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

Treatment of Boerhaave syndrome: experience from a tertiary center

BACKGROUND

Boerhaave syndrome is a rare, life-threatening condition, characterized by spontaneous esophageal rupture. This study aims to share our 13-year experience in managing Boerhaave syndrome.

METHODS

A retrospective, observational study was conducted of consecutive patients with Boerhaave syndrome who presented at our tertiary referral center, between 2011 and 2023. Patients were categorized by time to diagnosis, to assess the impact of diagnostic delay.

RESULTS

Among 21 patients, 13 (62%) were diagnosed early (< 24 h) and 8 (38%) late (> 24 h). In the early-diagnosed group (n = 13), 6 patients (46%) received primary intervention with stent placement in combination with surgical drainage (5 with mediastinal and pleural drainage and 1 with only pleural drainage), while 5 patients (38%) were initially treated with only a stent. One patient (8%) underwent surgical pleural drainage alone and one (8%) underwent an esophagectomy. Among the 8 late-diagnosed patients, 4 (50%) were primarily treated with both stent placement and surgical drainage (2 with mediastinal drainage, 1 with pleural drainage and 1 with both), 3 (38%) with only stent placement, and one (13%) was managed conservatively. Additional interventions were required in 14 patients (67%). Additional surgical drainage was performed in 5 of 8 patients who had initially been treated with stent only (63%) and in 2 of 10 patients who had initially received both stent and surgical drainage (20%). Stent complications occurred in 7 patients (37%), including leakage (16%), migration (16%), and bleeding (5%). The median hospital stay was 32 days (IQR 15-37) and the overall 90-day mortality was 14%. Mortality was significantly higher in late-diagnosed patients (n = 3, 38%) compared to those early diagnosed (n = 0, 0%) (p = 0.042), with all 3 deceased patients either refusing or being unfit for treatment.

CONCLUSION

Based on this study, we recommend prioritizing closure of the defect combined with drainage, while considering individual patient factors, including advanced age.

Small bowel obstruction due to migrated oesophageal metal stent

INTRODUCTION AND IMPORTANCE

Endoscopic oesophageal stents have numerous applications, including palliative management for unresectable oesophageal cancer, treatment of benign strictures and blocking early oesophageal perforations. However a significant limitation of fully covered self-expandable metallic stents (FC-SEMs) is their risk of migration. While oesophageal stenting is generally safe, it carries risks of mainly minor complications and a few major complications like tracheoesophageal fistulae, intestinal perforation, and, very rarely, intestinal obstruction due to stent migration. We hereby describe an instance of the last complication.

CASE PRESENTATION

A 48-year-old male with chronic kidney disease and hypertension presented with Boerhaave's syndrome which was successfully managed with FC-SEMs placement. He was lost to follow-up, but returned 8 months later presented with features of intestinal obstruction. Imaging revealed migrated FC-SEMs in the mid-jejunum with features of small bowel obstruction. After conservative management failed, he underwent exploratory laparotomy and stent retrieval. He had an uneventful post-operative recovery.

CLINICAL DISCUSSION

Boerhaave syndrome, a rare spontaneous oesophageal perforation, has seen evolving management strategies, from surgical repair to minimally invasive endoscopic interventions like self-expandable metallic stents (SEMs). While SEMs effectively manage perforations, migration remains a major complication, influenced by stent type and placement location. In this case, a migrated stent caused small bowel obstruction, necessitating surgical retrieval. This highlights the need for careful stent selection, close follow-up, and individualized management to prevent severe complications.

CONCLUSION

Migrating, covered SEMs, placed for oesophageal perforation, may cause intestinal obstruction necessitating surgical retrieval.

A Case of a Successfully Treated Patient With a Delayed Diagnosis of Boerhaave's Syndrome and Severe Complications

Boerhaave's syndrome is a rare critical condition manifesting as transmural esophageal rupture. It is usually associated with forceful emesis and increased intraesophageal pressure. Immediate aggressive surgical intervention is imperative in such cases. We present a patient with a late diagnosis of Boerhaave's syndrome who was successfully treated in our department. We performed a subtotal esophageal resection, esophagostomy, gastrostomy, pyloroplasty by Heineke-Mikulicz, debridement, bilateral early decortication of the lung, and cleaning of the pleural cavities and mediastinum.

Robotic surgery in the management of synchronous esophageal and gastric perforation after endoscopic dilation

Upper gastrointestinal perforation is a feared complication of diagnostic and therapeutic endoscopy, with an incidence of perforation between 0.3% and 5%. Even though is rare, the mortality rate can be as high as 40%. Currently, there is no consensus on the best therapeutic strategy and it usually depends on patient stability, the extent of perforation, time to diagnosis, surgeon experience and available resourcesWe present a case of a patient who presented to our institution to undergo an ambulatory oesophageal dilation. After dilation, the patient developed two full-thickness gastric perforations and a full-thickness oesophageal perforation without haemodynamic instability. All perforations were diagnosed and treated with a combination of intraoperative endoscopy and robotic surgery with excellent outcomes.We demonstrate that a robotic approach combined with intraoperative diagnostic endoscopy is a safe and feasible treatment option for esophageal and gastric perforations in a stable patient without large extraluminal contamination.

[Endoscopic vacuum therapy in minimally invasive treatment of esophageal perforations]

OBJECTIVE

To compare the results of endoscopic vacuum therapy (EVT) and open surgery for esophageal perforations.

MATERIAL AND METHODS

The study included 60 patients with esophageal perforations between 2010 and 2022. The main group included 29 patients who underwent minimally invasive treatment with EVT, the control group - 31 patients after open surgical interventions.

RESULTS

Pneumonia occurred in 21 (72%) and 14 (45%) patients (p=0.04), esophageal stenosis within the perforation zone - in 4 (13.8%) and 1 (3.2%) patient, respectively (p=0.188). Chronic esophageal fistulas were significantly more common in the control group (6 (20.7%) versus 15 (48.4%) patients, p=0.032). The overall duration of treatment (median) among survivors was significantly shorter in the main group: 33 (23; 48) versus 71.5 (59; 93.7) days (p=0.5). However, length of ICU-stay was slightly higher (11 (6; 16) versus 8.5 (5; 12.75) days, p=0.32). Mortality rate was 13.8% (n=4) and 29% (n=9), respectively (p=0.213). Minimally invasive technologies decreased the risk of fatal outcome by 10 times (OR 10.123, 95% CI 1.491-124.97, p=0.035) compared to traditional surgery.

CONCLUSION

EVT in complex minimally invasive treatment of patients with mechanical esophageal injuries is an effective method significantly reducing mortality and duration of inpatient treatment compared to traditional surgical approach.

Mackler's Triad: An Evolving Case of Boerhaave Syndrome in the Emergency Department

An elderly lady, known with a background history of Alzheimer's dementia, gastro-oesophageal reflux disease and a reported history of self-induced vomiting, presented to our emergency department with a two-day history of vomiting, diarrhoea, anorexia, and malaise. Initial clinical examination and investigations only demonstrated mild dehydration. Despite a satisfactory response to initial symptomatic treatment, with complete cessation of vomiting, the patient had a recent sudden deterioration. Due to continued forcible belching, it was found that she had developed a sudden onset of back pain and subcutaneous emphysema. A CT scan showed mid-oesophageal rupture along with pneumomediastinum and bilateral pneumothoraxes. The patient was subsequently diagnosed with Boerhaave syndrome. Due to her clinical factors and the risk of surgical management, it was decided that she should be managed non-operatively with oesophageal stenting and bilateral chest drains, which was met with a good clinical course and outcome.

Esophageal emergencies

The esophagus is a deeply located organ which traverses the neck, the thorax, and the abdomen and is surrounded at each level by vital organs. Because of its positioning injuries to the esophagus are rare. Their common denominator is the risk of the organ perforation leading to spillage of digestive contents in surrounding spaces, severe sepsis and eventually death. Most frequent esophageal emergencies are related to the ingestion of foreign bodies or caustic agents, to iatrogenic or spontaneous esophageal perforation and external esophageal trauma. Early diagnosis and appropriate management are the keys of successful outcomes.

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.

Subtotal esophagectomy followed by subtotal gastric reconstruction for Boerhaave's syndrome: Case report with literature review

INTRODUCTION

Boerhaave's syndrome, or spontaneous esophageal rupture, is a potentially fatal disease requiring prompt diagnosis and effective treatment. We report Boerhaave's syndrome in a patient who underwent subtotal esophagectomy and temporary cervical esophagostomy for esophageal perforation to the right thoracic cavity, followed by subtotal gastric reconstruction as the second step.

PRESENTATION OF CASE

A 70-year-old man with diarrhea and vomiting as chief complaints had underlying disease of reflux esophagitis. He experienced frequent hematemesis. Computed tomography (CT) at another hospital revealed right pleural effusion and abnormal mediastinal air and fluid retention around the esophagus, and he was transferred to our hospital. From the CT findings, he was diagnosed as having Boerhaave's syndrome with esophageal perforation into the right thoracic cavity. He was in shock, and emergency right thoracotomy was performed, revealing a severely purulent thoracic cavity, ruptured parietal pleura, and 5-cm perforation in the right front middle esophageal wall that was surrounded by mucosal necrosis. Subtotal esophagectomy, temporal cervical esophagostomy, and enteral feeding tube insertion were performed. After hospital discharge, he underwent subtotal gastric reconstruction 43 days postoperatively. His course was good, and he was transferred to another hospital for rehabilitation 36 days after reconstruction.

DISCUSSION

In Boerhaave's syndrome, depending on the size of the perforation and fragility of the esophageal wall, subtotal esophagectomy may be feasible.

CONCLUSION

Two-step reconstruction following esophageal rupture is possible after sufficient local infection control, and anastomosis can be performed if the patient's general condition is good, but only under conditions that guarantee no anastomotic leakage.

Current status of surgical treatment of Boerhaave's syndrome

BACKGROUND

Surgical treatment is usually required for Boerhaave's syndrome (post-emetic esophageal perforation), and the technique should be chosen based on the local infection status and patient's general condition. This study was performed to examine the current status of surgical treatment of Boerhaave's syndrome in Japan.

METHODS

Ninety-five patients with Boerhaave's syndrome who underwent surgical treatment from January 2010 to December 2015, obtained from a national survey were retrospectively analyzed. The details of each surgical treatment and the type of treatment performed according to the patients' characteristics were examined.

RESULTS

Primary closure was performed in 75 (78.9%) patients, T-tube insertion in 15 (15.8%), and esophagectomy in 5 (5.3%). The length of the postoperative stay was significantly shorter in patients who underwent primary closure (p = 0.0011). Esophagectomy tended to be performed more often in patients with a long perforation and was performed significantly more often in patients with a high C-reactive protein concentration (p = 0.0118). The postoperative hospital stay was significantly longer in patients with leakage of the primary closure site (p < 0.0001). As a result, leakage of the primary closure site was significantly correlated with a long duration from symptom onset to patient presentation (p = 0.042), diagnostic imaging of the intrathoracic perforation (p = 0.013), and abscess formation in the mediastinal cavity (p = 0.006).

CONCLUSIONS

Selection of an appropriate surgical procedure may contribute to reduced mortality rates in patients with esophageal rupture. With regard to primary closure, it is necessary to understand that leaks are likely to occur in patients with a long duration from symptom onset to presentation or with severe intrathoracic/mediastinal inflammation, and to select an appropriate surgical procedure in consideration of the degree of invasiveness and QOL.

Cognitive Aids for the Management of Thoracic Anesthesia Emergencies: Consensus Guidelines on Behalf of a Canadian Thoracic Taskforce

A cognitive aid is a tool used to help people accurately and efficiently perform actions. Similarly themed cognitive aids may be collated into a manual to provide relevant information for a specific context (eg, operating room emergencies). Expert content and design are paramount to facilitate the utility of a cognitive aid, especially during a crisis when accessible memory may be limited and distractions may impair task completion. A cognitive aid does not represent a rigid approach to problem-solving or a replacement for decision-making. Successful cognitive aid implementation requires dedicated training, access, and culture integration. Here the authors present a set of evidence-based cognitive aids for thoracic anesthesia emergencies developed by a Canadian thoracic taskforce.

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