforts, on a healthy oesophagus. We report the case of a 67-year-old patient, with no medical history, with BS treated in our department in hemodynamic shock. The initial CT scan performed after hemodynamic stabilization found a voluminous left pleurisy, pneumomediastinum and leakage of contrast medium in the left pleura. Emergency surgical management is performed by a minimally invasive approach using bilateral thoracoscopy which allows a quick favourable clinical evolution without digestive complications.
The minimally invasive approach by thoracoscopy is a good alternative for BS management with faster respiratory recovery, less postoperative pain and a shorter hospitalization.
A rare case of Boerhaave syndrome with cervico-thoracic esophageal junction rupture causing bilateral empyema; case report from Nepal
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Boerhaave syndrome is a rare finding where spontaneous rupture of esophagus occurs, usually in distal segment. It is a life threatening condition that requires urgent surgical intervention.
We present a case of 70 years male who presented with pleural effusion and later empyema following spontaneous rupture of cervico-thoracic junction of esophagus who was managed successfully with primary surgical repair.
Although Boerhaave syndrome is tricky to diagnose but it should be considered in all cases with a combination of gastrointestinal and pulmonary signs and symptoms.
Clinical correlation along with imaging such as HRCT chest or gastrografin study is required to come to a diagnosis, however surgical intervention should not be delayed to reduce the mortality.
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Citation Excerpt :
Anatomically, this usually affects the left posterolateral aspect of the distal oesophagus, owing to a lack of supporting mediastinal structures here. The tear is often located between the clasp and oblique fibres, extending upwards.3 Due to their size, rigidity, and pointed edges, dentures frequently impact in the oesophagus but ingestion of any foreign body of size with sharp edges can result in perforation.
Perforation of the upper gastrointestinal (UGI) tract is a surgical emergency. Causes of oesophageal perforation include spontaneous (Boerhaave's), iatrogenic or foreign body ingestion. Perforation of the stomach and duodenum is most often caused by peptic ulcer disease. Management involves obtaining an accurate clinical diagnosis, through a combination of patient assessment, imaging and endoscopy. It is important to differentiate intramural from full thickness oesophageal perforations as this will guide the definitive surgical or endoscopic management. Perioperative care of these patients is as important as the definitive management step. This article will summarise an approach to managing perforation of the UGI tract; from initial assessment to postoperative care.
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Esophageal rupture specifically results from an abrupt increase in esophageal pressure, as occurs with severe vomiting; this is known as Boerhaave's syndrome and accounts for 15% of esophageal disruptions.60 This usually involves a large tear located on the left border of the lower third of the thoracic esophagus.60,61 Esophageal rupture will cause significant contamination of the mediastinum and pleural cavity with gastric contents, leading to acute mediastinitis and sepsis.
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Vomiting could be one of the causes of intraesophageal pressure increase, since vomiting seems to be the antecedent episode in most cases [1,10,12–18]. The rupture or perforation occurs mostly on the left lateral part of the inferior third of the esophagus, measuring about 15–35 mm (mean 22 mm) [9–15,19]. It is reported that there is a male predominance of 2:1–5:1.
A 45-year-old male, an alcohol addict with asthma, was found dead in his home, after several days of continued drinking. A forensic autopsy was performed 3 days after the discovery of his death in order to specify the cause of death.
A longitudinal perforation penetrating all layers of the esophagus measuring 1.8 cm was present on the left wall approximately 2.0 cm from the gastroesophageal junction. There were 1900 mL of greenish to brownish turbid liquid in the left pleural cavity and 150 mL of greenish viscous liquid in the stomach. Histopathologically, an infiltration of numerous neutrophils was evident in the submucosa layer, proper muscular layer, and serous membrane of the esophagus, corresponding to the esophageal laceration. The serum C-reactive protein (CRP) concentration was determined to be 3.1 mg/dL. The alcohol concentrations were determined to be 1.49 mg/g in the right cardiac blood, 1.31 mg/g in the left cardiac blood, and 2.48 mg/g in urine.
Based upon the autopsy and histopathological findings, as well as the biochemical and toxicological analyses, we concluded that the cause of death was respiratory failure by pleural effusion, resulting from spontaneous esophageal perforation. This was the first report of a spontaneous esophageal perforation eventually causing respiratory failure.

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Original communicationAnatomy of the Boerhaave syndrome

Background

Material and Methods

Results

Conclusions

Section snippets

Experimental model

Results

Discussion

Gastroenterology

Hermann Boerhaave’s Atrocis, nec descripti prius morbid historiaThe first translation of the classic case report of rupture of the esophagus with annotations

Bull Med Libr Assoc

Boerhaave’s syndrome: analysis of the literature and report of 18 new cases

Dis Esophagus

Oesophageal injury: part 2The changing face of the management of ruptured oesophagus: Boerhaave’s syndrome

Gullet

Spontaneous rupture of the esophagus: an experimental and clinical study

Surg Gynecol Obstet

Spontaneous rupture of the esophagus

Ann Int Med

Spontaneous rupture of the esophagus

J R Coll Surg Edin

Rupture of oesophagus during childbirth

Br Med J

Rupture of the esophagus

Med Bull Vet Admin

Spontaneous rupture of the esophagus

Pennsylvania Med J

Original communication
Anatomy of the Boerhaave syndrome