Our experience on management of Boerhaave's syndrome with late presentation

Mediastinal hematoma as an unusual intrathoracic manifestation of Boerhaave Syndrome: A case report

INTRODUCTION

Boerhaave Syndrome (BS) is rare but life-threatening condition caused by a sudden increase in the intraluminal pressure due to vomiting. We present a case of BS manifesting as a posterior mediastinal hematoma, indicative of a potentially fatal condition.

PRESENTATION OF CASE

A 51-year-old man presented with acute chest pain after vomiting. Enhanced Computed Tomography revealed mediastinal fluid with a left pleural effusion, leading to a diagnosis of BS. Emergency surgery revealed a posterior mediastinal hematoma with active bleeding due to a torn proper esophageal artery. Hemostasis and a wall repair were performed, and the patient was discharged uneventfully.

DISCUSSION

This case highlights two important aspects. Firstly, a spontaneous esophageal perforation can manifest as a mediastinal hematoma due to the subpleural arterial injury, delaying bacterial spillage. While preoperative thoracentesis may not always diagnose BS accurately, bloody thoracic drainage can serve as an alternative diagnostic sign. Secondly, the mediastinal hematoma itself poses a serious risk, as it can lead to a catastrophic outcome even before bacterial contamination occurs, emphasizing the necessity of a timely surgical intervention in BS cases.

CONCLUSION

BS can manifest as a mediastinal hematoma, and the absence of gastrointestinal content in the thoracic drainage does not rule out the possibility of BS. Prompt surgical intervention remains essential, as a mediastinal hematoma alone can result in a catastrophic outcome. This case highlights the significance of a comprehensive diagnostic assessment for BS.

[Endoscopic vacuum therapy in minimally invasive treatment of esophageal perforations]

OBJECTIVE

To compare the results of endoscopic vacuum therapy (EVT) and open surgery for esophageal perforations.

MATERIAL AND METHODS

The study included 60 patients with esophageal perforations between 2010 and 2022. The main group included 29 patients who underwent minimally invasive treatment with EVT, the control group - 31 patients after open surgical interventions.

RESULTS

Pneumonia occurred in 21 (72%) and 14 (45%) patients (p=0.04), esophageal stenosis within the perforation zone - in 4 (13.8%) and 1 (3.2%) patient, respectively (p=0.188). Chronic esophageal fistulas were significantly more common in the control group (6 (20.7%) versus 15 (48.4%) patients, p=0.032). The overall duration of treatment (median) among survivors was significantly shorter in the main group: 33 (23; 48) versus 71.5 (59; 93.7) days (p=0.5). However, length of ICU-stay was slightly higher (11 (6; 16) versus 8.5 (5; 12.75) days, p=0.32). Mortality rate was 13.8% (n=4) and 29% (n=9), respectively (p=0.213). Minimally invasive technologies decreased the risk of fatal outcome by 10 times (OR 10.123, 95% CI 1.491-124.97, p=0.035) compared to traditional surgery.

CONCLUSION

EVT in complex minimally invasive treatment of patients with mechanical esophageal injuries is an effective method significantly reducing mortality and duration of inpatient treatment compared to traditional surgical approach.

[Surgical treatment of spontaneous esophageal rupture: long-term experience of the Sklifosovsky Research Institute for Emergency Care]

OBJECTIVE

To analyze the treatment outcomes in patients with spontaneous esophageal rupture (SER).

MATERIAL AND METHODS

The study included 106 patients with SER admitted to the Sklifosovsky Research Institute for the period from 1992 to 2015. The sample also included 91 patients who were referred from other hospitals. All patients were divided into 4 groups depending on surgical procedure: surgical drainage (Group I, n=19); suturing the esophageal defect without antireflux surgery (Group II, n=12); esophageal wall repair with fundoplication procedure (Group III, n=62); resection of the thoracic esophagus (Group IV, n=13).

RESULTS

In the 1^st group, complication rate was 100% and significantly exceeded these values in groups II, III, and IV (66.7%, 71%, and 69.2%, respectively; p=0.0318, p=0.0189, and p=0.0413). The length of hospital-stay was the lowest in group IV (mean 42 days) and group I (mean 55 days). Mortality rate in groups I, III and IV was 15-20% lower than in group II. Pneumonia and pleural empyema were significant predictors of poor outcome. Fundoplication improved postoperative outcomes in group III compared to group II. Resection of the thoracic esophagus performed in accordance with strict indications interrupts infectious process and shortens recovery period. Surgical drainage is followed by persistent contamination of mediastinum and pleural cavities that may quickly result a fatal outcome.

CONCLUSION

A differentiated approach to SER treatment can reduce the risk of complications and mortality.

Boerhaave's syndrome with late presentation. Experience in an Argentine single center: Case series

Background

In the year 1724, Hermann Boerhaave reported a case of a Dutch admiral who died due to spontaneous rupture of the esophagus following vomiting. The aim of this retrospective study is to analyze the therapeutic modality, morbidity and mortaliy of a group of patients with spontaneous esophageal rupture treated in our hospital.

Methods

Ten patients were treated from March 1990 to August 2016. Seven patients were males and three were females. The age range was, 52-72 years, with an average of 66.2 years. In four patients, the diagnosis and posterior treatment were performed within 24 h (Group I) and the remaining six patients after 24 h (Group II).

Results

The mean hospital stay was 36.6 days (range 17-62 days). The mortality rate was 50%, which was due to septic shock and the morbidity of patients who survived was 40% due to pneumonia in one case and fistula in another.

Discussions

This condition has a high mortality rate with a lethality that depends on the time between recognition of symptoms and proper surgical treatment.

Boerhaave’s syndrome: case report and review

Well-timed diagnostics of a spontaneous nontraumatic rupture of esophagus or Boerhaave’s syndrome, presents great difficulties because of his rarity and a variety of clinical implications. Esophagus ruptures may feign various organs pathology [2] that most often demands differential diagnostics with a stomach ulcer perforation, acute myocardial infarction, pulmonary artery embolism, aortic dissection and pancreatitis [16, 17]. The treatment can include conservative and surgical tools, but still accompanied by high mortality (up to 35%) [7]; results largely defined by the time between the moment of a rupture and start of the treatment. In addition to the review, described the experience of successful treatment of a patient with Boerhaave’s syndrome in the light of the generalized today data of world medical literature on this problem.

Surgical management of early and late esophageal perforation

Introduction

Esophageal perforation is a rare and life-threating problem with a 10%–40% mortality rate. Early diagnosis and treatment are important for prevention of complications. Strategies for treatment of esophageal perforation have been controversial for many years, especially in cases of late presentation.

Methods

We prospectively studied 27 patients (12 male, 17 female, mean age 42.7 ± 17.8 years) who presented with esophageal perforation from 1996 to 2015, and evaluated the results of surgical treatment. The patients were divided into 3 groups according to time of presentation: early (<24 h), intermediate (24–72 h), and late (>72 h). We also considered the etiology and site of esophageal perforation, complications, and mortality.

Results

Surgery was performed in 5 patients in the early group, 7 in the moderate group, and 15 in the late group. Primary repair was carried out in 5 cases, primary repair and reinforcement with a flap in 10, esophageal resection and reconstruction in 8, and a T-tube stent was used in 4. Four patients developed a fistula postoperatively, and there was one death due to respiratory failure. No relationship was found between complications and the cause of perforation, time of presentation, or type of treatment.

Conclusion

In patients without sepsis, primary repair can be an option even in those presenting late after esophageal perforation, with an acceptable result.

Epidemiology, diagnosis, and management of esophageal perforations: systematic review

We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.

Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies

BACKGROUND

The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.

METHODS

We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.

RESULTS

Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.

CONCLUSIONS

Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Cytomorphology of Boerhaave's syndrome: A critical value in cytology

Spontaneous esophageal perforation into the pleural cavity (Boerhaave's syndrome) is a rare life-threatening condition, which requires early diagnosis and urgent management. The diagnosis of such critical condition in many cases is delayed because of atypical clinical presentation, resulting in increased morbidity and mortality. Cytological examination of pleural fluid can provide early, fast and accurate diagnosis of such critical condition and help in better and early management of this disease. We describe a case of an 81-year-old female with esophageal perforation who presented with a left sided pleural effusion. The correct diagnosis was established in this case by observing gastrointestinal-like fluid characteristics of the thoracic drainage upon cytological and chemical analyses and the rupture was confirmed by esophagography. The cytological examination of pleural fluid revealed benign reactive squamous cells, fungal organisms, bacterial colonies, and vegetable material consistent with a ruptured esophagus. Cytological examination of pleural fluid is a rapid and accurate technique that can help in establishing the diagnosis of this challenging entity and guide initiation proper management of this unusual entity.

Current treatment and outcome of esophageal perforations in adults: systematic review and meta-analysis of 75 studies

BACKGROUND

The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.

METHODS

We performed a systematic review of esophageal perforations published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.

RESULTS

Analysis of 75 studies resulted in a pooled mortality of 11.9 % [95 % confidence interval (CI) 9.7-14.3: 75 studies with 2,971 patients] with a mean hospital stay of 32.9 days (95 % CI 16.9-48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632-3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.

CONCLUSIONS

Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.

Surgical treatment of esophageal perforations: the importance of a primary repair

PURPOSE

The aim of the current study was to evaluate the outcome after primary repair in comparison to other surgical treatments and the advantage of reinforcing the sutures with an absorbable polyglactin 910 prosthesis.

METHODS

All esophageal perforations surgically managed in this institution from January 1985 through April 2009 (n = 40) were retrospectively analyzed. Patients that underwent surgery with primary sutures (group A, n = 24) were compared with patients that received other surgical procedures (group B, n = 16). The time to initiate treatment (within or after the first 24 h) and if the suture was reinforced with a polyglactin 910 mesh were also analyzed in group A patients.

RESULTS

The outcome was more favorable in group A than group B in terms of time in the intensive care unit (p = 0.005), and rate of reoperation (p = 0.005). There was no difference in the outcome after the primary suture with or without mesh reinforcement, although the rate of fistulization was lower in patients with a mesh (17 vs. 50 %, p = 0.19).

CONCLUSIONS

Primary repair has a better outcome than other surgical treatment, even when performed more than 24 h after symptom onset, but not later than 48 h. Reinforcing the sutures with an absorbable polyglactin 910 mesh therefore seems to improve the outcome.

A case of rapid diagnosis of Boerhaave syndrome by thoracic drainage

BACKGROUND

Boerhaave syndrome is a rare and often fatal syndrome. Delayed diagnosis and treatment is closely associated with prolonged morbidity and increased mortality. In general, esophagography is usually chosen as the diagnostic procedure, but it has a relatively high false-negative rate. There are no reports, to our knowledge, regarding the efficacy of thoracic drainage, although it is easier to perform and more immediate than esophagography in the emergency department.

OBJECTIVES

To report the efficacy of thoracic drainage for rapid diagnosis and treatment of Boerhaave syndrome.

CASE REPORT

An 80-year-old woman was admitted with vomiting and sudden onset of postprandial chest pain radiating to the back. Initially, myocardial infarction or aortic dissection was suspected, but was excluded by point-of-care tests and computed tomography (CT) scan, which revealed a left-sided pneumothorax, heterogeneous left pleural effusion, and pneumomediastinum at the lower level of the esophagus. Boerhaave syndrome was suspected and confirmed by thoracic drainage, which drained off bloody fluid and residual food such as broccoli. Emergency thoracotomy was performed within 4 h after onset of symptoms. The patient made an uneventful recovery.

CONCLUSION

Findings in this case indicate that chest pain, left-sided massive effusion on chest radiography, and left-sided massive heterogeneous effusion on CT scan are important for the diagnosis of Boerhaave syndrome. Subsequent thoracic drainage is useful for confirming Boerhaave syndrome, and such a strategy might lead to a good prognosis for patients with this rare but critical disease.

Aggressive surgical treatment in late-diagnosed esophageal perforation: a report of 11 cases

Introduction. Esophageal perforation is a relatively uncommon and lethal disease usually resulting from endoscopic procedures. Delay in the diagnosis and treatment occurs in more than 50% of cases, leading to a mortality rate of 40% to 60%, but this rate decreases is 10%–25% if treatment is carried out within 24 hours of perforation. Case Presentation. To analyze the characteristics, etiology, site of perforation, presentation, time interval till diagnosis, treatment and outcome of patients with esophageal perforation. Over a five-year period, from October 2004 through March 2009, 11 patients with esophageal perforation were referred to the division of thoracic surgery of a tertiary referral hospital. In eight patients, perforations were thoracic with delayed diagnosis for at least 48 hours. Two patients had cervical esophageal perforation, and one patient had early-diagnosed Boerhaave's syndrome. Eight patients are alive after followup for a period ranging from eight months to five years. In the remaining three patients, cancer was the underlying disease and the reason of death. Conclusion. No patient with esophageal perforation should be deprived from surgical repair due to delayed diagnosis. All, except preterminal patients, should undergo exploration after resuscitation, and appropriate treatment should be carried out depending on the findings during operation. Aggressive treatment is necessary in the case of established mediastinitis.

Esophageal perforations

The incidence of esophageal perforation (EP) has risen with the increasing use of endoscopic procedures, which are currently the most frequent causes of EP. Despite decades of clinical experience, innovations in surgical technique and advances in intensive care management, EP still represents a diagnostic and therapeutic challenge. EP is a devastating event and mortality hovers close to 20%. Ambiguous presentations leading to misdiagnosis and delayed treatment and the difficulties in management are responsible for the high morbidity and mortality rates. A high variety of treatment options are available ranging from observational medical therapy to radical esophagectomy. The potential role of interventional endoscopy and the use of stents for the treatment of EP seem interesting but remain to be evaluated. Surgical primary repair, with or without reinforcement, is the preferred approach in patients with EP. Prognosis is mainly determined by the cause, the location of the injury and the delay between perforation and initiation of therapy.