Alternative management of delayed spontaneous oesophageal perforation by endoscopic stenting

Boerhaave’s syndrome or spontaneous perforation of the oesophagus is a life-threatening condition that carries high mortality. Delayed diagnosis has a mortality rate of 20%–50%. While surgical intervention has been the mainstay of treatment, advancements in endoscopy and oesophageal stenting have allowed for alternative management. Our case involves a 33-year-old man with self-induced emesis and DKA. After 10 days in the ICU, he developed a large right pleural effusion, which was treated with chest tube placement. Upper GI study confirmed delayed Boerhaave’s syndrome. A self-expanding stent was inserted followed by percutaneous endoscopic gastrostomy (PEG) for decompression and jejunal extension for nutrition. He developed empyema and underwent right thoracotomy for washout and lung decortication. Stent was exchanged once due to recurrent leak following migration and removed after 40 days. Endoscopic stent placement with PEG with jejunal extension followed by thoracotomy is a viable alternative to primary repair of delayed oesophageal perforation.

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AB006. 74. Thoracoscopic debridement and primary repair of spontaneous oesophageal perforation (Boerhaave’s syndrome)

Mesentery and Peritoneum ◽

10.21037/map.2018.ab006 ◽

2018 ◽

Vol 2 ◽

pp. AB006-AB006

Author(s):

Jessie A. Elliott ◽

Louise Buckley ◽

Thomas J. Murphy

Keyword(s):

Primary Repair ◽

Oesophageal Perforation ◽

Boerhaave’S Syndrome ◽

Boerhaave's Syndrome

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EP.WE.1015Management of Boerhaave Syndrome

British Journal of Surgery ◽

10.1093/bjs/znab308.108 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Charlotte Florance ◽

Katie Jones ◽

Krishna Singh

Keyword(s):

Early Recognition ◽

Primary Repair ◽

Relevant Literature ◽

Anterior Wall ◽

Oesophageal Perforation ◽

Vacuum Therapy ◽

Boerhaave’S Syndrome ◽

Prolonged Stay ◽

Boerhaave's Syndrome ◽

Post Surgery

Abstract Aim Boerhaave’s Syndrome is a rare and fatal condition, characterised by a distal oesophageal tear induced by an abrupt rise in intra-luminal pressure. Treatment remains controversial; we present a recent case and review relevant literature. Methods A retrospective analysis of case-notes was performed, and a literature review undertaken on PubMed. Results A 58-year-old male presented as an emergency with severe chest pain, having choked and vomited following the ingestion of steak. Computed tomograpy scan of the thorax demonstrated a large pneumomediastinum associated with an oesophageal perforation on the anterior wall and bilateral pleural effusions. A primary laparoscopic repair was performed with jejunostomy placement for feeding. The post-operative period was complicated by a prolonged stay on intensive care with sepsis secondary to mediastinitis. A contrast swallow performed eleven days post-surgery confirmed no persistent leak and the patient was discharged five days later. Boerhaave’s syndrome accounts for 10% of oesophageal perforations and is typically associated with a history of overindulgence and vomiting. Stable patients with a contained disruption and minimal contamination, can be managed conservatively. Endoscopic therapies include clipping small perforations, self-expanding stents for larger defects, and endoluminal vacuum therapy. Operative interventions comprise primary repair, debridement and drainage of thoracic cavity, diversion operations and single stage resection with or without primary reconstruction. Conclusion Boerhaave’s Syndrome is associated with significant morbidity and mortality, but with early recognition and prompt intervention, patients can be successfully managed. Options include conservative, endoscopic and surgical, depending upon the site and size of the perforation.

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Inadvertent Percutaneous Endoscopic Gastrostomy Tube Placement through the Transverse Colon to the Stomach Causing Intractable Diarrhea: A Case Report

Diagnostic and Therapeutic Endoscopy ◽

10.1155/2011/849460 ◽

2011 ◽

Vol 2011 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

David T. Burke ◽

Andrew I. Geller ◽

Alexios G. Carayannopoulos ◽

Richard Goldstein

Keyword(s):

Percutaneous Endoscopic Gastrostomy ◽

Transverse Colon ◽

Delayed Diagnosis ◽

Tube Placement ◽

Common Mechanism ◽

Percutaneous Endoscopic Gastrostomy Tube ◽

Endoscopic Gastrostomy ◽

Tube Removal ◽

Peg Tube

Background. Among patients with chronic disease, percutaneous endoscopic gastrostomy (PEG) tubes are a common mechanism to deliver enteral feedings to patients unable to feed by mouth. While several cases in the literature describe difficulties with and complications of the initial placement of the PEG, few studies have documented the effects of a delayed diagnosis of a misplaced tube. Methods. This case study reviews the hospitalization of an 82 year old male with an inadvertent placement of a PEG tube through the transverse colon. Photos of the placement in the stomach as well as those of the follow up colonoscopy, and a recording of the episodes of diarrhea during the hospitalization were made. Results. The records of this patient reveal complaints of gastrointestinal distress and diarrhea immediately after placement of the tube. Placement in the stomach was verified by endoscopy, with discovery of the tube only after a follow up colonoscopy. The tube remained in place after this discovery, and was removed weeks after the diarrhea was unsuccessfully treated with antibiotics. After tube removal, the patient recovered well and was sent home.

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Boerhaave’s syndrome in a sixty-two-year-old Nigerian man: delayed diagnosis secondary to premorbid symptomatology

MGM Journal of Medical Sciences ◽

10.4103/mgmj.mgmj_40_21 ◽

2021 ◽

Vol 8 (4) ◽

pp. 446

Author(s):

PeterK Uduagbamen ◽

TaamakaD Ngubor ◽

Tomiwa Omokore ◽

NwachukwuO Nwachukwu

Keyword(s):

Delayed Diagnosis ◽

Boerhaave’S Syndrome ◽

Boerhaave's Syndrome

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Outcomes following Boerhaave’ syndrome

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2013.95.8.557 ◽

2013 ◽

Vol 95 (8) ◽

pp. 557-560 ◽

Cited By ~ 2

Author(s):

CL Connelly ◽

PJ Lamb ◽

S Paterson-Brown

Keyword(s):

Hospital Stay ◽

Primary Repair ◽

Length Of Hospital Stay ◽

Good Survival ◽

Boerhaave’S Syndrome ◽

Direct Closure ◽

Tube Drainage ◽

T Tube ◽

Boerhaave's Syndrome ◽

The Mean

Introduction Boerhaave’s syndrome is associated with high mortality and morbidity. This study aimed to assess outcome following treatment in a specialist upper gastrointestinal surgical unit. Methods Patients were identified from a prospectively collected database (Lothian Surgical Audit) and their records reviewed. Primary outcomes were mortality and serious morbidity. Secondary outcomes included time to theatre, operation undertaken and length of hospital stay. Results Twenty patients with Boerhaave’s syndrome were identified between 1997 and 2011. Four patients (20%) died in hospital. The mean time to theatre from symptom onset was 2.4 days. This was 7.3 days in the patients who died compared with 1.5 days in survivors. Five patients underwent primary repair of rupture, eleven underwent direct closure over a T-tube and one rupture was irreparable. Three patients were managed non-operatively and all survived. Outcomes were similar for the different surgical groups. There was one death following primary closure (20%) and two after T-tube drainage (18%). The mean length of hospital stay was 35.7 days after T-tube drainage and 20.5 days after primary repair. The 3 patients with small, self-contained leaks had a mean length of stay of 5.7 days. Conclusions Aggressive surgical management with direct repair is associated with good survival in patients with Boerhaave’s syndrome. Delayed time to theatre is associated with increased mortality. Patients with small, contained leaks without signs of sepsis can be managed non-operatively with a good outcome.

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Primary Endoscopic Stenting Versus Surgery in the Acute Management of Patients with Boerhaave's Syndrome

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2009.03.1004 ◽

2009 ◽

Vol 69 (5) ◽

pp. AB344

Author(s):

Nicoline C. Van Heel ◽

Pauline M. De Jong ◽

Jelle Haringsma ◽

Helma Van Grevenstein ◽

Hugo W. Tilanus ◽

...

Keyword(s):

Endoscopic Stenting ◽

Acute Management ◽

Boerhaave’S Syndrome ◽

Boerhaave's Syndrome

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Third time recurrent Boerhaave’s syndrome: a case report

Journal of Medical Case Reports ◽

10.1186/s13256-021-02779-5 ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

Adam Zeyara ◽

Martin Jeremiasen ◽

Oscar Åkesson ◽

Dan Falkenback ◽

Michael Hermansson ◽

...

Keyword(s):

Early Diagnosis ◽

Stent Placement ◽

Recurrent Disease ◽

Primary Repair ◽

English Literature ◽

White Male ◽

Esophageal Disease ◽

Boerhaave’S Syndrome ◽

Vacuum Assisted Closure ◽

Boerhaave's Syndrome

Abstract Background Effort rupture of the esophagus or Boerhaave’s syndrome is a rare entity, and prognosis is largely dependent on early diagnosis and treatment. Recurrent effort ruptures are very rare, only reported in a few case reports in English literature. We present a case with a third time effort rupture, and to the best of our knowledge there are no such previous publications. Furthermore, the presented case is also distinct because each episode was treated by different methods, reflecting the pathophysiology of recurrent disease as well as the last decade’s advancements in the management of esophageal perforations in our clinic and globally. Case presentation The patient is a 60-year-old White male, suffering from alcohol abuse, mild reflux esophagitis, and a history of effort esophageal ruptures on two previous occasions. He was now admitted to our ward once again because of a third bout of Boerhaave’s syndrome. The first time, 10 years ago, he was managed by thoracotomy and laparotomy with primary repair, and the second time, 5 years ago, by transhiatal mediastinal drainage through a laparotomy and endoscopic stent placement. Now he was successfully managed by endovascular vacuum-assisted closure therapy alone. Conclusions Recurrent cases of Boerhaave’s syndrome are very rare, and treatment must be tailored individually. The basic rationale is, however, no different from primary disease: (1) early diagnosis, (2) adequate drainage of extraesophageal contamination, and (3) restoration of esophageal integrity. Recurrent disease is usually contained and exceptionally suitable for primary endoscopic treatment. To cover the full panorama and difficult nature of complex esophageal disease, endoscopic modalities such as stent placement and endovascular vacuum-assisted closure, as well as the capacity for prompt extensive surgical interventions such as esophagectomy, should be readily accessible within every modern esophageal center.

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

Endoscopy International Open ◽

10.1055/s-0043-124075 ◽

2018 ◽

Vol 06 (01) ◽

pp. E92-E97 ◽

Cited By ~ 5

Author(s):

Khalil Aloreidi ◽

Bhavesh Patel ◽

Tim Ridgway ◽

Terry Yeager ◽

Muslim Atiq

Keyword(s):

Interventional Radiology ◽

Endoscopic Treatment ◽

Case Series ◽

Therapeutic Endoscopy ◽

Boerhaave’S Syndrome ◽

Surgical Interventions ◽

Boerhaave's Syndrome ◽

Case Series Study ◽

Threatening Condition ◽

Esophageal Stenting

Abstract 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.

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