Boerhaave's Syndrome麻醉處理之病例報告

Anesthetic Management of Boerhaave's Syndrome

Boerhaave's syndrome是食道自然的破裂，這是一種罕見的疾病，如果沒有早期的診斷及有效的治療，它是會危及生命的。其發生的機轉可能是食道中食物殘留產生腐敗微生物，胃液及消化酵素等污染了縱膈腔，發生縱膈炎及食道周圍壞死。如果能及早進行積極的外科清除治療，尚有一線生機，否則最後只有死路一條。我們報告二個病例，一個是早期外科清創治療，病人存活下來；另一個是清創不夠，發生縱膈腔炎，後來不幸死亡。提醒同仁注意Boerhaave's syndrome是會致命的，除了清創手術要做徹底，手術過程中的麻醉處理也是相當重要。由於病患通常會合併敗血症甚至休克，麻醉誘導應使用適當的藥物，麻醉中也必須注意水分、電解質及酸鹼的平衡，維持生命徵象，才能保障病患的安全。

Boerhaave's syndrome or spontaneous esophageal perforation is a life threatening condition which demands early diagnosis and urgent management. Although very selective patients can be treated nonoperatively, in most patients, better overall results can only be attained with early aggressive surgery. Clinical data and accounts of anesthetic management of this condition scarely appear in medical literature. Managing these patients for surgery is among the most challenging tasks facing the anesthesiologist because they may develop septic syndrome with shock. A rapid-sequence induction is mandatory, and the procedures that may aggravate the injury to esophagus should be avoided. Inotropic support and close attention to fluid balance may be required during operation. Because Boerhaave's syndrome is rare, we report here two cases to illustrate possible anesthetic implications of this disease. Both patients underwent thoracotomy to relieve empyema of mediastinum under general anesthesia. The first patient recovered completely after operation due to early diagnosis and treatment, but the second patient developed multiple organ failure and died after operation due to delayed diagnosis of esophageal rupture and severe sepsis. Because survival is directly related to the time to diagnosis and treatment, all clinicians need to be aware of this lethal disease.