Surgical management of Boerhaave's syndrome with early and delayed diagnosis in adults: a retrospective study of 88 patients

Clinical efficacy of different therapeutic strategies in patients with spontaneous rupture of the esophagus: a multicenter retrospective cohort study

BACKGROUND

The therapeutic strategy for patients with spontaneous rupture of the esophagus includes surgical repair, endoscopic therapy, supportive care, and others. However, no evidence exists to direct clinical decision-making regarding the choice of operative and nonoperative management. The aim of this study was to determine the clinical efficacy of different therapeutic strategies in both general and stratified patients.

METHODS

This study retrospectively analyzed a consecutive cohort of 101 patients at nine tertiary referral hospital centers in China. Patients were divided into operative and nonoperative groups based on the initial treatment. Short-term outcomes, including 90-day mortality, length of hospital stay, and postoperative leakage were compared. Subgroup analysis was performed based on treatment timing and Pittsburgh perforation severity score (PSS).

RESULTS

Of 101 patients, 60 (58.4%) underwent operative management. A significant difference of 90-day mortality between operative and nonoperative groups was observed (15.0% vs. 34.1%, P=0.031). Operative management tend to yield similar therapeutic benefits in timely (OR, 0.250; 95% CI, 0.05-1.14, P=0.073) and delayed (OR, 0.42; 95% CI, 0.12-1.47, P=0.175) treatment groups. Based on PSS stratification, operative management significantly decreased the risk of 90-day mortality (OR, 0.211; 95% CI, 0.064-0.701; P=0.011) for patients in low- and moderate-risk groups but may be detrimental for patients in high-risk group (OR, 1.333; 95% CI, 0.233-7.626; P=0.746).

CONCLUSIONS

Operative management might be superior to nonoperative management for low- and moderate-risk patients with spontaneous rupture of the esophagus. However, for patients at high risks, operative management might not provide additional benefits compared with nonoperative management. Further research involving larger sample sizes is required for accurate patient stratification and conclusive evidence-based guideline.

The perilous consequences of bowel preparation: a case study with literature review of Boerhaave syndrome

Colonoscopy is widely acknowledged as a prevalent and efficacious approach for the diagnosis and treatment of gastrointestinal disorders. In order to guarantee an effective colonoscopy, it is imperative for patients to undergo an optimal bowel preparation regimen. This entails the consumption of a substantial volume of a non-absorbable solution to comprehensively purge the colon of any fecal residue. Nevertheless, it is noteworthy to acknowledge that the bowel preparation procedure may occasionally elicit adverse symptoms such as nausea and vomiting. In exceptional instances, the occurrence of excessive vomiting may lead to the rupture of the distal esophagus, a grave medical condition referred to as Boerhaave syndrome (BS). Timely identification and efficient intervention are imperative for the management of this infrequent yet potentially perilous ailment. This investigation presents a case study of a patient who developed BS subsequent to the ingestion of mannitol during bowel preparation. Furthermore, an exhaustive examination of extant case reports and pertinent literature on esophageal perforation linked to colonoscopy has been conducted. This analysis provides valuable insights into the prevention, reduction, and treatment of such serious complications.

Laparoscopic Repair of Spontaneous Esophageal Perforation After Multiple Endoscopic Failures

Spontaneous esophageal perforation (SEP) (Boerhaave syndrome) carries high morbidity and mortality. Delay in diagnosis, because of the non-specific complaints and the rarity of the condition, further increases the mortality. While patients diagnosed early can be managed by primary closure of esophageal perforation, those presenting beyond 24 hours often require an esophagectomy with salivary diversion and feeding access with a plan for the reconstruction of the alimentary tract at a later date. In a minority of patients with a controlled esophageal fistula and feeding access, source control could be achieved by endotherapy. Patients with mediastinitis and associated systemic sepsis would be better served by surgical intervention. We present a case of an SEP with a delayed diagnosis, who underwent three unsuccessful endotherapy attempts and decortication before referral for surgical repair. The patient had an established esophageal fistula. He underwent a laparoscopic repair of the fistula. Postoperative recovery was uneventful. At the one-year follow-up, the patient was asymptomatic and had gained weight. Though surgery is the treatment of choice, the optimal management of SEP with delayed diagnosis is not clearly defined. In the current era of advanced endotherapy, more cases are being managed endoscopically. However, they carry a high failure rate, resulting in increased morbidity among the patients. Early involvement of a surgical team in the decision-making is crucial for optimal outcomes of the disease.

Boerhaave's syndrome with rupture of the right wall of the esophagus after oral administration of sulfate solution

A 63-year-old male took magnesium sulfate for bowel cleansing and subsequently developed severe nausea and vomiting. He then suffered from acute epigastric pain and compression pain in the right chest, with dyspnea, chest tightness and palpitation. Physical examination revealed subcutaneous emphysema in the neck, with crepitus and diminished breathing sounds on the right side of the chest. A thoracic computed tomography (CT) scan showed mediastinal emphysema, right-sided pleural effusion and pneumothorax.