Surgical management of Boerhaave's syndrome in a tertiary oesophagogastric centre

Mackler's Triad: An Evolving Case of Boerhaave Syndrome in the Emergency Department

An elderly lady, known with a background history of Alzheimer's dementia, gastro-oesophageal reflux disease and a reported history of self-induced vomiting, presented to our emergency department with a two-day history of vomiting, diarrhoea, anorexia, and malaise. Initial clinical examination and investigations only demonstrated mild dehydration. Despite a satisfactory response to initial symptomatic treatment, with complete cessation of vomiting, the patient had a recent sudden deterioration. Due to continued forcible belching, it was found that she had developed a sudden onset of back pain and subcutaneous emphysema. A CT scan showed mid-oesophageal rupture along with pneumomediastinum and bilateral pneumothoraxes. The patient was subsequently diagnosed with Boerhaave syndrome. Due to her clinical factors and the risk of surgical management, it was decided that she should be managed non-operatively with oesophageal stenting and bilateral chest drains, which was met with a good clinical course and outcome.

Transhiatal esophagectomy in Boerhaave syndrome - Case report and literature review

INTRODUCTION

Boerhaave syndrome or spontaneous rupture of the esophagus wall is a rare life-threatening condition. It is more common in male gender and is due to a very swift rise in intraluminal pressure during vomiting. The patient usually presents with chest pain after vomiting. In some cases, there is subcutaneous emphysema in the neck or upper chest. Due to its rarity, the diagnosis is often not straightforward. Chest radiography can reveal pneumothorax, pleural effusion or pneumomediastinum, but diagnosis is more likely possible with an oral contrast X-ray study.

CASE PRESENTATION

This paper reports a clinical case with surgical approach, in a 68-years old patient with a 48 h period between onset of symptoms and diagnosis of a Boerhaave syndrome. Firstly, the patient was admitted with a presumptive diagnosis of pneumonia. The patient was with chest pain, fever and vomiting. An emergent transhiatal esophagectomy was performed with primary anastomosis with no significant post-operative morbidity and allowing for the patient to return to previous daily routine with a good quality of life.

DISCUSSION AND CONCLUSION

Boerhaave syndrome is a rare life-threatening surgical condition. Surgery is the most effective treatment. It is necessary to have a high index of suspicion. Treatment should promptly start because prognosis is related with time from diagnosis, with increasing mortality rate if no treatment is performed.

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

BACKGROUND

Boerhaave syndrome is a rare and life-threatening condition characterized by a spontaneous transmural tear of the oesophagus. There remains wide variation in the condition's management with non-operative management (NOM) and surgery being the two main treatment strategies. The aim was to review the presentation, management and outcomes for patients treated for Boerhaave syndrome at our institution and to compare these data with that previously reported within the Australasian literature.

METHODS

A retrospective case series was performed for consecutive patients diagnosed with Boerhaave syndrome at our institution between January 2000 and January 2020. A systematic review of the Australasian literature was also performed.

RESULTS

In case series, 15 patients were included (n = 2 NOM, n = 13 operative). The most common operative technique was primary repair with intercostal drainage via thoracotomy. Major complications occurred in 11 (73%) patients. Median Comprehensive Complication Index was 53.4 (interquartile range: 50). There was a significantly lower Comprehensive Complication Index associated with primary repair when compared to oesophageal resection (P = 0.01). There was one death, in the operative management group. Median length of hospital stay was 33 days (interquartile range: 58). In systematic review, 11 articles were included; four case series and seven case reports. From these, 23 patients met inclusion criteria. The majority of patients (83%) were managed operatively, with only four undergoing NOM. Seven patients died, representing an overall mortality rate of 30%.

CONCLUSIONS

We provide an updated overview of the management of Boerhaave syndrome within Australasia. Aggressive operative management is associated with reasonable outcomes.

An Overview of Gastroduodenal Perforation

Gastroduodenal perforation may be spontaneous or traumatic and the majority of spontaneous perforation is due to peptic ulcer disease. Improved medical management of peptic ulceration has reduced the incidence of perforation, but still remains a common cause of peritonitis. The classic sub-diaphragmatic air on chest x-ray may be absent and computed tomography scan is a more sensitive investigation in the stable patient. The management of perforated peptic ulcer disease is still a subject of debate. The majority of perforated peptic ulcers are caused by Helicobacter pylori, so definitive surgery is not usually required. Perforated peptic ulcer is an indication for operation in nearly all cases except when the patient is asymptomatic or unfit for surgery. However, non-operative management has a significant incidence of intra-abdominal abscesses and sepsis. Primary closure is achievable in traumatic perforation, but the management follows the Advanced Trauma Life Support (ATLS) principles.

Challenges faced in the management of complicated Boerhaave syndrome: a tertiary care center experience

Spontaneous esophageal perforation is rare and is associated with high morbidity and mortality. A spectrum of various surgical modalities ranging from primary surgical repair to esophagectomy is available for its management. The optimal management of patients presenting late in a hemodynamically stable condition is not clearly defined in the literature. A retrospective review of all patients with Boerhaave syndrome managed by a single surgical team in a tertiary care center between 2008 and 2019 was performed (n = 16). Eleven patients were initially managed in the medical intensive care unit (MICU) as non-esophageal cause and 5 patients were referred after failed management (conservative/endoscopic). Demographics, clinical presentation, characteristics of perforation, initial diagnosis, and treatment were analyzed. All patients were males with a mean age of 42.2 years. A history of ethanol use was present in 6 patients. The median delay in diagnosis and referral was 16 days (range: 11-40 days). The common presenting symptoms were chest pain (n=11), dyspnoea (n=10), vomiting (n=4) and cough (n=2). The perforation was directed into right, left, and bilateral pleural cavities in 6, 8, and 2 patients respectively. The location of perforation was distal esophagus except for one patient. One patient was successfully treated with conservative management. The remaining patients underwent esophagectomy as a definitive surgical procedure. There was no significant postoperative morbidity and mortality. Esophagectomy can be done as a one-stage definitive procedure for patients with Boerhaave syndrome who present late in a hemodynamically stable condition with acceptable morbidity and good long term outcome.

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.

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.

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.

Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option?

A best evidence topic was written according to a structured protocol. The question addressed was, 'Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option?' Seven papers were identified that provided the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. A total of 147 patients from the studies had oesophageal perforation, while 86 had oesophagectomies for delayed oesophageal perforation (DOP; defined as a perforation diagnosed after 24 h) and 57 had conservative procedures. The mortality rate ranged from 0 to 18% for patients with oesophagectomies, increasing to 50% with double exclusion and reaching as high as 68% in primary repair. In one report, it was found that conservative procedures inflicted higher morbidity than oesophagectomy, which eliminated the perforation, the source of sepsis and the underlying oesophageal disease; another study came to the same conclusion. One study concurred that oesophageal perforation was a surgical disease and only a few cases qualified for conservative procedures. In a review of 34 patients who had DOP, 19 were treated with conservative procedures and 15 oesophagectomy; the mortality rate for patients treated by conservative procedures was 68%, whereas it was 13.3% for patients treated by oesophagectomy. In another study, among the patients treated with conservative procedures, at least one required an additional operation and about 33.3% of patients who survived had continued difficulty with swallowing. In four of the studies, the authors observed that oesophagectomy for DOP was a better surgical option, which decreased mortality, and one study compared the treatment outcome between conservative procedures and oesophagectomy. The primary end-point in all the studies was elimination of the source of sepsis by extirpating the perforated oesophagus in comparison with conservative procedures. However, the consensus of opinion in all the presented evidence was in support of the theory that oesophagectomy was safer and better than conservative procedures. In conclusion, oesophagectomy for DOP was superior to conservative procedures. The limitation of the present review was the lack of many randomized controlled trials.

Advances in the management of esophageal perforation

Therapy for acute esophageal perforation in the last decade has benefited from newer technology in endoscopy and imaging. Success with nonoperative therapies such as endoluminal stenting and clipping has improved outcomes and shortened length of stay in selected patients. Iatrogenic injury currently comprises most acute esophageal perforation, and nonoperative therapy may be appropriate in a significant percentage of patients. The decision regarding operative vs non-operative therapy is best done by a dedicated surgical team with experience in all the surgical and endoscopic treatment options. Boerhaave syndrome occurs less often and may be treated with endoscopic therapy, although it more likely requires operative intervention. This article reviews current advances in the diagnosis and management of acute esophageal perforation.