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.

Boerhaave's Syndrome: An Unusual Geriatric Presentation

Boerhaave's syndrome (BS) is a non-iatrogenic spontaneous esophageal perforation that, if not appropriately recognized and managed, can cause localized infections such as mediastinitis, pneumonia, and empyema, as well as systemic infections with significant morbidity and mortality rates. An autonomous 83-year-old male presented to the emergency department with a three-day history of behavioral changes. Three days earlier, the patient had a self-limited episode of cough, nonspecific thoracalgia, palpitations, prostration, and pallor. On physical examination, he was alert but had temporal disorientation, hypoxemia, and pulmonary auscultation with abolished breath sounds in the middle third of the left chest. Laboratory tests showed hypoxemia, elevated C-reactive protein (28.2 mg/dL), and D-dimer (3.28 µg/mL). A chest X-ray revealed periaortic small bubbles, left atelectasis, and left pleural effusion. Computed tomographic angiography of the chest showed infra-carinal esophageal rupture, small bubbles of the anterior pneumomediastinum, and a loculated left pleural empyema. Mediastinitis and empyema due to BS were assumed. He underwent left thoracic drainage, broad-spectrum antibiotics, and the placement of a surgical esophageal prosthesis. He was discharged after 48 days. The condition known as BS is frequently misdiagnosed, mostly as a result of the lack of a preexisting pathological background and the wide array of potential symptoms that may manifest. The diagnosis in this particular case was rendered particularly complex due to the combination of an unusual presentation and a delayed seeking of medical attention. Against all expectations, our patient was successfully treated.

A rare case of Boerhaave syndrome with cervico-thoracic esophageal junction rupture causing bilateral empyema; case report from Nepal

INTRODUCTION AND IMPORTANCE

Boerhaave syndrome is a rare finding where spontaneous rupture of esophagus occurs, usually in distal segment. It is a life threatening condition that requires urgent surgical intervention.

CASE PRESENTATION

We present a case of 70 years male who presented with pleural effusion and later empyema following spontaneous rupture of cervico-thoracic junction of esophagus who was managed successfully with primary surgical repair.

CLINICAL DISCUSSION

Although Boerhaave syndrome is tricky to diagnose but it should be considered in all cases with a combination of gastrointestinal and pulmonary signs and symptoms.

CONCLUSION

Clinical correlation along with imaging such as HRCT chest or gastrografin study is required to come to a diagnosis, however surgical intervention should not be delayed to reduce the mortality.

Single-centre review of the management of intra-thoracic oesophageal perforation in a tertiary oesophageal unit: paradigm shift, short- and long-term outcomes over 15 years

BACKGROUND

Oesophageal perforation is an uncommon surgical emergency associated with high morbidity and mortality. The timing and type of intervention is crucial and there has been a major paradigm shift towards minimal invasive management over the last 15 years. Herein, we review our management of spontaneous and iatrogenic oesophageal perforations and assess the short- and long-term outcomes.

METHODS

We performed a retrospective review of consecutive patients presenting with intra-thoracic oesophageal perforation between January 2004 and Dec 2020 in a single tertiary hospital.

RESULTS

Seventy-four patients were identified with oesophageal perforations: 58.1% were male; mean age of 68.28 ± 13.67 years. Aetiology was spontaneous in 42 (56.76%), iatrogenic in 29 (39.2%) and foreign body ingestion/related to trauma in 3 (4.1%). The diagnosis was delayed in 29 (39.2%) cases for longer than 24 h. There was change in the primary diagnostic modality over the period of this study with CT being used for diagnosis for 19 of 20 patients (95%). Initial management of the oesophageal perforation included a surgical intervention in 34 [45.9%; primary closure in 28 (37.8%), resection in 6 (8.1%)], endoscopic stenting in 18 (24.3%) and conservative management in 22 (29.7%) patients. On multivariate analysis, there was an effect of pathology (malignant vs. benign; p = 0.003) and surgical treatment as first line (p = 0.048) on 90-day mortality. However, at 1-year and overall follow-up, time to presentation (≤ 24 h vs. > 24 h) remained the only significant variable (p = 0.017 & p = 0.02, respectively).

CONCLUSION

Oesophageal perforation remains a condition with high mortality. The paradigm shift in our tertiary unit suggests the more liberal use of CT to establish an earlier diagnosis and a higher rate of oesophageal stenting as a primary management option for iatrogenic perforations. Time to diagnosis and management continues to be the most critical variable in the overall outcome.

Two-staged surgical management for complicated Boerhaave syndrome with esophagectomy and deferred gastroplasty: A case report

INTRODUCTION AND IMPORTANCE

Boerhaave syndrome is a rare, challenging entity with high morbimortality rates. Therefore, early diagnosis and prompt treatment are needed. However, a standardized technique has not been developed, especially in large esophageal ruptures.

PRESENTATION OF CASE

A female patient of 69 years with an acute thoracic syndrome consistent with severe retrosternal pain of sudden onset, radiating to the left hemithorax, vomiting, and dyspnea that began after food intake associated with subcutaneous emphysema, hypotension, and tachycardia. An A-CT was performed, revealing an esophageal perforation, and Boerhaave syndrome was diagnosed. The patient was taken to esophagectomy and gastroplasty. 2,5 years after the procedure, the patient was without long-term complications, and only dysphagia was present.

CLINICAL DISCUSSION

The differential diagnoses of acute thoracic syndromes are needed to be ruled out; however, it usually delays the diagnosis of Boerhaave syndrome. Therefore, early diagnosis (<24 h) may impact this patient's outcomes. On the other hand, esophagectomy can be feasible to control the acute condition and permit a digestive tract reconstruction.

CONCLUSION

In patients with large esophageal ruptures and concomitant septic shock, an esophagectomy is an option to control the source of infection and to permit early digestive tract reconstruction.

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 Syndrome: An Unexpected Complication of Diabetic Ketoacidosis

Boerhaave syndrome (BS) is a rare gastrointestinal condition related to esophageal rupture that carries a high mortality rate without prompt medical attention. BS is commonly associated with repeated episodes of severe retching, straining, or vomiting. Diabetic ketoacidosis (DKA), a serious acute complication of diabetes, is characterized in part by laboratory findings of profound hyperglycemia and ketoacidosis. Clinically, nausea and vomiting are seen commonly in DKA patients, which can often include repeated forceful retching, but rarely associated with esophageal rupture. In this article, we will describe a case of BS secondary to repeated episodes of emesis in the setting of DKA.

Boerhaave Syndrome: A Report of Two Cases and Literature Review

Boerhaave’s syndrome is a rare yet serious condition associated with high mortality and morbidity. Diagnosis of this syndrome is usually done with the aid of imaging and prompt management should be initiated to improve the outcomes. Treatment for this syndrome has been mainly surgical since its discovery by Herman Boerhaave; however, multiple endoscopic approaches have been successfully used recently with the advancement of this field. Here, we describe two cases of Boerhaave’s syndrome that were endoscopically managed along with a brief literature review of the different endoscopic methods used to manage this syndrome.

Outcomes after hybrid minimally invasive treatment of Boerhaave syndrome: a single-institution experience

BACKGROUND

Spontaneous esophageal perforation or Boerhaave syndrome is a life-threatening emergency, associated with significant morbidity and mortality. In this retrospective series we describe our single-center experience with a hybrid minimally invasive treatment approach for the treatment of Boerhaave syndrome.

METHODS

Clinical data of all patients who presented with spontaneous esophageal rupture between January 2009 and December 2019 were analyzed. All patients underwent esophageal endoscopic stenting to seal the perforation and debridement of the contaminated mediastinal and pleural cavity through video-assisted thoracoscopic surgery (VATS). Primary outcome measure was defined as in-hospital death and 30-day mortality.

RESULTS

Twelve patients were included with a median age of 63 years (interquartile range [IQR] 51-74 years) of whom 58% (n = 7) were male. The median Pittsburg perforation severity score was 6.5 (IQR 6-9). Endoscopic reintervention was required in 8 patients (67%), primarily due to stent dislocation. In addition, 5 patients (42%) required re-VATS due to empyema formation. Thirty-day mortality and in-hospital mortality were respectively 17% (n = 2) and 25% (n = 3).

CONCLUSION

Endoscopic stenting in combination with thoracoscopic debridement is an effective and safe minimally invasive hybrid approach for the treatment of Boerhaave syndrome. This is depicted by the relatively low mortality rates, even among patients with high perforation severity scores. The relatively low mortality rates may be attributed to the combined approach of rapidly sealing the defect and decontamination of the thorax. Future studies should aim to corroborate this evidence which is limited by its sample size and retrospective nature.

Transgastric Drainage for Esophageal Injuries: A Dynamic Strategy for a Heterogenous Patient Cohort

BACKGROUND

Esophageal injury is a rare but potentially lethal surgical emergency. It is associated with significant morbidity and mortality because of mediastinal contamination and difficulty of access. Surgery in such septic patients exacts a heavy physiological price, mandating consideration of more conservative measures. We review our experience with transgastric drainage for esophageal perforation and high-risk anastomotic dehiscence.

PATIENTS AND METHODS

A select cohort of patients presenting with esophageal perforation, or complex anastomotic leaks, over 10 years were considered for transgastric drainage (TGD). A modified 36F chest drainage tube was inserted by percutaneous endoscopic gastrostomy technique, either endoscopically or at open surgery, and a negative pressure (-10 cmH2O) was applied until the leak had sealed. Endpoints include, length of stay, restoration of gastrointestinal tract continuity and mortality.

RESULTS

Of 14 patients treated, 10 had perforations and 4 had complex anastomotic leaks. Ten patients had drainage alone, while 4 required concomitant operative intervention. The median duration of drain insertion for those treated with TGD alone was 19.5 days. Complete restoration of gastrointestinal tract continuity was achieved in all patients. There was no procedure-related morbidity or mortality.

CONCLUSION

These results show that TGD is a safe and effective management strategy. We advocate its use alone or as an adjunct to operative treatment for esophageal perforation or anastomotic leaks. This is the first report of completely endoscopic TGD for esophageal perforation.

Successful Late Endoscopic Stent-Grafting in a Patient with Boerhaave Syndrome

Patient: Male, 53-year-old

Final Diagnosis: Spontaneous esophageal rupture

Symptoms: Chest pain • dyspena • hydropneumothorax • purulent discharge from the umbilicus • vomiting

Medication: —

Clinical Procedure: Endoscopic stent-grafting • enteral feeding • pleural drainage

Specialty: Gastroenterology and Hepatology • Surgery

[Surgical treatment of spontaneous esophageal rupture: long-term experience of the Sklifosovsky Research Institute for Emergency Care]

OBJECTIVE

To analyze the treatment outcomes in patients with spontaneous esophageal rupture (SER).

MATERIAL AND METHODS

The study included 106 patients with SER admitted to the Sklifosovsky Research Institute for the period from 1992 to 2015. The sample also included 91 patients who were referred from other hospitals. All patients were divided into 4 groups depending on surgical procedure: surgical drainage (Group I, n=19); suturing the esophageal defect without antireflux surgery (Group II, n=12); esophageal wall repair with fundoplication procedure (Group III, n=62); resection of the thoracic esophagus (Group IV, n=13).

RESULTS

In the 1^st group, complication rate was 100% and significantly exceeded these values in groups II, III, and IV (66.7%, 71%, and 69.2%, respectively; p=0.0318, p=0.0189, and p=0.0413). The length of hospital-stay was the lowest in group IV (mean 42 days) and group I (mean 55 days). Mortality rate in groups I, III and IV was 15-20% lower than in group II. Pneumonia and pleural empyema were significant predictors of poor outcome. Fundoplication improved postoperative outcomes in group III compared to group II. Resection of the thoracic esophagus performed in accordance with strict indications interrupts infectious process and shortens recovery period. Surgical drainage is followed by persistent contamination of mediastinum and pleural cavities that may quickly result a fatal outcome.

CONCLUSION

A differentiated approach to SER treatment can reduce the risk of complications and mortality.

Circumferential esophageal perforation resulting in tension hydropneumothorax in a patient with septic shock

Esophageal perforations occur traumatically or spontaneously and are typically associated with high mortality rates. Early recognition and prompt management are essential. We present the case of a 76-year-old man who was admitted to the medical intensive care unit with fulminant Clostridium difficile colitis, shock, and multi-organ failure. After an initial period of improvement, his condition rapidly deteriorated despite aggressive medical management, and he required mechanical ventilation. Radiography after endotracheal intubation showed interval development of pneumomediastinum and bilateral hydropneumothorax with tension physiology. Chest tube placement resulted in the drainage of multiple liters of dark fluid, and pleural fluid analysis was notable for polymicrobial empyemas. Despite the unusual presentation, esophageal perforation was suspected. Endoscopy ultimately confirmed circumferential separation of the distal esophagus from the stomach, and bedside endoscopic stenting was performed with transient improvement. Two weeks after admission, he developed mediastinitis complicated by recurrent respiratory failure and passed away. This report further characterizes our patient’s unique presentation and briefly highlights the clinical manifestations, management options, and outcomes of esophageal perforations.

Contemporary management of traumatic cervical and thoracic esophageal perforation: The results of an Eastern Association for the Surgery of Trauma multi-institutional study

BACKGROUND

Traumatic esophageal perforation is rare and associated with significant morbidity and mortality. There is substantial variability in diagnosis and treatment. Esophageal stents have been increasingly used for nontraumatic perforation; however, stenting for traumatic perforation is not yet standard of care. The purpose of this study was to evaluate current management of traumatic esophageal perforation to assess the frequency of and complications associated with esophageal stenting.

METHODS

This was an Eastern Association for the Surgery of Trauma multi-institutional retrospective study from 2011 to 2016 of patients with traumatic cervical or thoracic esophageal injury admitted to one of 11 participating trauma centers. Data were collected and sent to a single institution where it was analyzed. Patient demographics, injury characteristics, initial management, complications, and patient mortality were collected. Primary outcome was mortality; secondary outcomes were initial treatment, esophageal leak, and associated complications.

RESULTS

Fifty-one patients were analyzed. Esophageal injuries were cervical in 69% and thoracic in 31%. Most patients were initially managed with operative primary repair (61%), followed by no intervention (19%), esophageal stenting (10%), and wide local drainage (10%). Compared with patients who underwent operative primary repair, patients managed with esophageal stenting had an increased rate of esophageal leak (22.6% vs. 80.0%, p = 0.02). Complication rates were higher in blunt compared with penetrating mechanisms (100% vs. 31.8%, p = 0.03) despite similar Injury Severity Score and neck/chest/abdomen Abbreviated Injury Scale. Overall mortality was 9.8% and did not vary based on location of injury, mechanism of injury, or initial management.

CONCLUSION

Most patients with traumatic esophageal injuries still undergo operative primary repair; this is associated with lower rates of postoperative leaks as compared with esophageal stenting. Patients who have traumatic esophageal injury may be best managed by direct repair and not esophageal stenting, although further study is needed.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Successful conservative treatment of spontaneous intrathoracic esophageal perforation using a temporary covered esophageal stent with a check valve: a case report

Background

Spontaneous esophageal perforation is a potentially life-threatening condition with high morbidity and mortality rates. While surgical treatment has been employed for esophageal perforation, we have adopted conservative treatment with an esophageal stent for patients in a poor physical condition because we consider controlling sepsis and improving the physical status are the highest priorities; additionally, the surgical trauma could be fatal for these patients.

Case presentation

A 60-year-old male complaining of left chest and back pain after vomiting was transferred to a local hospital. Computed tomography and chest X-ray examinations showed left tension pneumothorax, pneumomediastinum, and bilateral pleural effusion suspicious of spontaneous intrathoracic esophageal perforation. He was transferred to our hospital for further treatment. After arrival, he developed septic shock with acute respiratory failure. We considered that surgical treatment was too invasive and chose conservative treatment with an esophageal stent. Under general anesthesia, we first inserted a 20-Fr. trocar in the left posterior pleural space, and a large volume of the dark pleural effusion was discharged. We then performed endoscopy and found a pinhole perforation in the left posterolateral wall of the lower esophagus. We inserted both a silicon-covered esophageal stent with a check valve and a double elemental diet (W-ED) tube. We then inserted an 18-Fr. trocar into the left anterior wall. These procedures were performed less than 24 h after onset. As intensive medical care, the patient was administered broad-spectrum antibiotics and catecholamine. The two trocars and the W-ED tube were under continuous suction at − 5 cmH₂O and at − 20 cmH₂O every 30 s. On the 6th day, we inserted an additional thoracic drainage tube into the left pleura under CT guidance. The patient was discharged from the ICU to the general ward on the 7th day. We removed the stent almost triweekly, and the esophageal perforation was completely healed on the 45th day. He was discharged home on the 70th day.

Conclusion

Conservative treatment with a temporary self-expanding covered stent with a check valve, sufficient drainage, and W-ED tube nutrition was useful and effective in this unstable case of spontaneous intrathoracic esophageal perforation.

Laparoscopic transhiatal suture closure for spontaneous esophageal rupture: a case report

BACKGROUND

Spontaneous esophageal rupture is a rare but serious disease with high mortality. Conservative treatment and endoscopic therapy have been reported, but surgical treatment is still a basic modality of therapy. In addition to thoracotomy, recent studies have reported treatment with thoracoscopic surgery and laparoscopic transhiatal repair. In this study, we report a patient who underwent laparoscopic transhiatal suture closure for spontaneous esophageal rupture with favorable postoperative course. We also discuss indication for laparoscopic surgery for spontaneous esophageal rupture.

CASE PRESENTATION

A 70-year-old man visited our hospital with chief complaints of epigastric pain and vomitus niger. He was diagnosed with spontaneous esophageal rupture in the left wall of the lower esophagus by computed tomography and upper gastrointestinal (GI) series. At 11 h after the onset of symptoms, we performed laparoscopic transhiatal suture closure and lavage drainage. We performed transhiatal esophageal replacement using the 5-hole approach. We observed a perforation of 2 cm in diameter at the site of the rostral portion approximately 4 cm from the esophageal hiatus. All layers were closed with three stitches using 3-0 absorbable sutures. No perforation was observed in the thoracic cavity. The total operative time was 178 min, and total bleeding was 2 ml. He had no postoperative complications and was discharged on day 15 after the procedure. He received continuous proton pump inhibitor therapy as an outpatient. Healing cicatrization was found at the site of rupture by esophagogastroscopy. The patient was advised to improve his lifestyle and has shown no signs of recurrence over 2 years from the date of surgery.

CONCLUSIONS

Simple closure of all the layers using laparoscopic transhiatal simple closure was useful in the treatment of esophageal rupture as a less invasive approach for patients who meet the following conditions: stable general condition, intrathoracic perforation, and the perforation site is identified as the lower esophagus by pre-operative examination.

Iatrogenic esophageal perforation that could be treated indirectly by cervical esophagostomy and laparoscopic surgery

•

It is very rare case that each esophageal stump become connected and patent spontaneously.

•

Two-stage surgery is useful for esophageal perforation if radical operation is difficult.

•

Esophageal perforation can be resolved without direct closure if appropriate drainage is performed.

Introduction

Successful nonoperative management has been reported for esophageal perforation; however, some cases require surgery.

Case presentation

We presented the case of an 85-year-old woman with iatrogenic thoracic esophageal perforation in whom primary repair or resection of the perforated esophagus was difficult because she was elderly and had severe aortic valve stenosis. Therefore, we selected a two-stage surgery; laparoscopic gastrostomy, jejunostomy, posterior mediastinal drainage, and cervical esophagostomy were performed. We planned reconstruction after the perforation was closed, but endoscopic examination revealed spontaneous patency of each esophageal stump. Endoscopic balloon dilation was necessary because of esophageal stenosis; however, anastomotic surgery was unnecessary.

Conclusion

This case report suggests that esophageal perforation is resolved without direct closure if appropriate drainage is performed.

Minimally invasive surgical management of spontaneous esophageal perforation (Boerhaave's syndrome)

BACKGROUND

Spontaneous esophageal perforation (Boerhaave's syndrome) is a highly morbid condition traditionally associated with poor outcomes. The Pittsburgh perforation severity score (PSS) accurately predicts risk of morbidity, length of stay (LOS) and mortality. Operative management is indicated among patients with medium (3-5) or high (> 5) PSS; however, the role of minimally invasive surgery remains uncertain.

METHODS

Consecutive patients presenting with Boerhaave's syndrome with intermediate or high PSS managed via a thoracoscopic and laparoscopic approach from 2012 to 2018 were reviewed. Demographics, clinical presentation, management, and outcomes were analyzed.

RESULTS

Ten patients (80% male) with a mean age of 61.3 years (range 37-81) were included. Two patients had intermediate and eight had high PSS (7.9 ± 2.8, range 4-12). The mean time from onset of symptoms to diagnosis was 27 ± 12 h and APACHE II score was 13.6 ± 4.9. Thoracoscopic debridement and primary repair was performed in eight cases, with two perforations repaired primarily over a T-tube. Laparoscopic feeding jejunostomy was performed in all patients. Critical care LOS was 8.7 ± 6.8 days (range 3-26), while inpatient LOS was 23.1 ± 12.5 days (range 14-46). Mean comprehensive complications index was 42.1 ± 26.2, with grade IIIa and IV morbidity in 60% and 10%, respectively. One patient developed dehiscence at the primary repair, which was managed non-operatively. In-hospital and 90-day mortality was 10%.

CONCLUSION

Minimally invasive surgical management of spontaneous esophageal perforation with medium to high perforation severity scores is feasible and safe, with outcomes which compare favorably to the published literature.

Multimodal Treatment Strategies for Esophageal Perforation

PURPOSE

Esophageal perforation constitutes a potentially life-threatening condition, and this study aimed to evaluate the indications and outcome for the different treatment modalities.

PATIENTS AND METHODS

In total, 43 patients with esophageal perforation were considered for this retrospective analysis. Age, sex, length of hospital stay and intensive care treatment, in-hospital mortality, localization of perforation and etiology, treatment modality, and 90-day morbidity were analyzed.

RESULTS

Most patients suffered from Boerhaave syndrome and from iatrogenic esophageal perforation. In total, 63% of patients (26/41) received successful nonoperative treatment, whereas 36% required additional surgery. Two patients (5%) underwent primary surgery. In all cases no esophagectomy was necessary. In-hospital mortality was 7%. During the 90-day follow-up 1 patient with stenosis required repetitive dilatations.

CONCLUSIONS

Initial endoscopic treatment, either by stent or by endosponge, alone or combined with an additional operative treatment, seems feasible in patients suffering from esophageal perforation. In all patients, there was no need for esophagectomy.

Boerhaave syndrome in an elderly man successfully treated with 3-month indwelling esophageal stent

Boerhaave syndrome refers to a spontaneous perforation of the esophagus that results from severe straining or vomiting. This uncommon situation may lead to serious outcome with chemical mediastinitis, and is associated with high morbidity and mortality. Surgery, although associated with high morbidity and mortality remains the treatment of choice, whereas endoscopic management with stent placement is preserved to treat inoperable patients. Removal of the stent is generally recommended after 4-6 weeks. We report a case of an elderly patient who presented with a large complicated Boerhaave's mid-esophageal perforation, with a complete recovery after a 3-month treatment with a long esophageal stent.

Outcome after stenting and débridement for spontaneous esophageal rupture

OBJECTIVES

Surgical repair has been the most common treatment of esophageal effort rupture (Boerhaave syndrome). Stent-induced sealing of the perforation has increasingly been used with promising results. We present our eight years´ experience with stent-based and organ-preserving treatment.

MATERIALS AND METHODS

Medical records of 15 consecutive patients with Boerhaave syndrome from February 2007 to May 2015 were retrospectively registered in a database. Treatment was sealing of the perforation by stenting, chest tube drainage and débridement of the contaminated thorax. After median 25 months nine out of 10 patients responded to questions on fatigue and Ogilvie's dysphagia score.

RESULTS

Fifteen patients, aged median 67.5 years (range 39-88), had a primary hospital stay of 20 days (range 1-80 days). Overall in-hospital mortality was 13%. Observation time was 44 months (range 0-87) and 10 patients were alive of August 2017. Ten patients (67%) needed surgical chest débridement. Five patients (33%) were restented for leakage, migration and for stent removal. Eleven patients (73%) had complications, which included pleural empyema (n = 4), fatal aortic bleeding, lung arterial bleeding, lung embolism, drain-induced lung laceration and respiratory failure. Dysphagia score was low (median 0.5) meaning that they were able to feed themselves. Total fatigue score (mean 14.6) was slightly increased (p = .05) compared with a reference population.

CONCLUSIONS

The mortality rate after initial stenting of effort rupture seems to be comparable to standard surgical repair. Most patients required further intervention, either by restenting and/or surgical débridement. The functional result in these patients was satisfactory.

Endoscopic Treatment of Boerhaave Syndrome Using Polyglycolic Acid Sheets and Fibrin Glue: A Report of Two Cases

Boerhaave syndrome, the spontaneous perforation of the esophagus, is an emergency, life-threatening condition. Current endoscopic treatment options include clipping and stenting, but the use of polyglycolic acid (PGA) sheets for treating the condition has not been reported. In recent years, PGA sheets have been used after endoscopic submucosal dissection to prevent perforations and stricture formation in patients treated for early-stage carcinoma. We report the cases of two patients with Boerhaave syndrome who were successfully treated using PGA sheets. The present clinical outcomes suggest that the use of PGA sheets is feasible and safe for treating patients with Boerhaave syndrome, and that they may be another treatment option.

Thoracoscopic primary repair with mediastinal drainage is a viable option for patients with Boerhaave's syndrome

Background

Spontaneous esophageal rupture (Boerhaave's syndrome) is an emergency that can cause life-threatening conditions. Various procedures have been used to treat Boerhaave's syndrome. However, a standard surgical procedure has not been established. Herein, we report our experience with primary suture of the ruptured esophagus via a thoracoscopy or laparotomy.

Methods

Between November 2002 and May 2015, 11 patients with Boerhaave's syndrome presented to our department and were managed using one of two surgical procedures based on the surgeon's discretion. Six patients underwent a thoracoscopic primary suture and drainage (group A); 5 patients underwent a primary suture via laparotomy followed by thoracoscopic drainage (group B). Patient medical records were retrospectively reviewed.

Results

The mean interval between initial perforation and surgery was 13.7 h (group A) and 17.2 h (group B) (P=0.7307). The mean operative time was 190 min (group A) and 249 min (group B) (P=0.106). Patient baseline characteristics and surgical outcomes were similar for both surgical procedures. One patient in each group experienced postoperative leakage that did not require surgical intervention.

Conclusions

The results suggest that thoracoscopic esophageal repair, as well as suturing via laparotomy, is a good surgical alternative for patients with Boerhaave's syndrome.

Non-surgical management of Boerhaave's syndrome: a case series study and review of the literature

BACKGROUND AND STUDY AIMS

 Boerhaave's syndrome (BS) is a life-threatening condition with morbidity and mortality rates as high as 50 % in some reports. Until recently, surgical intervention has been the mainstay of management plans. With advances in therapeutic endoscopy, however, there has been increasing interest in non-surgical options including endoscopic esophageal stenting.

PATIENTS AND METHODS

 We reviewed the medical records of all patients diagnosed with BS and managed with endoscopic interventions between November 2011 and November 2016. The following variables were collected: patient demographics, clinical presentations, locations of esophageal perforation, primary interventions, complications, and outcomes.

RESULTS

 Six patients were found to be diagnosed with BS during the study period. The median age at presentation was 55. There were 4 males and 2 females. The most common site of perforation was in the distal esophagus. The most common presenting symptom was chest pain (67 %) following an episode of vomiting or retching. Four patients (66.7 %) developed septic shock. Endoscopic treatment with a fully covered esophageal stent was the primary intervention in all patients (100 %). Interventional radiology was consulted in all cases for fluid drainage and chest tube placements. Clinical resolution of the BS was achieved in all patients (100 %) without any subsequent surgical interventions. There were no deaths within the study group, and the average follow-up duration was 2 years.

CONCLUSION

 Endoscopic treatment seems to be an effective management strategy in patients with BS. We also noted satisfactory results in patients presenting with sepsis, presumably due to urgent, interventional radiology-guided fluid drainage.

Outcomes following the main treatment options in patients with a leaking esophagus: a systematic literature review

Leakage from the esophagus and gastroesophageal junction can be lethal due to uncontrolled contamination of the mediastinum. The most predominant risk factors for the subsequent clinical outcome are the patients' delay as well as the delay of diagnosis. Two major therapeutic concepts have been advocated: either prompt closure of the leakage by insertion of a self-expandable metal stent (SEMS) or more traditionally, surgical exploration. The objective of this review is to carefully scrutinize the recent literature and assess the outcomes of these two therapeutic alternatives in the management of iatrogenic perforation-spontaneous esophageal rupture as separated from those with anastomotic leak. A systematic web-based search using PubMed and the Cochrane Library was performed, reviewing literature published between January 2005 and December 2015. Eligible studies included all studies that presented data on the outcome of SEMS or surgical exploration in case of esophageal leak (including >3 patients). Only patients older than 15 years of age by the time of admission were included. Articles in other languages but English were excluded. Treatment failure was defined as a need for change in therapeutic strategy due to uncontrolled sepsis and mediastinitis, which usually meant rescue esophagectomy with end esophagostomy, death occurring as a consequence of the leakage or development of an esophagorespiratory fistula and/or other serious life threatening complications. Accordingly, the corresponding success rate is composed of cases where none of the failures above occurred. Regarding SEMS treatment, 201 articles were found, of which 48 were deemed relevant and of these, 17 articles were further analyzed. As for surgical management, 785 articles were retrieved, of which 82 were considered relevant, and 17 were included in the final analysis. It was not possible to specifically extract detailed clinical outcomes in sufficient numbers, when we tried to separately analyze the data in relation to the cause of the leakage: i.e. iatrogenic perforation-spontaneous esophageal rupture and anastomotic leak. As for SEMS treatment, originally 154 reports focused on iatrogenic perforation, 116 focused on spontaneous ruptures, and only four described the outcome following trauma and foreign body management. Only five studies used a prospective protocol to assess treatment efficacy. Regarding a leaking anastomosis, 80 reports contained information about the outcome after treatment of esophagogastrostomies and 35 reported the clinical course after an esophagojejunostomy. An overall success rate of 88% was reported among the 371 SEMS-treated patients, where adequate data were available, with a reported in hospital mortality amounting to 7.5%. Regarding the surgical exploration strategy, the vast majority of patients had an attempt to repair the defect by direct or enforced suturing. This surgical approach also included procedures such as patching with pleura or with a diaphragmatic flap. The overall reported success rate was 83% (305/368) and the in-hospital mortality was 17% (61/368). The current literature suggests that a SEMS-based therapy can be successfully applied as an alternative therapeutic strategy in esophageal perforation rupture.

Treatment of spontaneous esophageal rupture with transnasal thoracic drainage and temporary esophageal stent and jejunal feeding tube placement

BACKGROUND

Spontaneous rupture of the esophagus is a rare but life-threatening thoracic emergency, with high rates of clinical misdiagnosis and mortality. This article summarizes our experience in the treatment of spontaneous esophageal rupture with transnasal thoracic drainage and temporary esophageal stent and jejunal feeding tube placement.

METHODS

We retrospectively assessed the medical records of 19 patients with spontaneous esophageal rupture treated using our intervention protocol. Patients received local anesthesia and sedation prior to undergoing transnasal drainage catheter placement into the thoracic abscess cavity, followed by temporary esophageal stent and jejunal feeding tube placement. After the operation, abscess lavage, nutritional support, and anti-inflammatory treatment were given. The transnasal thoracic drainage catheter, esophageal stent, and feeding tube were removed after the healing of the abscess cavity.

RESULTS

In all, 19 covered esophageal stents were placed in 19 patients with spontaneous esophageal rupture. All operations were technically successful. After an average of 84.06 days, the stents were successfully removed from 17 patients. No cases of massive hemorrhage, esophageal rupture, or other complications occurred during stent removal. An 82-year-old patient died of heart failure 2 months after the operation. One patient died of sudden massive hematemesis and hematochezia 55 days after the operation. In one patient, the esophageal injury failed to heal completely.

CONCLUSION

Our treatment protocol is simple, minimally invasive, and efficacious and may be an alternative for patients who are not candidates for surgery, have a high risk of postoperative complications, or wish to undergo minimally invasive surgery.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Successful primary repair of late diagnosed spontaneous esophageal rupture: A case report

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Diagnosis of spontaneous rupture of the esophagus is often delayed.

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Significant contamination of the mediastinum and pleural space is not uncommon.

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Debridement and drainage of the mediastinum and pleural space are necessary to control sepsis.

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Debridement of necrotic tissue is necessary.

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Primary repair in layers of the esophagus is possible in majority of the cases regardless of the time lapsed from rupture.

Introduction

Spontaneous esophageal rupture is rare, roughly 300 cases reported annually. Diagnosis is often delayed or missed. Overall mortality is about 20%. This feared high mortality rate has led to the misconception that primary esophageal repair should be avoided in late diagnosed patients. We report a successful primary repair of spontaneous esophageal rupture which was delayed for more than two weeks.

Methods

A 53 year-old male presented to our medical service after falsely having been treated for pneumonia at an outside hospital. He was subsequently diagnosed with spontaneous esophageal rupture and treated with over the scope clips followed by stenting. Persistent leak into mediastinum made surgical exploration necessary. At exploration a primary repair could be performed successfully.

Results

Unsuccessful endoscopic management of esophageal perforation that was delayed for two weeks underwent primary surgical repair without complications.

Conclusion

Primary closure of late diagnosed spontaneous esophageal rupture can be successful, even when it is complicated by a prolonged delay in treatment and failed endoscopic procedures. We conclude that primary surgical repair should be attempted in patients with spontaneous esophageal rupture if tissues are viable.

Management and outcome of esophageal stenting for spontaneous esophageal perforations

Treatment of spontaneous esophageal perforation (SEP) consists of different conservative, surgical and endoscopic treatment modalities. In this study, we evaluated the clinical efficacy and the outcome of covered self-expanding stent (CSES) treatment of SEP. All patients with SEP treated by CSES at our institution between 2005 and 2014 were included in this prospective single-center study. The data were collected from a prospective database based on clinical, endoscopic and operative reports. Follow-up data were procured by contacting the patients or their family doctors. The patient data were analyzed concerning course of treatment, leakage sealing rate, complications, and mortality. Patients with iatrogenic or malignant perforations were excluded. In total, 16 patients underwent endoscopic CSES placement for SEP between 2005 and 2014. Sealing of the leakage was immediately successful in 50% (8 patients). A second stent was placed in 5 patients, but did not achieve sealing of the perforation in any case, requiring a switch in treatment to a surgical procedure (n=4) or drainage of the persisting leakage (n=4). In-hospital mortality was 13%. Only delayed treatment was identified as a risk factor for inferior outcome. Patients with successful CSES treatment had a shorter ICU- and hospital stay and had a reduced risk of developing esophageal stenosis (RR: 0.4) or persisting dysphagia despite treatment (RR: 0.33). Endoscopic treatment of SEP is beneficial to the patient if immediately successful, but in our experience, failure rates are higher than described in the literature. Secondary placement of CSES was not successful when initial stent treatment failed, while both surgical intervention and drainage of the perforation showed good results in sealing the leakage.

Boerhaave syndrome - case report

CONTEXT:

Boerhaave syndrome consists of spontaneous longitudinal transmural rupture of the esophagus, usually in its distal part. It generally develops during or after persistent vomiting as a consequence of a sudden increase in intraluminal pressure in the esophagus. It is extremely rare in clinical practice. In 50% of the cases, it is manifested by Mackler's triad: vomiting, lower thoracic pain and subcutaneous emphysema. Hematemesis is an uncommon yet challenging presentation of Boerhaave's syndrome. Compared with ruptures of other parts of the digestive tract, spontaneous rupture is characterized by a higher mortality rate.

CASE REPORT:

This paper presents a 64-year-old female patient whose vomit was black four days before examination and became bloody on the day of the examination. Her symptoms included epigastric pain and suffocation. Physical examination showed hypotension, tachycardia, dyspnea and a swollen and painful abdomen. Auscultation showed lateral crackling sounds on inspiration. Ultrasound examination showed a distended stomach filled with fluid. Over 1000 ml of fresh blood was extracted by means of nasogastric suction. Esophagogastroduodenoscopy was discontinued immediately upon entering the proximal esophagus, where a large amount of fresh blood was observed. The patient was sent for emergency abdominal surgery, during which she died. An autopsy established a diagnosis of Boerhaave syndrome and ulceration in the duodenal bulb.

CONCLUSION:

Boerhaave syndrome should be considered in all cases with a combination of gastrointestinal symptoms (especially epigastric pain and vomiting) and pulmonary signs and symptoms (especially suffocation).

Open surgery versus stent placement in failed primary surgical treatment of esophageal perforation - a single institutional experience

BACKGROUND

Surgical treatment is an accepted method to manage esophageal perforation, but in many cases it may result in failure. This paper compares the efficacy of surgical treatment and stenting in patients after previous surgical intervention for esophageal perforation.

METHODS

A single-institution retrospective study was performed in a group of patients treated for esophageal perforation admitted to our centre from 2010 to 2015. Seventy eight patients (76.5%) with esophageal perforation received surgical treatment. In this group of patients, the mean time between perforation and treatment was 80.6 h (24-240 h). Spontaneous and iatrogenic perforation was observed in 33 (42.3%) and 45 (57.7%) patients, respectively. Partial esophageal resection was performed in 11 cases (14.1%). The perforation site was sutured in the remaining 67 patients (85.9%). Surgical treatment failed in 29 cases (37.2%).

RESULTS

In patients with failed previous surgical treatment, revision surgery was performed in 14 patients (48.3%) (group A), and a large-diameter self-expandable stent was implanted in 15 cases (51.7%) (group B). Perforation in the thoracic and distal esophagus was observed in 5 (35.7%) and 9 (64.3%) patients from group A, and in 7 (46.7%) and 8 (53.3%) patients from group B, respectively. The mean intubation time in both groups was 30.3 and 12.5 days (p < 0.001), respectively. The mean daily drainage within five days after the intervention was 350 mL in group A, and 500 mL in group B (p < 0.02). In both groups hospitalisation time was 41.5 and 19.4 days, respectively (p < 0.001). Six patients died (42.8%) following revision surgery, and 2 (13.3%) patients died after stent implantation (p < 0.001).

CONCLUSIONS

Intubation time, hospitalization, and the rate of fatal complications in patients who underwent stent implantations were significantly lower compared to reoperated patients; however, the rate of prolonged drainage was lower in patients who underwent revision surgery. In conclusion, stent implantation is a significantly superior method to treat persistent leakage following failure of previous surgical treatment.

Management of esophageal perforation in the endoscopic era: Is operative repair still relevant?

BACKGROUND

With the introduction of new treatment paradigms for esophageal perforation, the management of this highly morbid condition is evolving. We reviewed our experience to investigate the modern management and outcomes of esophageal perforations with a focus on operatively repaired patients.

METHODS

A retrospective review of all esophageal perforations was conducted between August 2003 and January 2016.

RESULTS

A total of 48 patients were identified, with iatrogenic injury in 19 (40%), spontaneous perforation in 18 (38%), and traumatic/foreign body causes in 11 (23%). The distal esophagus was the site of perforation in 63% of the patients, and the duration of time between perforation and treatment was <24 hours in 60%. Nonoperative management was employed in 18 (38%) and operative repair in 30 (primary operative repair = 20, drainage = 4, esophagectomy = 6). Iatrogenic and traumatic perforations were more likely to be treated nonoperatively (68%), while all spontaneous perforations were treated by operative intervention. There were no complications or mortalities in the nonoperative group and only a 5% reintervention rate. In the operative group, complications occurred in 10 (33%), reinterventions in 13 (43%), and mortality in 2 (7%) patients.

CONCLUSION

Our study highlights the importance of considering the etiology of a perforation when planning management and the success of nonoperative treatment with careful patient selection. In addition, operative repair in septic patients yielded excellent outcomes and should be the standard for comparison in future studies exploring endoscopic approaches.

Removable self-expanding metal stents insertion for the treatment of perforations and postoperative leaks of the esophagus

BACKGROUND

Esophageal rupture, spontaneous or iatrogenic, is associated with significant morbidity and mortality. The current study aims at highlighting the various clinical scenarios, where esophageal fully covered self-expanding removable metal stents (FCSEMS) can be used in esophageal rupture.

METHODS

In patients who underwent insertion of FCSEMS between January 2013 and June 2014, all data regarding demographics, indications, insertion, removal, and outcomes were studied retrospectively.

RESULTS

Seven patients underwent the placement of esophageal covered SEMS. Two patients had Boerhaave syndrome, two had leak following the repair of aortic aneurysm, one had extensive esophageal injury following transesophageal echocardiography, one had carcinoma esophagus with tracheaesophageal fistula, and one had dehiscence of esophagogastric anastomosis. Stent insertion was successful in all the patients; one had stent migration which was managed endoscopically. Two patients died due to underlying illness; the rest had successful removal of stents after 8-10 weeks and good outcomes.

CONCLUSION

Esophageal FCSEMS placement is safe and effective modality in management of patients with esophageal rupture.

An Unusual Case of Spontaneous Esophageal Rupture after Swallowing a Boneless Chicken Nugget

A 25-year-old previously healthy man presented to our Emergency Department with shortness of breath and epigastric pain after swallowing a boneless chicken nugget one hour prior to presentation. Physical examination revealed epigastric rigidity and tenderness. Serology was normal except for mildly elevated bilirubin and amylase. Computed tomography (CT) scan of the chest revealed a distal esophageal rupture with accompanying pneumomediastinum and left-sided pleural effusion. Treatment was initiated with administration of intravenous fluids and broad-spectrum antibiotics. Subsequently, an esophageal stent was inserted endoscopically in addition to VATS (Video-Assisted Thoracoscopic Surgery) drainage of the left-sided pleural space. This case illustrates an unusual presentation of Boerhaave's syndrome: a rare and life-threatening form of noniatrogenic esophageal rupture most often preceded by forceful vomiting. Our case demonstrates that physicians should maintain an index of suspicion for spontaneous esophageal rupture in patients presenting with shortness of breath and epigastric pain even in the absence of preceding vomiting, cough, or seizure. Additionally, ingestion of boneless, shell-less foods may be sufficient to cause rupture in individuals without underlying esophageal pathology. CT scan of the thorax and upper abdomen should be performed in these patients to rule out this rare and life-threatening diagnosis.

Surgical Endoscopic Vacuum Therapy for Defects of the Upper Gastrointestinal Tract

INTRODUCTION

Intraluminal therapy used in the gastrointestinal (GI) tract was first shown for anastomotic leaks after rectal resection. Since a few years vacuum sponge therapy is increasingly being recognized as a new promising method for repairing upper GI defects of different etiology. The principles of vacuum-assisted closure (VAC) therapy remain the same no matter of localization: Continuous or intermittent suction and drainage decrease bacterial contamination, secretion, and local edema. At the same time, perfusion and granulation is promoted. However, data for endoscopic vacuum therapy (EVT) of the upper intestinal tract are still scarce and consist of only a few case reports and small series with low number of patients.

OBJECTIVES

Here, we present a single center experience of EVT for substantial wall defects in the upper GI tract.

METHODS

Retrospective single-center analysis of EVT for various defects of the upper GI tract over a time period of 4 years (2011-2015) with a mean follow-up of 17 (2-45) months was used. If necessary, initial endoscopic sponge placement was performed in combination with open surgical revision.

RESULTS

In total, 126 polyurethane sponges were placed in upper gastrointestinal defects of 21 patients with a median age of 72 years (range, 49-80). Most frequent indication for EVT was anastomotic leakage after esophageal or gastric resection (n = 11) and iatrogenic esophageal perforation (n = 8). The median number of sponge insertions was five (range, 1-14) with a mean changing interval of 3 days (range, 2-4). Median time of therapy was 15 days (range, 3-46). EVT in combination with surgery took place in nine of 21 patients (43 %). A successful vacuum therapy for upper intestinal defects with local control of the septic focus was achieved in 19 of 21 patients (90.5 %).

CONCLUSION

EVT is a promising approach for postoperative, iatrogenic, or spontaneous lesions of the upper GI tract. In this series, EVT was combined with operative revision in a relevant proportion of patients.

Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system

OBJECTIVE

The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population.

METHODS

In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups.

RESULTS

Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS.

CONCLUSIONS

The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.

Acute oesophageal symptoms

Acute oesophageal symptoms include acute dysphagia or food bolus impaction (most commonly due to strictures, Schatzki ring and eosinophilic oesophagitis), acute chest pain with odynophagia due to oesophageal infections, motility disorders and acute oesophageal rupture (of which oesophageal intramural haematoma is a subtype). Acute full thickness oesophageal rupture carries a high mortality if not recognised early; the clinical features and conditions with which this may be confused are presented and discussed.

Successful primary staple-repair of thoracic oesophagus after delayed presentation of a spontaneous perforation

INTRODUCTION

Spontaneous perforation of the oesophagus is diagnosed late in over 50% of cases. Misdiagnosis may be due to atypical presentations. Primary repair is technically demanding in this setting and the risk of failure is high.

PRESENTATION OF CASE

An 85 year-old lady presented with an atypical cohort of mild nonspecific symptoms in spite of a pleuro-mediastinal purulent collection secondary to an undiagnosed spontaneous perforation of the oesophagus occurred seven days before. Despite the extent of perforation (3cm in length), the late diagnosis and the necrosis of the muscular wall, the oesophagus was successfully repaired by means of a stapler.

DISCUSSION

The mechanism of the atypical presentation is discussed and possible modalities of treatment of delayed oesophageal perforations are reviewed, with particular reference to primary repair and to the possible use of staplers within this setting.

CONCLUSION

Even large spontaneous perforations of the oesophagus can result in a contained abscess, with no frank sepsis. Diagnosis can be missed for days in these cases. The attempt at primary repair of the oesophagus is still indicated. The use of a stapler is preferable in such cases as a perfect mucosal approximation is provided with minimal manipulation and with the use of inert, well tolerated material, which does not tend to become infected.

Endoscopic management of Boerhaave's syndrome presenting with hematemesis

Hematemesis is an uncommon yet challenging presentation of Boerhaave's syndrome. Here, we present minimally invasive management of an esophageal perforation with hematemesis using esophageal stenting in an elderly male with multiple comorbidities.

Hamman and Boerhaave syndromes - diagnostic dilemmas in a patient presenting with hyperemesis gravidarum: a case report

INTRODUCTION

Hyperemesis gravidarum describes persistent vomiting leading to fluid and electrolyte imbalance. It is the commonest reason for admission in the first half of pregnancy. We describe a case of Hamman syndrome secondary to hyperemesis gravidarum. We also discuss Boerhaave syndrome: a particularly rare condition with only a handful of cases being described in the literature.

CASE PRESENTATION

A 17 year old admitted with hyperemesis gravidarum was diagnosed with Hamman syndrome after complaining of chest pain due to the presence of subcutaneous emphysema and pneumomediastinum on chest radiograph. She was treated conservatively for potential ruptured oesophagus but then self-discharged against medical advice.

CONCLUSION

Subcutaneous emphysema is an alarming finding in any pregnancy and should be treated in a timely and cautious manner. This case report adds weight to the previous literature advocating a conservative versus surgical approach to the management of a woman with Hamman syndrome secondary to hyperemesis gravidarum.

A rare case of oesophageal rupture: Boerhaave's syndrome

A 70-year-old patient was referred to our emergency department with severe retrosternal pain after forceful vomiting. Computed tomography (CT) scan revealed a left-sided oesophageal rupture with accompanying pneumomediastinum and bilateral pleural effusions. Conservative treatment with cessation of oral intake, intravenous broad-spectrum antibiotics, parenteral fluids and nutrition and left sided tube thoracostomy was initiated initially. After 5 days, however, the patient deteriorated. Follow-up CT scan demonstrated a mediastinal fluid collection as well as loculated pleural empyema. Open thoracotomy with mediastinal debridement and pleural drainage was performed, after which he made a slow but full recovery. Spontaneous oesophageal rupture due to an abrupt rise in intraluminal pressure caused by vomiting is also known as Boerhaave's syndrome. It is a rare but potentially life-threatening condition. Many patients present with atypical symptoms, and therefore, physicians should have a high index of suspicion in any patient presenting with vomiting and retrosternal pain. When Boerhaave's syndrome is suspected, a CT scan of the thorax and upper abdomen should be performed since treatment depends on clinical and radiological findings. Conservative management (cessation of oral intake, nasogastric decompression, administration of intravenous fluids and parenteral nutrition, intravenous broad-spectrum antibiotics and proton pump inhibitors and tube thoracostomies) may only be considered in patients with a contained rupture without systematic symptoms of infection. In these patients, endoscopic bridging of the tear with a self-expandable stent is also an option. Primary surgical repair (either by thoracotomy or by video assisted thoracoscopy (VATS)) should be considered when patients present with sepsis and/or large non-contained leaks or with severe mediastinal decontamination.

Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes

BACKGROUND

Factors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known.

OBJECTIVES

To evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure.

DESIGN

Retrospective.

SETTING

Academic tertiary referral center.

PATIENTS

All patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012.

INTERVENTION

Esophageal stent placement and removal.

MAIN OUTCOME MEASUREMENTS

Factors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure).

RESULTS

Sixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (<3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002).

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

Temporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.

Combined Placement of Covered Self-Expanding Metallic Stents and Nasojejunal Tube for Managing Large Lower Esophageal Perforations

Covered self-expanding metallic stents (cSEMSs) have emerged as effective treatment option for esophageal perforations. However, the large lower esophageal perforations where the cSEMS is placed across gastroesophageal junction have lower healing rates because refluxed gastric contents constantly irritate perforation and also there is increased risk of stent migration. Moreover, gastric mucosa tends to prolapse into lumen of lower end of stent causing its obstruction, leading to seepage of saliva and fluids from upper end of stent even in the patients who are on parenteral nutrition. We present our experience of a novel technique of combined cSEMS and nasojejunal tube (NJT) placement in four patients (two males) with benign large lower esophageal perforations. The NJT was placed through the stent into the jejunum through which patients were given enteral feeding. The stents were placed 5 - 21 days after esophageal perforation with the size of perforation ranging from 4 to 6 cm. As the NJT formed a loop in stomach, it prevented migration of stent. And also its presence in lumen of stent prevented its obstruction by prolapsing gastric mucosa, thereby preventing seepage of saliva and fluids from side of stent. Both stents and NJT were removed after 6 weeks and leak closed in all patients. Combined cSEMS and NJT placement seems to be safe and effective for treating large lower esophageal perforations. NJT placement seems to decrease risk of migration, prevents seepage of fluids and permits early enteral nutrition, thereby improving the healing rates.