Minimally invasive surgical management of Boerhaave's syndrome: a narrative literature review

Abstract

Treatment of Boerhaave's syndrome is controversial. Formal thoracotomy and laparotomy were considered the gold standard treatment in the past. However, these approaches are associated with significant surgical trauma, stress, and postoperative pain. Recently published studies reported the application of minimally invasive surgery in the setting of such esophageal emergency. However, the application of minimally invasive surgery in the setting of Boerhaave's syndrome is debated and evidence is puzzled. The aim of this study was to summarize the current knowledge on minimally invasive treatment of Boerhaave's syndrome. PubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of Boerhaave's syndrome in the setting of minimally invasive surgery (thoracoscopy or laparoscopy) were included. Sixteen studies and forty-eight patients were included. The age of the patient population ranged from 37 to 81 years old and 74% were males. The time shift period from symptoms onset to surgical treatment ranged from 5 to 240 hours with 10 patients (20.8%) having surgery more than 24 hours from symptoms onset. Vomiting (100%), chest/epigastric pain (88%), and dyspnea (62%) were the most commonly reported symptoms. The perforation size ranged from 6 to 30 mm with 96% of patients suffering from distal esophageal tear. Video-assisted thoracoscopy (VATS) was the most commonly reported surgical approach (75%), followed by laparoscopy (16.7%), and combined thoraco-laparoscopy (6.2%). In case of VATS, a left approach was adopted in 91% of patients with selective lung ventilation. Primary suture was the most commonly performed surgical procedure (60%) with interrupted single or dual-layer repair. Surgical debridement (25%), primary repair reinforced with gastric or omental patch (8%), esophageal repair over T-tube (6%), and endoscopic stenting combined with laparoscopic debridement (2%) were also reported. The postoperative morbidity was 64.5% with pneumonia (42%), pleural empyema (26%), and leak (19%) being the most commonly reported complications. The overall mortality was 8.3%. Boerhaave's syndrome is a rare entity. Minimally invasive surgical treatment seems promising, feasible, and safe in selected patients with early presentation and stable vital signs managed in referral centers. In the management algorithm of Boerhaave's syndrome, a definitive indication to adopt minimally invasive surgery is lacking and its potential role mandates further analysis.

Keywords: Boerhaave’s syndrome; esophageal perforation; laparoscopy; minimally invasive surgery; thoracoscopy.

Figure 1

The 15 mm distal esophageal perforation was laparoscopically sutured with absorbable interrupted stitches.