GastroenterologiaJaponica

Vol. 12, No. 2

Copyright9 1977 by The JapaneseSocietyof Gastroenterology

Printedin Japan

--Case Report--

S P O N T A N E O U S RUPTURE OF THE E S O P H A G U S R E P O R T OF TWO CASES SUCCESSFULLY TREATED BY INTRAVENOUS HIGH CALORIC NUTRITION AND REVIEW OF 59 CASES COLLECTED FROM JAPANESE LITERATURE Shozo M O R I , M.D., Morio KASAI, M.D., Toshio W A T A N A B E , M.D., Nobumitsu SAKAI, M.D. and T a k a y a K I M U R A , M.D.

Second Department of Surgery, Tohoku University Hospital, Sendai, Japan Summary For the period from 1951 through 1975, 4 cases of spontaneous rupture of the esophagus have been successfully treated at the IInd Department of Surgery, Tohoku University Hospital, Sendal, Japan. Two cases of them conservatively treated with intravenous high caloric nutrition were reported. Fiftynine Japanese cases of spontaneous rupture of the esophagus were reviewed. Symptoms, diagnosis, treatment and prognosis of the disease were discussed.

Key Words: spontaneousrupture of the esophagus hyperalimentation. Spontaneous rupture of the esophagus was first described by Boerhaave in 1724, and was generally known as a rare but catastrophic disease. For the period covering from 1951 through 1975, 4 cases of the disease have been successfully treated at the I I n d D e p a r t m e n t of Surgery, Tohoku University Hospital, Sendai, J a p a n . T w o cases of them conservatively treated with intravenous high caloric nutrition were reported. 59 cases of spontaneous rupture of the esophagus were collected from Japanese literature and reviewed.

Case report Case 1. A 50-year-old man had been in good health until J a n u a r y 7, 1973 when he suddenly complained of severe pain in the left upper portion of the a b d o m e n following several episodes of vomiting. H e took a considerable a m o u n t of alcohol beverage the night before

the episode. He was admitted to a local hospital on the afternoon of the same day. O n admission puls rate was 150 per minute, systolic blood pressure was 70 m m H g and respiratory rate was 28 per minute. Auscultation of the chest showed normal heart sound and breath sound, and there was tenderness in the epigastrium. Acute pancreatitis was suspected, for which conservative treatment with intravenous infusion, antibiotic and oxygen therapy was started. The condition of the patient improved temporarily until the next morning when dyspnea appeared. Auscultation of the chest revealed decreased breath sound on the left. Chest x-ray film showed a left hydropneumothorax. Even after 1500 ml of serosanguineous fluid was aspirated from the left thorax by thoracentesis, hydropneumothorax developed again. Left thoracotomy was carried out because of suspicion of rupture of the esophagus 36 hours

Spontaneous Ruptureof Esophagus

April 1977

after the onset of the symptoms. A large c a v i t y of p y o t h o r a x c o n t a i n i n g p r u l e n t fluid was found, b u t the l o c a t i o n of the r u p t u r e d esophagus was not identified. A large d r a i n was inserted into the c a v i t y a n d the t h o r a x was closed. S u b s e q u e n t l y g a s t r o s t o m y was m a d e . T h e left lung was e x p a n d e d a n d g e n e r a l c o n d i t i o n o f the p a t i e n t i m p r o v e d r a p i d l y after the operation. P o s t o p e r a t i v e b a r i u m swallow study disclosed a leakage of c o n t r a s t m e d i u m from the left wall of the lower esophagus into the left p l e u r a l cavity. O r a l feeding was discontinued a n d t u b e feeding t h r o u g h g a s t r o s t o m y was started. P l e u r a l fluid d i d n o t decrease because of r e g u r g i t a t i o n from the s t o m a c h a n d the p a t i e n t b e c a m e g r a d u a l l y e m a c i a t e d . I n a d d i t i o n r e p e a t e d b l o o d transfusion was necessary for gastrointestinal b l e e d ing. O n the 120th d a y the p a t i e n t was transfered to our d e p a r t m e n t . E x a m i n a t i o n r e v e a l e d a m a l n o u r i s h e d , deh y d r a t e d a n d a n e m i c a d u l t m a l e with a 41 kg of b o d y weight. B o d y t e m p e r a t u r e was 37.9~ puls rate 130 a n d blood pressure

71

100/80 m m H g . R e s p i r a t o r y m o v e m e n t s of the t h o r a x were restricted on the left side a n d b r e a t h sound o f the left chest was m a r k e d l y diminished. T h e r e was no tenderness in the a b d o m e n . L a b o r a t o r y d a t a a r e shown in T a b l e 1. C u l t u r e o f p l e u r a l fluid r e v e a l e d streptococcus v i r i d a n s a n d klebsiella. E s o p h a g o g r a m revealed a l e a k a g e of c o n t r a s t m e d i u m from esophagus into the large space of p y o t h o r a x of the left chest (Fig. 1). P e r f o r a t i o n of the esophagus was 3.6 cm in length on the x - r a y film. T o p r e v e n t r e g u r g i t a t i o n from the s t o m a c h , tube feeding t h r o u g h g a s t r o s t o m y was discontinued a n d continuous suction of gastric c o n t e n t was done. I n t r a v e n o u s high caloric n u t r i t i o n with glucose a n d crystaline a m i n o acids solution was started. A d m i n i s t r a t i o n of antibiotics a n d d a i l y i r r i g a t i o n of the p l e u r a l c a v i t y b y p r o v i d o n e iodine solution were carried out. G e n e r a l c o n d i t i o n of the p a t i e n t r a p i d l y i m p r o v e d (Fig. 2). B o d y w e i g h t i n c r e a s e d s e r u m a l b u m i n level elevated while p l e u r a l

Table 1. Laboratory data of 2 cases with rupture of

the esophagus

RBC WBC Hb Ht Na K C1 B.S. BUN P.P. Alb. I.I CCFT ZTT TTT GOT GPT AIP

Case 1

Case 2

365 x 104 8000 10.2 g/dl 38% 138 mEq/L 4.6 " 95 70 mg/dl 12 mg/dl 7.6 g/dl 38.6% 5 ~16.8 7.3 25 26 9.5

380 x 104 13000 -39% 136 mEq/L 3.1 " 100 " 135 mg/dl 23 mg/dl 6.6 g/dl 51.1 o/ ,o 5 -12.2 0.4 13 3 5.2

Fig. 1.

72

drainage decreased. Esophagogram after 66 days of intravenous nutrition revealed a closure of esophagopleural fistula (Fig. 3). Pyothorax cured spontaneously within 4 weeks

Case

M.H. 9 [] [] []

FAT AMINON.ID XYLITOL FnUCTOSE

[ ] GLUCOSE ADMISSION

I.

'W~I[

[ ] TUBEFEEDING l C.VH

DISCHARGE

W I C.VH I

RR

5.0

3,0

Vol. 12, No. 2

s. M O R I E T A L .

x

At B. x / x

'gl "S 45

~ :

*~--.-,-....~....o-. ~ ' ' ' ~ ' ~

41

(+) 35

......

2000100"~I~DRAINAGE 0ML VOLUMEI

after oral feeding was started. The patient was discharged on 106th day after admission and has been doing well. Case 2. A 55 year-old man suddenly vomited and complained of severe substernal pain 2 hours after drinking of 3 bottles of beer. The vomitus contained a small amount of blood. As mild substernal pain continued for the following 2 days, he visited a local hospital on August 29, 1973. G.I. series disclosed a leakage of contrast medium through the esophagus into the mediastinum. A diagnosis of spontaneous rupture of the esophagus was made and the patient was transfered to our surgical department. Examination revealed a well nourished man with body temperature of 39~ Puls rate was 120, respiration 36 per minute and blood pressure 118/82 m m H g . On auscultation of the chest no abnormality was noted and there was no tenderness in the abdomen. Laboratory data are shown in T a b l e 1. Chest

Fig. 2.

Fig. 3.

Fig. 4.

April 1977

SpontaneousRupture of Esophagus

esophagus into the left mediastinum (Fig. 4, 5). Electrocardiogram showed sinus tachycardia and elevation of ST-segment. Because of relatively good condition of the patient and absence of pneumohydrothorax, conservative treatment was chosen. Oral feeding was discontinued and intravenous high caloric nutrition with glucose and crystaline amino acids was started. Administration of large doses of antibiotics was done. The course of the patient after admission was shown in Fig. 6. One week later body temperature and puls rate became normal and substernal pain disappeared. Widening of mediastinum on x-ray film and abnormal change of electrocardiogram were gradually improved. Esophagogram on the 20th day after admission revealed disappearance of leakage and oral feeding was begun. The patient was discharged on the 71th day after the onset.

Fig. 5.

Case

ca~/ ooo. ~ o

1

.....

l.R.

o.oo.~,oo0o oo ~~ o0 0,

.

~ ] FAT

~176 o,

~

c,~uc0sc

~ ";,7,7.7,7,,7,7"7,;/;,;~;,t73{~7,Y,3":,7"

8.0-1

RR _

ol

ALB. X~X

t

B.T.

I

5

x

10

~

-x~

15

73

x

20

25 DaY

Fig. 6. x-ray revealed a widening of the mediastinum but there were no mediastinal emphysema nor pneumothorax. Esophagogram disclosed a leakage of contrast medium through the lower

R e v i e w o f 59 C a s e s Fifty nine cases of spontaneous rupture of the esophagus including our 4 cases were collected from the Japanese literature for the period covering from 1935 through 1975. The ages ranged from 5 days to 76 years. Thirty two of 59 patients (55.9%) were between the ages of 30 and 49 years with a mean of 42.8 years. Fifty three were males (89.8%) and 6 females (Table 2). The most common site of rupture was the lower esophagus just above the diaphragm, usually on the left side, which was seen in 43 of 59 cases. Tears at the cervical esophagus and upper esophagus were very rare (Table 3). All tears were single in number and vertical in direction except 2 of transverse disruption. The size of tears varied fi-om 0.3 cm to 11 cm and less than 5 cm in 35 cases (59.3%) ( T a b l e 4). Vomiting was the most common initial symptom and found in 45 of 59 cases (76.3%).

74

Vol. 12, No. 2

S. M O R I E T A L .

T a b l e 2.

Age and sex of 59 cases

Age in years

0-9

10-19

20-29

30-39

40-49

Male Female

0

0

4

16

1

1

2

1

Total

l

l

6

17

T a b l e 3.

60 69

15

8

8

1

1

0

0

1

0

0

53 6

15

8

9

l

l

59

Right

Left

Upper esophagus Middle esophagus Lower esophagus Unknown

1 1 2

1 1 2

2 10

2 26

Total

4

4

12

28

Size of rupture and prognosis of 59 cases

T a b l e 5.

Prognosis Diameter 0 - 0.9 cm 1.0

-

Cured 3

1.9

2.0 2.9 3.0 3.9 4.0 4.9 5.0 5.9 6.0 6.9 7.0 7.9 8.0- 8.9 9.0 9.9 10.0 10.9 11.0 11.9 Unknown Total

Died 2

Total

I

2

3

11 5 2 0 0 0 1 0 0 1 4

15 6 6 3 1 0 1 0 0 1 18

28

59

Unknown

Total

3 8

2 6 43 8

11

59

Initial symptoms of 59 cases

Vomiting Abdominal pain Chest or Back pain Dyspnea Subcutaneous emphysema Dysphagia Fever Cyanosis

Total 5

4 1 4 3 1 0 0 0 0 0 14 31

70 79 Unknown

Location and size of the rupture of 59 cases

\nterior Posterior

T a b l e 4.

50-59

was often accompanied Occurrence

of pain

45 33 31 21 7 1 1 1

by abdominal rigidity.

was sudden

and

severe,

a n d s o m e t i m e s r a d i a t e d to t h e b a c k .

Usually

vomiting preceded pain but in some instances pain

occurred

before

or

without

vomiting.

C h e s t p a i n o c c u r r e d i n 31 cases. D y s p n e a w a s r e c o g n i z e d i n 21 cases. In

15 cases, t h e v o m i t u s

amount

of

blood.

contained

Vomiting

had

varying

respiration,

a

neous

close

correlation with alcohol intake and in 34 of 45

cases

(75.6%)

vomiting

drinking alcohol (Table Abdominal

chondrium

of, a n d was

next

emphysema

rigidity and

were

Rapid subcuta-

emphasized

as

a

d i a g n o s t i c t r i a d b y B a r r e t 1~ a n d A n d e r s o n 2~. I n this series, h o w e v e r , s u b c u t a n e o u s e m p h y s e m a w a s f o u n d i n o n l y 7 cases.

p a i n w a s also c o m m o n

was the most common

after

5).

f o u n d i n 33 o f 59 cases (55.9~o). complained

occurred

abdominal

and was

Epigastrium

I n a case o f n e w - b o r n

infant, cyanosis and

dyspnea were initial symptoms.

region, where pain was

Generally a sudden onset was characteristic.

t h e left o r r i g h t h y p o -

H o w e v e r , o u r s e c o n d case h a d m i l d s y m p t o m

common.

These

pain

and visited hospital on the 3rd day after the

SpontaneousRupture of Esophagus

April 1977

T a b l e 6.

Initial diagnosis of 59 cases

Rupture of the esophagus Pneumothorax or Pyothorax Acute abdomen Others Unknown

T a b l e 7.

onset of symptoms. A correct diagnosis was made in 20 of 59 cases (33.9%) and 9 cases were erroneously diagnosed as an acute abdomen such as perforated peptic ulcer, bleeding ulcer or acute pancreatitis. An exploratory laparotomy was performed in 13 cases ( T a b l e 6). Twenty eight of 59 cases died, mortality being 47.5%. Mortality in the early period covering from 1935 to 1971 was 18/26, 69.2% and in the recent period during from 1971 through 1975 was 10/33, 30.3%. Five of 28 cases died within 24 hours after onset of

2() 9 16 7 7

Mortality of 59 cases Cured

Died

Mortality

1935-1970 1971-1975

8 23

18 10

69.2% 30.3%

Total

31

28

47.5%

T a b l e 8.

75

T r e a t m e n t in 59 cases

Treatment

Cured

Drainage Direct suture Esophagectomy with esophagogastrostomy Subtotal thoracic esophagectomy Gastrectomy Gastrostomy Exploratory laparotomy only Conserva tire

14 7 3 2 1 1 0 3

8 11 1 0 1 o 1 6

36.4~ 61.1% . 25.0~ 0 % 50.0% o % 100 % 66.7%

22 18 4 2 2 1 1 9

Total

31

28

47.5%

59

T a b l e 9.

3 6 18 48 12 11 16 10 10 19 6 16 8 20 19 4 30

days hours hours hours hours * days hours hours hours hours days hours months days hours days hours

Total

Results of 18 cases treated by direct suture

H o u r s from rupture to operation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Died (Mortality)

Diameter of r u p t u r e

Postoperative leakage

4.0 cm * 3.7 cm 4.0 cm 2.0 cm * 2.5 cm 2.0 cm 2.0 cm 3.0 cm 2.0 cm 3.0 cm 2.5 cm * * 2.0 cm 2.0 cm 1.0 cm

+ q+ qq+ * -* + -q-q* --*

Results cured, cured, cured, cured, cured, cured, cured, died, died, died, died, died, died, died, died, died, died, died,

I1 months 1.5 months * 15 months 65 months * * 20 hours 4 days 9 days 23 hours 2 months 4 days 2 years 25 days 23 hours 7 days 4 days

76

Vol. 12, No. 2

S. M O R I E T A L .

Table 10. 1045 cases of esophageal diseases treated

at the Second Department of Surgery, Tohoku University Hospital from 1951 through 1974 Name of disease N u m b e of r cases Carcinoma 887 Sarcoma 1 Leiomyoma 4 Cyst 1 Hemangioma 1 Polyp 1 Congenital atrsea 29 Congenital stenosis 2 Diverticula 27 Esophagobronchial fistula 2 Hiatus hernia 24 Achalasia 22 Chalasia 5 Varices 11 Foreign body 3 Corrosive stricture 18 Ulcer 2 Sclerodermia 1 Spontaneous rupture 4 Total

1,045

symptoms, additional 7 within 5 days, 4 within 10 days and 9 survived longer than 11 days and died later ( T a b l e 7). Methods of treatment employed in 59 cases are summarized in T a b l e 8. In 50 cases of them some surgical procedures were carried out. Open or closed thoracotomy drainage was made in 22 cases, direct suture of the esophageal tear in 18 cases, partial esophagectomy including the ruptured site in 6 and simple gastrectomy in 2. Eight of 22 cases treated by drainage died and mortality was 36.4%. A correlation was not noted between the interval from onset to drainage and prognosis. Direct suture of esophageal tear was performed in 18 cases, among whom 11 died, mortality being 61.6%. Break-down of the sutured site of the esophagus occurred in all of 7 survivors, except 1 in whom break of the suture site was not described (Table 8, 9).

There were 4 cases treated by esophagectomy with esophagogastrostomy, among whom 3 survived. There were 2 survivors treated by subtotal thoracic esophagectomy with cervical esophagostomy for diversion of oral secretion and gastrostomy for tube feeding. There were 9 cases treated conservatively in this series, and 6 of 9 died before a correct diagnosis was made. Discussion

From 1951 through 1975 there have been 4 cases of spontaneous rupture of the esophagus treated at I I n d Department of Surgery, Tohoku University Hospital. They took only 0.4% of 1045 cases of esophageal diseases treated during the same period (Table 10). Recently, reported cases of spontaheous rupture of the esophagus have increased in number and results of treatment have been improved. A sudden abnormal elevation ofintraluminal pressure has been considered as a main cause of rupture of the esophagus. As possible factors causing high intraluminal pressure of the esophagus, vomiting, retching, straining at defecation, labor of childbirth, convulsive seizure and lack of neuromuscular coordination during vomiting have been documented by many authors ls). Experimental studies on bursting pressure were reported by Kinsella 6), Mackler 7~ and Derbes 3). As anatomical weakness of the lower esophagus, lack of the external supporting tissues and entrance of nerves and vessels were suggested by Derbes. It is usually difficult to prove pre-existing pathological changes such as esophagitis, stricture and ulceration at operation or autopsy. We consider that although rupture may take place in the completely normal esophagus, preexisting changes of the esophagus may take an important role in causing spontaneous rupture because m a n y of the patients are considerablly heavy drinker and some of them

SpontaneousRuptureof Esophagus

April 1977

have the history of mild dysphagia and heart burn. Therefore, if the term "spontaneous" implies the absence of pre-existing esophageal lesion, it is not always adequate. It seems reasonable that "spontaneous" means a lack of direct trauma, foreign bodies or instrumentaion. On the other hand, the terms "postemetic rupture a~'' or "emetogenic rupture 9~'' are not always correct, because a rupture can occur without emesis. There was a considerable confusion concerning the etiology of Mallory-Weiss syndrome and spontaneous rupture of the esophagus 9,10~. Although vomiting can be a cause of both diseases, there are differences in location of lesion, severity of symptoms, clinical course and mortality between them. Kelly ll) reported a case of spontaneous intramural esophageal perforation in 1972 and Smith ~2~ reported 3 cases of esophageal apoplexy in 1974. These cases seemed to be an incomplete type of spontaneous rupture of the esophagus. In order to improve the prognosis of the disease, early diagnosis and early adequate management are important. Anderson 2~ stated "A diagnosis of this condition is usually not difficult if one think of it". We support Anderson's opinion because symptoms of the disease are usually characteristic. X-ray examination of the chest and abdomen is most useful for the correct diagnosis. " V Sign" of Naclerio ~a~, emphysema of the mediastinum and pneumohydrothorax are diagnostic signs of the

disease.

A

difinitive

diagnosis

of

rupture of the esophagus is obtained by contrast medium study. There are two types of death in the patients

77

ment are usual causes of late deaths. Many kinds of procedure have been applied for treatment of the disease. Surgical repair of tear and drainage are procedures frequently used for the disease and there are m a n y discussions regarding the first choice for treatment of esophageal rupture. Samson a~ stated " p r o m p t resuscitation, exploratory operation and closure of the rents were the guiding precepts". Heberer 5> emphasized also advantages of operative closure of tear of the esophagus regarding mortality and duration of treatment. However in the present series, the mortality is 36.4% in cases treated by drainage, whereas it is 61.1 o/o in cases treated by a direct closure of tear. Unsatisfactory result of surgical repair in the present series is accounted for delayed surgery and frequent leakage. Samson 8~ stated " T h e critical period seems to be approximately 15 hours". Abbott 14) mentioned 12 hours as a critical period and Anderson 2> 24 hours. When a direct suture of esophageal tear is selected for the first treatment, it is important to mind of frequent occurrence of leakage and to place a suction catheter around the sutured site. There are several cases which underwent esophagectomy with esophagogastrostomy or subtotal thoracic esophagectomy with cervical esophagostomy and gastrostomy. They seem too aggressive, however, for the patient in shock state. Thal and Hatafuku ~5~ reported a case in whom a tear of the terminal esophagus was successfully repaired by fundic-patch method. The procedure seemed to be useful for a repair in delayed cases.

Other surgical pro-

with this disease, one is an early death and

cedures have been reported by some authors.

another a late death.

Abbott m described a new T-tube drainage

Respiratory and cir-

culatory distress are direct causes of early

operation.

deaths.

esophageal exclusion and diversion with re-

Sepsis subsequent to severe purulent

mediastinitis and pleuritis and poor nourish-

duced

UrscheP 6) reported a method of

mobidity

and

mortality.

Derbes 4~

78

stated " I f surgery is not performed all patients die promptly. O n l y 35% of 71 patients survived 24 hours, 11% to the end of the second day, and none lived longer than 1 week". Although this c o n c e p t seems to be generally true, but there are 3 survivors treated conservatively in the present series. All of t h e m had an esophageal tear of a small size with unruptured pleura and showed mild clinical symptoms. A correct diagnosis was m a d e early and an a d e q u a t e treatment was p r o m p t l y started. These factors seems to be m i n i m u m requirements for successful conservative treatment of an esophageal rupture. It is likely that the mechanism preventing reflux at the esophagogastric junction is easily destroyed by a lower esophageal rupture. Gastroesophageal reflux not infrequently disturbed the healing of esophageal perforation. Gastrostomy for suction drainage is considered useful. I m p r o v e m e n t of the nutritional state of patients is i m p o r t a n t after the patients get out from the early shock state. As a tube feeding through gastrostomy is not appropriate because of frequent reflux of gastric content into the pleural cavity through the esophageal tear, feeding should be given t h r o u g h jejunostomy. Intravenous high caloric nutrition can replace the feeding through a jejunostomy. We consider that treatment of spontaneous rupture of the esophagus consists of the following procedures: (1) Intravenous infusion, respiratory support, intensive antibiotic therapy are the treatment in the early shock state. X - r a y examination of the chest and esophagogram

Vol. 12. No. 2

s. M O R I E T A L .

are i m p o r t a n t

diagnosis.

for the early correct

(2) As soon as after diagnosis is

established t h o r a c o t o m y should be performed. Suction and irrigation of the pleural cavity and the mediastinum with a large q u a n t i t y of

saline and insertion of large drainage tube are necessary. Direct closure of the tear should be attempted only in the patients in the early state, and the fundic-pateh repair m a y be selected. (3) Gastrostomy for decompression and jejunostomy for tube feeding are placed. (4) Intravenous high carolic nutrition is effective for preventing gastroesophageal reflux and giving sufficient nutrients. References

1) Barrett, N.R.: Spontaneous perforation of the oesophagus; review of the literature and report of three new cases. Thorax, 1 : 48-70, 1946. 2) Anderson, R.L.: Spontaneous rupture of the esophagus. Amer. J. Surg., 93: 282-290, 1957. 3) Derbes, V.J. and Mitchell, R.E.: Rupture of the esophagus. Surgery, 39: 688-709, 1956. 4) Debes, V.J. and Mitchell, R.E.: Rupture of the esophagus. Surgery, 39: 865-888, "1956. 5) Heberer, G., et al.: Pathogenese und Therapie der Oesophagusrupturen. Chirurg., 37: 433-440, 1966. 6) Kinsella, T.J., et al.: Spontaneous rupture of the esophagus. J. Thorac. Surg., 17: 613-631, 1948. 7) Mackler, S.A.: Spontaneous rupture of the esophagus and experimental and clinical study. Surg. Gynec. Obstet., 95" 345-356, 1952. 8) Samson, P.C.: Postemetic rupture of the esophagus. Surg. Gynec. Obstet., 93" 221-229, 1951. 9) Zikria, B.A., et al.: Mallory-Weiss syndrome and emetogenic (spontaneous) rupture of the esophagus. Ann. Surg., 162: 151-155, 1965. 10) Small, A.R. and Ellis, P.R.: Laceration of distal esophagus due to vomiting (the Mallory-Weiss syndrome) : report of a case with massive hemorrhage and recovery after repair of the laceration. New Engl. J. Med., 258: 285-286, 1958. 11) Kelly, D.L.: Spontaneous intramural esophageal perforation. J. Thorac. Cardiovasc. Surg., 63: 504-507, 1972. 12) Smith, G., et al.: Oesophageal apoplexy. Lancet, 1 : 390-392, 1974. 13) Naclerio, E.A.: The "V Sign" in the diagnosis of spontaneous rupture of the esophagus (an early roentgen clue). Amer. J. Surg., 93: 291-298, 1957. 14) Abbott, O.A, et al.: Atraumatic so-called "spontaneous" rupture of the esophagus, a review of 47 personal cases with comments on a new method of surgical therapy. J. Thorac. Cardiovasc. Surg., 59: 67-83, 1970.

April 1977

SpontaneousRupture of Esophagus

5) Thal, A.P. and Hatafuku, T.: Improved operation for esophageal rupture. J. Amer. med. Ass., 188: 826-828, 1964.

79

16) Urschel, H.C., et al.: Improved management of esophageal perforation: exclusion and diversion in continuity. Ann. Surg., 179: 587-591, 1974.

Received February 8, 1977 Accepted February 21, 1977 Address requestsfor reprints to : Dr. Shozo Mori, M.D., 2nd Dept. of Surgery, Tohoku Univ., 1-1, Seiryo-cho, Sendai, 980 Japan.