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TORAKOCHIRURGIA

Acute oesophageal necrosis – a case report

Ostra martwica przełyku – opis przypadku

Norbert Wójcik 1 , Janusz Wójcik 2 , Tomasz Grodzki 2 , Bartosz Kubisa 2 , Jarosław Pieróg 2

1 Wydział Lekarski Pomorskiej Akademii Medycznej w Szczecinie

2 Oddział Kliniczny Chirurgii Klatki Piersiowej Pomorskiej Akademii Medycznej w Szczecinie

Kardiochirurgia i Torakochirurgia Polska 2010; 7 (1): 44–47

Abstract

A case of a 59-year old woman with subtotal oesophageal ne-

crosis is described. This state developed 9 days after earlier

suture of an oesophageal wall rupture due to Boerhaave’s syn-

drome. She underwent three-ield subtotal oesophagectomy

with full recovery.

Key words: Boerhaave syndrome, oesophageal necrosis, AEN,

subtotal oesophagectomy.

Streszczenie

W pracy przedstawiono przypadek 59-letniej chorej z subtotal-

ną martwicą przełyku, która rozwinęła się po 9 dniach od jego

wcześniejszego zeszycia z powodu zespołu Boerhaave. Chorą

ponownie operowano, wykonując trójpolową resekcję przełyku

i uzyskując pełne wyleczenie.

Słowa kluczowe: zespół Boerhaave, martwica przełyku, AEN,

subtotalna resekcja przełyku.

Introduction

Gangrenous inlammation is the most serious among

all gastrointestinal tract inlammations. Isolated acute

oesophageal necrosis (AEN) has a high burden of mortality,

reaching 50%, especially when perforation occurs [1-3]. In

this paper we present a case of a patient sufering from

Boerhaave syndrome, where AEN occurred. She was suc-

cessfully treated by subtotal oesophagectomy.

Fig. 1. Chest computed tomography obtained before admittance

to the thoracic surgery department

Case presentation

A 59-year old woman (case No. 7808/09) was admitted

to our department on 6 July 2009 at night. The initial diagno-

sis consisted of diaphragmatic oesophageal hiatal hernia,

minor left pneumothorax, bilateral hydrothorax conirmed

by attached thorax CT (Fig. 1) and additional obesity of class

II/III. The patient reported vomiting, diarrhoea, left hemitho-

rax pain and dyspnoea. At the time of admittance her phy-

sical status was relatively good. No dyspnoea and no acute

infection symptoms were reported. The radiographic oeso-

phageal water-soluble contrast study conirmed para-oeso-

phageal hernia. No pneumothorax was observed (Fig. 2).

Despite the reassuring radiological result, the patient was

qualiied for gastroscopy followed by operative treatment

on 7 July 2009. A gastric tube was inserted, broad-spectrum

antibiotic therapy implemented, electrolyte equalization and

hydration begun. Gastroscopy revealed a 4 cm long linear

supracardiac oesophageal rupture. Left thoracotomy sho-

wed a ibrinous mediastinal and pleural reaction around the

oesophageal rupture mimicking incarcerated stomach. A do-

uble layer suture of the rupture was performed followed by

broad mediastinal opening, generous lush and drainage of

Address for correspondence: Norbert Wójcik, student VI roku Wydziału Lekarskiego PAM w Szczecinie, ul. Sokołowskiego 9/1, 70-891 Szczecin,

tel. +48 502 102 770, fax::+48 91 462 08 36, e-mail: noert@wp.pl

Kardiochirurgia i Torakochirurgia Polska 2010; 7 (1)

TORAKOCHIRURGIA

was present. On POD 7 suppuration of the post-thoracoto-

my wound was revealed. A radiographic contrast study was

planned for the following day, but circulatory and respiratory

crisis occurred and the patient was transferred back to the

ICU and ventilated by the respirator. Gastroscopy was done

on POD 9, after slight improvement of patient status. It re-

vealed oesophageal suture dehiscence and features of an

extensive AEN (Fig. 3). Immediate subtotal McKeown oeso-

phagectomy was performed and gastroesophageal anasto-

mosis was done using two linear staplers. Anti-eventration

sutures secured the laparotomy approach. Twelve days after

the second operation the radiographic contrast study con-

irmed gastroesophageal anastomosis tightness and the

patient was redirected from the ICU to the thoracic surgery

department. Twenty-eight days after the second operation

the post-thoracotomy wound was resutured and the patient

was fully recovered.

Fig. 2. Water-soluble contrast chest X-ray shows supradiaphrag-

matic contrast collection

Discussion

The treatment of oesophageal perforation accompa-

nied by mediastinitis and hydrothorax consists of double

layer reconstruction of the rupture, with extensive dra-

inage of the mediastinum and pleura performed early, if

possible within 24 hrs. Successful oesophagectomy un-

der these circumstances was also described [4–7]. Late

operative treatment worsens the prognosis dramatically

and limits treatment possibilities to drainage and gastric

or intestinal alimentation [7, 8]. Isolated or concomitant

necrosis of the entire oesophageal wall is a similarly

rare indication for oesophagectomy with respect to the

limitations mentioned above [9, 10]. Here the secondary

development of AEN with recurrent perforation occur-

red after the primary oesophageal reconstruction in the

postoperative course, despite the efective mediastinal

drainage, stomach drainage by the gastric tube and an-

tibiotic treatment. This situation prevented transition of

the mediastinitis into the irreversible phase and enabled

oesophagectomy within a favourable period, resulting in

complete recovery.

Fig. 3. The specimen of the resected oesophagus shows macrosco-

pic features of complete oesophageal necrosis (spec. No. 13887/09)

– necrosis massiva cum suppuratione

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