Combined surgical and endoscopic management after delayed diagnosis of Boerhaave’s syndrome

A. Miftaroski, A. Stanescu, A. Meyer, F. Pugin, B. Egger

Objective

Boerhaave’s syndrome or spontaneous esophageal rupture is a rare but potentially lethal disease. The transmural perforation is mostly provoked by violent vomiting with high intraesophageal pressure. The disease is associated with a high mortality (20% to 50%) especially when there is a treatment delay lasting longer than 24 hours.

Methods

We are presenting the case of a 56 years old male patient admitted in a peripheric hospital after an episode of violent vomiting followed by chest pain and dyspnea. Chest x-ray performed in the ER was not suspicious. Upon clinical deterioration a CT scan was performed the next morning with the finding of a distal esophageal rupture and left pleura effusion. After immediate thoracic drainage the patient was then transferred to our hospital 19 hours after the initial event. Emergency laparotomy with anterior phrenotomy, primary esophageal repair, Dor’s fundoplication and intraesophageal stenting by endoscopy was performed. Furthermore a lavage of the left thoracic cavitiy was done through the pleura tear in the mediastinum. The post-operative period was then marked by the suspicion of pleural empyema on day 3 p.i. (post intervention) with placement of two CT-guided drainages. Afterwards an uneventful follow-up with oral re-feeding on day 5 p.i was performed. The esophageal stent was evacuated on day 14 p.i. and the patient discharged home the day after. The first pleural drain was removed in the outpatient clinics on day 20 and the second on day 33 p.i.

Results

There is no consensus in the literature concerning the optimal treatment of esophageal leaks. However, Boerhaave’s syndrome has to be distinguished from little iatrogenic lesions, which may be successfully treated conservatively (endoscopically). The 3-4 cm big Boerhaave’s tear typically occurs in the left posterolateral aspect of the distal esophagus and is often accompanied by a synchronous rupture of the left pleura with the additional risk of pleural empyema. In our opinion there is no place for a conservative treatment in such situations and surgical exploration with repair and drainage is mandatory.

Conclusion

According to the literature delayed surgical treatment lasting longer than 24h increases mortality up to 50%. In such cases a combined endoscopic (stent) and surgical approach may save lives and therefore be the treatment of choice.