It has been reported that the most common cause of esophageal rupture or perforation is severe vomiting, accounting for 64%, followed by other mechanical factors, such as trauma, overeating and cough, accounting for 19% [5]. Traumatic esophageal ruptures accounted for 4–14% of all esophageal perforations [6]. Both traumatic esophageal rupture and spontaneous esophageal perforation had a low incidence and were associated with significant mortality. Early diagnosis and appropriate intervention were needed to reduce incidence rate and mortality [6, 7].
The awareness of this disease and doctor's experience can make the early diagnosis of this disease. Actually, only about 30% of cases were diagnosed as rupture of the esophagus at their first visit to hospital. In case of doubt, esophagography should be performed with an aqueous contrast agent (such as meglumine diatrizoate). When mediastinal or thoracic leakage is observed, the disease can be diagnosed. CT may also be useful in the diagnosis of diseases, especially in these critically ill patients. Endoscopic examination seems to be a relative contraindication owing to need to inject air into the esophagus.
For treatment, primary repair can be performed in patients with esophageal perforation or rupture within 24 hours. However, the treatment of late esophagus perforation or rupture remains controversial [8]. At present there is no consensus on the optimal treatment strategy to handle these patients due to the lack of many randomized controlled trials. Surgery and conservative treatment including thoracic cavity drainage are feasible options, but surgical treatment is safer and better than conservative procedures, and may achieve better results than conservative treatment [9–11]. Fukushima et al., reported that the mortality rates after surgery and conservative treatment were 7.7% and 50.0%, respectively, indicating that the prognosis of the surgical treatment group was good [12]. If surgical treatment is indicated, what is the choice of primary repair or esophagectomy with or without immediate reconstruction? In fact, it is generally accepted that the treatment of this disease must be individualized according to the location, cause and clinical characteristics of the rupture or perforation (such as the length of time between onset and treatment, the degree of mediastinitis or chest infection, the extent of esophageal injury, concurrent medical conditions and hemodynamic stability) [13].
The patient not only had a large esophageal rupture, but also had a time interval of more than 24 hours between the occurrence and diagnosis of the rupture. Was it reasonable for the patient to perform thoracic esophagectomy and cervical esophagogastrostomy at the same period under the condition of serious pleural infection? It has been recommended that esophagectomy should be conducted if extensive esophageal rupture occurs [9], and the length of esophageal rupture was considered as an indicator of esophagectomy[14]. Okonta KE suggested that esophagectomy was superior to conservative treatment for delayed benign esophageal perforation (defined as a perforation diagnosed after 24h) [10]. Although the left thorax of the patient was seriously infected, his nutritional status was good and his hemodynamics was relatively stable. After thoracotomy, the pus and necrotic tissue in the thorax could be completely removed. After repeated large-scale washing with normal saline and Poseidon iodine, the thorax was very clean, almost reaching the level of wound cleaning. So we performed an entire thoracic portion esophagectomy with an immediate reconstruction with left neck approach esophagogastrostomy according to our experience, furthermore the tubular stomach was pulled up to the left neck trans-esophageal bed way, rather than trans-substernal pathway. Because of the simultaneous anastomosis, the patient avoided esophageal rejection and staged surgery, and achieved good results.
In conclusion, esophageal rupture caused by high-pressure gas is rare, and surgery is an effective treatment option for such disease. It was safe and technically feasible for our treatment strategy to undertake an esophagectomy with an immediate reconstruction with left neck approach esophagogastrostomy for the patient with an extensive thoracic esophageal rupture and concomitant empyema and mediastinitis.