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

Abstract

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.

Keywords: Boerhaave syndrome; esophageal perforation; esophageal rupture; esophagectomy.

Figure 1:

flowchart showing the number of patients treated for esophageal perforation between 2008 and 2019

Figure 2:

A) 81 year old patient referred with persistent leak from right ICD; B,C) picture shows right transhiatal esophagectomy specimen with hemoclip and OVESCO clip (arrow) retrieved from the esophageal rent; D) transhiatal esophagectomy specimen with the OVESCO clip and the hemoclips

Figure 3:

A) CT chest showing left pleural effusion (white arrow) post esophageal rupture; B) chest x-ray showing endoscopically placed SEMS in situ; C) post stent removal, CT thorax showed a 3mm esophagopleural fistula from the distal esophagus to the left pleural cavity; D) post repeat stenting and stent removal, CT thorax showed tracheoesophageal fistula (arrow) and no leak from the distal esophageal perforation

Figure 4:

A) CT thorax showing the mucocele of the remnant esophagus (arrow); B) intraoperative picture showing giant mucocoele of the remnant esophagus looped (arrow) by a right thoracotomy incision; C) drainage of the mucocele with a suction catheter (arrow) followed by remnant esophagectomy after decompression