Clinical Study on the Treatment Outcome and Strategy for Spontaneous Esophageal Rupture

We report herein on a review of 34 patients with spontaneous rupture of the esophagus treated in our department, which include 22 cases of the extra-mediastinal rupture type and 12 cases of the intra-mediastinal rupture type. We clinically analyzed the cases with reference to the diagnosis, treatment strategy and treatment outcome. The onset of the rupture was after vomiting in all the cases. Most of the patients were complaining of chest and back pain. The ratio of the correct diagnosis was 55.9％ and the median time to diagnose after the onset was 11 (4-168) hours. The most common perforation site was the left-lower thoracic esophagus (85.3％). The median perforation size was 3 (1-8) cm longitudinally, and the perforation size of the extra-mediastinal rupture type was statistically significantly longer. In the 12 cases of the intra-mediastinal rupture type, we performed surgical treatment in 6 cases, and conservative treatment in 6 cases. In the 22 cases of the extra-mediastinal rupture type, we performed surgical treatment in 21 cases, and conservative treatment in 1 case, which was transferred from another hospital after a certain interval. As for surgical treatment, direct closure alone of the perforation site with a left thoracotomy was performed in 10 cases, direct closure of the perforation site with a gastric fundic patch via the transhiatal approach was performed in 15 cases, and esophagectomy with cervical esophagostomy followed by secondary reconstruction was performed in 2 cases. The outcome of the intra-mediastinal rupture type was satisfactory in all cases. The emergency operations for the extra-mediastinal rupture type were associated with complications such as anastomotic leakage, pyothorax and as on in 9 cases (33.3%) with a mortality rate of 3.7% (only 1 case of post-operative death). To prevent post-operative pyothorax and mediastinal abscess, the drainage tubes in the posterior space of the left diaphragm and the left side of the thoracic descending aorta were regarded necessary in addition to the conventional thoracic drainage tube. Early appropriate diagnosis and choice of the treatment strategy for spontaneous esophageal rupture are thought to be important to achieve satisfactory results.