Management of Boerhaave syndrome in Australasia: a retrospective case series and systematic review of the Australasian literature

Successful Endoscopic Closure of Esophageal Perforation in Boerhaave Syndrome Using the Over-the-Scope Clip

Boerhaave syndrome (BS) is a rare but potentially fatal condition. Although surgery is considered the standard treatment, endoscopic therapy has acquired an important role as a minimally invasive management approach. The authors describe 2 cases of middle-aged male patients, presenting with spontaneous esophageal perforation after severe straining and vomiting. In the first case, the patient presented with a bone impaction in the upper esophagus successfully removed by rigid esophagoscopy. After the procedure, a chest X-ray/cervicothoracic computerized tomography scan (CT) showed a left hydropneumothorax and pneumomediastinum with oral contrast leak at the lower esophagus. In the second case, the patient presented to the Emergency Department with severe chest pain after an episode of vomiting. The CT showed a massive pneumomediastinum, subcutaneous emphysema, and an oral contrast leak compatible with BS. The patient was initially submitted to surgical suture, but contrast extravasation persisted after 12 days. After multidisciplinary team discussion of both patients, an upper gastrointestinal endoscopy was performed, which revealed pericentimetric wall defects at the distal esophagus. These were successfully closed using an over-the-scope clip (OTSC). After at least a 9-month follow-up, patients have remained clinically well with no relapse. The authors highlight the severity of these clinical cases and the endoscopic option that proved to be decisive in addressing BS. The favorable outcomes suggest a role for the OTSC approach in closing spontaneous esophageal perforation both as first-line and as rescue therapy after a surgical failure.

Early Diagnosis and Surgical Management of Boerhaave Syndrome: A Case Report

Boerhaave syndrome is a rare condition of spontaneous esophageal perforation after multiple episodes of forceful emesis. Due to its high morbidity and mortality rates, early diagnosis and treatment are key prognostic factors. Herein, we present a case of Boerhaave syndrome, which was initially misinterpreted as a coronary event due to similar confusing symptoms. However, a diagnosis was made without delay and confirmed with a chest computed tomography (CT) scan, which revealed pneumomediastinum. The patient was treated surgically by primarily repairing the rupture with an omentum patch reinforcement, draining the mediastinum and both pleural cavities, and creating a feeding jejunostomy. After a long stay in the ICU and the Surgical Department, the patient was discharged in good clinical condition with normal oral feeding.

Spontaneous oesophageal perforation secondary to renal colic

Boerhaave syndrome is a rare but potentially life-threatening condition that involves a full-thickness tear of the oesophagus. It accounts for around 15% of all cases of oesophageal perforations and is associated with up to 40% of mortality. Vomiting has been found to be associated with the development of Boerhaave syndrome. However, the aetiology of vomiting varies broadly in the available literatures from alcohol indulgence to marathon running, and from panic attack to radiotherapy for cancer. We present here an unusual case of Boerhaave syndrome where the patient developed spontaneous oesophageal perforation in the setting of renal colic.

Boerhaave syndrome: Successful conservative treatment. Case report and literature review

INTRODUCTION AND IMPORTANCE

Spontaneous esophageal perforation or "Boerhaave" syndrome is an uncommon pathology, with high rates of morbidity and mortality. Clinical scores such as the Pittsburgh classification could guide the treatment and helps to assess mortality risk. Conservative management could be performed in selected cases.

CASE PRESENTATION

We present a 19-year-old male patient with a previous history of anxiety and depression, who enters the emergency room with vomiting and epigastric pain followed by swelling at the neck and dysphagia. Neck tomography and chest tomography were obtained showing subcutaneous emphysema. Conservative management was indicated and after 10 days of in-hospital stay and no complications, the patient was discharged. Any complication was observed after 30, 60, and 90 days of follow-up.

CLINICAL DISCUSSION

Selected patients with Boerhaave syndrome could benefit from conservative management. Risk classification could be performed using the Pittsburgh score. Nil per os, antibiotic treatment, and nutritional support are the cornerstone of nonoperative management.

CONCLUSION

Boerhaave syndrome it's an infrequent pathology, with mortality rates ranging between 30 and 50 %. Early identification and on-time management are required to have favorable outcomes. Pittsburgh score can be used to guide the selection of patients who benefit from conservative treatment.

Current approach for Boerhaaves syndrome: A systematic review of case reports

BACKGROUND

There is no consensus on the appropriate therapeutic strategy for Boerhaave syndrome due to its rarity and changing therapeutic approaches. We conducted a systematic review of case reports documenting Boerhaave syndrome.

AIM

To assess the therapeutic methods and clinical outcomes and discuss the current trends in the management of Boerhaave syndrome.

METHODS

We searched PubMed, Google scholar, MEDLINE, and The Cochrane Library for studies concerning Boerhaave syndrome published between 2017 and 2022.

RESULTS

Of the included studies, 49 were case reports, including a total of 56 cases. The mean age was 55.8 ± 16 years old. Initial conservative treatment was performed in 25 cases, while operation was performed in 31 cases. The rate of conservative treatment was significantly higher than that of operation in cases of shock vital on admission (9.7% vs 44.0%; P = 0.005). Seventeen out of 25 conservative cases (68.0%) were initially treated endoscopic esophageal stenting; 2 of those 17 cases subsequently underwent operation due to poor infection control. Twelve cases developed postoperative leakage (38.7%), and 4 of those 12 cases underwent endoscopic esophageal stenting to stop the leakage. The length of the hospital stay was not significantly different between the conservative treatment and operation cases (operation vs conservation: 33.52 ± 22.69 vs 38.81 ± 35.28 days; P = 0.553).

CONCLUSION

In the treatment of Boerhaave syndrome, it is most important to diagnose the issue immediately. Primary repair with reinforcement is the gold-standard procedure. The indication of endoscopic esophageal stenting or endoluminal vacuum-assisted therapy should always be considered for patients in a poor general condition and who continue to have leakage after repair.

Successful Late Endoscopic Stent-Grafting in a Patient with Boerhaave Syndrome

Patient: Male, 53-year-old

Final Diagnosis: Spontaneous esophageal rupture

Symptoms: Chest pain • dyspena • hydropneumothorax • purulent discharge from the umbilicus • vomiting

Medication: —

Clinical Procedure: Endoscopic stent-grafting • enteral feeding • pleural drainage

Specialty: Gastroenterology and Hepatology • Surgery