Surgery>>>>>The Esophagus and Diaphragmatic Hernia
Question 27#

Following a night of heavy drinking, a 43-year-old otherwise healthy man has sudden onset of severe chest pain after vomiting. Esophagram confirms esophageal rupture just proximal to the GEJ. What is the preferred operative exposure?

A. Right thoracotomy
B. Right thoracotomy with laparotomy
C. Left thoracotomy
D. Left thoracotomy with laparotomy
E. Midline laparotomy

Correct Answer is C

Comment:

The key to optimum management is early diagnosis. The most favorable outcome is obtained following primary closure of the perforation within 24 hours, resulting in 80 to 90% survival. The most common location for the injury is the left lateral wall of the esophagus, just above the GEJ. To get adequate exposure of the injury, a dissection similar to that described for esophageal myotomy is performed. A flap of stomach is pulled up and the soiled fat pad at the GEJ is removed. The edges of the injury are trimmed and closed primarily. The closure is reinforced with the use of a pleural patch or construction of a Nissen fundoplication.