Treatment of Boerhaave's Syndrome

Suspecting a fatal condition on a plain chest radiograph; Boerhaave syndrome

Spontaneous oesophagus rupture, also known as Boerhaave syndrome, is a rare but near-fatal medical condition and despite recent medical advancements, it remains a diagnostic challenge for front-door clinicians. The authors describe a similar presentation in an elderly gentleman who presented to the emergency department with sudden chest pain post vomiting. His initial chest radiograph showed bilateral dense consolidations and pleural effusions, and was treated as sepsis secondary to bilateral pneumonia. He underwent computed tomography pulmonary angiogram to rule out pulmonary embolism because of his chest pain with elevated D-dimer which confirmed the diagnosis of oesophagus rupture. His care was transferred to Surgical and Intensive care colleagues with plans for radiological chest drain insertion to limit contamination of mediastinum, however the patient became hypoxic and hypotensive and despite maximal organ support passed away within 6 hours of admission. Retrospect review of chest radiograph revealed Peri-oesophageal air tracking, a sign of Boerhaave syndrome. The aim of this case is to emphasise the importance of raising the suspicion of Boerhaave syndrome in patients with sudden chest pain, unexplained pleural effusion or pneumothorax with a history of recent vomiting as early diagnosis holds the key to prompt lifesaving management.

Successful conservative treatment of spontaneous intrathoracic esophageal perforation using a temporary covered esophageal stent with a check valve: a case report

Background

Spontaneous esophageal perforation is a potentially life-threatening condition with high morbidity and mortality rates. While surgical treatment has been employed for esophageal perforation, we have adopted conservative treatment with an esophageal stent for patients in a poor physical condition because we consider controlling sepsis and improving the physical status are the highest priorities; additionally, the surgical trauma could be fatal for these patients.

Case presentation

A 60-year-old male complaining of left chest and back pain after vomiting was transferred to a local hospital. Computed tomography and chest X-ray examinations showed left tension pneumothorax, pneumomediastinum, and bilateral pleural effusion suspicious of spontaneous intrathoracic esophageal perforation. He was transferred to our hospital for further treatment. After arrival, he developed septic shock with acute respiratory failure. We considered that surgical treatment was too invasive and chose conservative treatment with an esophageal stent. Under general anesthesia, we first inserted a 20-Fr. trocar in the left posterior pleural space, and a large volume of the dark pleural effusion was discharged. We then performed endoscopy and found a pinhole perforation in the left posterolateral wall of the lower esophagus. We inserted both a silicon-covered esophageal stent with a check valve and a double elemental diet (W-ED) tube. We then inserted an 18-Fr. trocar into the left anterior wall. These procedures were performed less than 24 h after onset. As intensive medical care, the patient was administered broad-spectrum antibiotics and catecholamine. The two trocars and the W-ED tube were under continuous suction at − 5 cmH₂O and at − 20 cmH₂O every 30 s. On the 6th day, we inserted an additional thoracic drainage tube into the left pleura under CT guidance. The patient was discharged from the ICU to the general ward on the 7th day. We removed the stent almost triweekly, and the esophageal perforation was completely healed on the 45th day. He was discharged home on the 70th day.

Conclusion

Conservative treatment with a temporary self-expanding covered stent with a check valve, sufficient drainage, and W-ED tube nutrition was useful and effective in this unstable case of spontaneous intrathoracic esophageal perforation.

Laparoscopic Management of Boerhaave's syndrome: a case report with an intraoperative video

Background

Boerhaave’s syndrome involves a sudden elevation in the intraluminal pressure of the esophagus, causing a transmural perforation. It is associated with high morbidity and mortality. Its treatment is challenging, and early surgical intervention is the most crucial prognostic element.

Case presentation

We present a case of a 32 year-old male who presented after severe emesis with an acute onset of epigastric pain. He was diagnosed with Boerhaave’s syndrome. Displaying signs of shock mandated immediate surgical exploration with laparoscopic primary repair.

Conclusion

The golden period of the first 24 hrs of the event still applies to cases of esophageal perforation. The scarcity of these cases makes a comparison between the various treatment methods difficult. Our data support the use of laparoscopic intervention with primary repair as the mainstay of treatment for the management of esophageal perforation.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0576-7) contains supplementary material, which is available to authorized users.

Endoluminal Therapies for Esophageal Perforations and Leaks

Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.

Primary closure of a spontaneous esophageal rupture under hand-assisted laparoscopy: a case report

Spontaneous rupture of the esophagus, which is also known as Boerhaave’s syndrome, is a rare life-threatening condition that requires urgent surgical management. The optimal treatment involves surgical repair of the esophageal defect, which is usually accomplished via laparotomy, thoracotomy, or both, and mediastinal debridement. Here, we report a case of spontaneous rupture of the esophagus that was treated with suturing repair and drain insertion using a hand-assisted laparoscopic approach.

Learning the hard way: when a CT scan misleads your diagnosis

Oesophageal injury due to blunt trauma is extremely rare, and when it presents it carries a very high mortality. Time is of essence and if not promptly recognised these injuries could have devastating consequences. We report a case emphasising the importance of oesophagoscopy in diagnosing oesophageal injuries. A young man presented to our emergency ward as an unwitnessed road traffic accident after receiving first aid from a secondary care facility. At presentation, he was haemodynamically stable with decreased power in lower limbs, and with severe neck and back pain. There was high suspicion of spinal injury, which was later evident on clinical and on radiological findings. A CT scan revealed oesophageal injury, indicated by contrast extravasation, which was convincing enough to proceed without endoscopy. Surprisingly, the apparently convincing injury picked up on CT scan marked by contrast extravasation turned out to be an artefact, which led to a negative surgical exploration.

Outcomes following Boerhaave's syndrome

INTRODUCTION

Boerhaave's syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit.

METHODS

Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay.

RESULTS

Twenty patients with Boerhaave's syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days.

CONCLUSIONS

Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave's syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

Boerhaave's Syndrome: Still a Diagnostic and Therapeutic Challenge in the 21st Century

Boerhaave's syndrome is a rare but potentially fatal condition characterised by a transmural tear of the distal oesophagus induced by a sudden increase in pressure. Diagnosis is challenging as the classic triad of vomiting, abdominal or chest pain, and subcutaneous emphysema is absent in many patients. Management is multidisciplinary and relies on rapid, distinct, and repeated imaging. Treatment has not been standardised and may be conservative, endoscopic, or surgical. We present a typical case which illustrates possible diagnostic pitfalls and the therapeutic conundrum surrounding management of the syndrome. Based on time of presentation and eventual presence of sepsis, a therapeutic algorithm is proposed.

[Emergency interventions for perforation and bleeding in esophageal cancer patients]

Bleeding and perforation in esophageal cancer patients are rare but associated with a high morbidity and mortality. Because of disappointing results after primary surgical exploration and resection endoscopic intervention was introduced as the primary treatment option with an improved outcome. Aortoesophageal and esophagobronchial fistulas may occur spontaneously or secondary to stenting of the esophagus. They are uncommon but fatal if untreated. The first option is prompt placement of a stent graft as a bridging solution followed by surgical treatment.

Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours

Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.

Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours

Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.

Boerhaave syndrome: a diagnostic conundrum

A 79-year-old man presented to the Emergency Department with abdominal pain 1 day after an elective total knee replacement. The patient was confused and drowsy, with a high fever, hypotension and uncontrolled atrial fibrillation. He subsequently developed respiratory failure, requiring admission to intensive care. It was then noted that a large pleural effusion had developed between two chest radiographs performed only 4 h apart. A pigtail catheter inserted into the pleural space revealed a transudate of pH 7.0 with an amylase of 17 220 U (serum amylase 54 U), and thus a diagnosis of spontaneous oesophageal rupture or Boerhaave syndrome was made. Despite drainage of the pleural space, the patient developed shock and multiorgan failure requiring mechanical ventilation, renal replacement therapy and cardiovascular support. The oesophageal leak was treated conservatively with intercostal tube drainage; the patient made a full recovery and was discharged from hospital 75 days later.