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Perioperative management of a patient presenting with a spontaneously ruptured esophagus

[La prise en charge périopératoire d'un patient qui présente une rupture sophagienne spontanée]

From the Department of Anaesthesiology and Critical Care Medicine and the Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.

Dr. Chandra Kant Pandey, Department of Anaesthesiology and Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India. Phone: 0091-522-440715, ext. 2490; Fax: 0091-522-440017; E-mail: ckpandey{at}sgpgi.ac.in

Purpose: To report a case of spontaneous rupture of the esophagus and its anesthetic management.

Clinical features: A 52-yr-old male presented with a seven day history of chest pain, respiratory distress, and swelling in the neck following forceful vomiting. Examination revealed hypotension, decreased air entry in the right lower lung field with crepitations, epigastric tenderness with abdominal distension and guarding of both right and left hypochondria. A contrast esophagogram showed extravasation of contrast material from the lower third of the esophagus into the mediastinum without pleural cavity involvement. Reinforced primary closure of a 5-cm transmural tear in the right anterolateral wall of the esophagus 5 cm above the gastro-esophageal junction was performed along with right-sided chest drainage.

The anesthetic drugs and technique in this case were selected to avoid any increase in intra-abdominal pressure to prevent further spillage of gastric contents into the mediastinum through the perforation. Invasive monitoring was used to assess early hemodynamic changes and to administer fluid therapy and vasoactive drugs. Due to prolonged surgery, lung congestion, large fluid shifts, a long surgical incision and abnormal arterial blood gases, the patient was ventilated mechanically in the intensive care unit. Subsequently he developed an esophageal leak, septic shock, and multiple organ failure and died.

Conclusion: In a patient with a spontaneous rupture of esophagus, the anesthetic considerations include avoidance of further aggravation of the esophageal tear, and resuscitation from a morbid inflammatory condition.