P-EGS25 Boerhaave’s Syndrome Secondary to Symptomatic COVID-19 Infection

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has infected over 140 million people worldwide (1). COVID-19 symptoms primarily involve the respiratory system. However, recent data suggests that gastrointestinal symptoms occur in 11-61% of cases (2, 3).Boerhaave’s syndrome is a rare and dangerous disorder of the gastrointestinal tract, associated with a mortality rate of up to 50% (4). It most commonly occurs due to a lack of coordination between upper and lower oesophageal sphincters during forceful emesis, leading to an abrupt rise in intra-oesophageal pressures which leads to a transmural tear (5). Less commonly, a tear can be secondary to prolonged coughing (6). The majority of tears occur in the distal posterolateral third of the oesophagus and have an average length of 2.2 cm (7). Risk factors include males, excess alcohol or food consumption (6). We present a case of Boerhaave’s syndrome secondary to prolonged coughing, from COVID-19 infection. The tear was 8 cm in length in the mid anterior oesophagus. The patient survived a major operation and prolonged intensive care stay. Meloy et al. (8) published one case of oesophageal rupture in symptomatic COVID-19 – unfortunately the patient passed away before intervention. Methods A 75-year-old Caucasian female was day seven of COVID-19 infection and had been coping in the community with a continuous dry cough and mild shortness of breath. She presented to Accident and Emergency in the late afternoon when her cough developed into unremitting retching, vomiting, a global headache and epigastric pain disproportionate to presentation. No associated haematemesis or change in bowel habit. Past medical history was significant for hypertension, hypothyroidism, depression and anxiety. Previous surgical history included an open appendicectomy, cholecystectomy and resection of a melanoma. She was previously independent, consumed alcohol socially, a non-smoker and compliant with her regular medications.A CT chest with contrast demonstrated distal oesophageal rupture transversely with pneumomediastinum and extensive surgical emphysema in the neck and secondary bilateral pleural effusions, consistent with Boerhaave’s syndrome. The patient was taken to theatre the next morning for an oesophago-gastro-duodenoscopy (OGD), right posterolateral thoracotomy and primary repair of the oesophageal perforation.On endoscopy, an 8cm defect in the anterior oesophagus starting at the T4 vertebral level was identified and was repaired using tunnelled permanent mesh. During the surgery, mediastinitis was noted and washed out. The antimicrobial therapy was altered post-operatively to intravenous tazocin and fluconazole. Results The management of this patient was a huge multidisciplinary team achievement. She spent forty-six days recovering in ICU, intubated, ventilated and sedated with noradrenaline vasopressor support. The patient developed a severe acute kidney injury, requiring haemofiltration. The mediastinal fluid culture grew Enterococcus faecalis, sensitive to vancomycin and antibiotic therapy was adjusted accordingly. The patient’s recovery was burdened by seizures, whilst being weaned off sedation, and episodes of bradycardia and asystole, most of which were self-resolving except one requiring thirty seconds of cardio-pulmonary resuscitation. After chest drain removal, the patient redeveloped a right sided loculated pleural effusion so a further drain was inserted.A gastrografin contrast swallow study performed thirty-five days post-operatively demonstrated no evidence of contrast leak although some tracheobronchial aspiration. She was later stepped down to the ward and recovered very well. However, a component of post-ICU delirium and low mood was persistent. The patient had a repeat water-soluble contrast study on day 77 which demonstrated a contained anastomotic leak, managed conservatively. She was deemed medically ready for discharge at day 110. She was readmitted due to dysphagia secondary to a stricture at the site of mesh repair. OGD was performed and a stent was inserted. Conclusions COVID-19 infection may lead to an abnormal presentation of Boerhaave’s syndrome, with oesophageal tears being secondary to coughing, longer and more proximal.Peri-operative morbidity in COVID patients is elevated and clinicians should consider the short and long term implications of this to provide a holistic approach to care. Clinicians should maintain an awareness of the diversity of COVID-associated complications whilst ensuring that they do not succumb to the diagnostic overshadowing that becomes commonplace during a pandemic.

Diagnostic challenge and surgical management of Boerhaave’s syndrome: a case series

Background Boerhaave’s syndrome is the spontaneous rupture of the esophagus, which requires early diagnosis and treatment. Symptoms may vary, and diagnosis can be challenging. Case presentation Case 1: A 54-year-old Chinese man presented to us with sudden-onset epigastric pain radiating to the back following hematemesis. Upper gastrointestinal endoscopy revealed a full-thickness rupture of the esophageal wall. Subsequent computed tomography showed frank pneumomediastinum and heterogeneous pleural effusion. Immediately, esophageal perforation repair operation and jejunostomy were performed. The postoperative period was uneventful, and he was discharged. Case 2: A 62-year-old Chinese man was admitted to the emergency department with thoracic dull pain and chest distress. Chest computed tomography scan showed pneumomediastinum and large left-sided pleural effusion. Esophagus fistula was confirmed by contrast esophagography. Then, we performed thoracotomy to repair the esophageal tear as well as to debride and irrigate the left pleural space. His postoperative period was uneventful, with no leakage or stricture. Case 3: The patient was a 69-year-old Chinese male presenting with severe retrosternal and upper abdominal pain following an episode of forceful vomiting. Thoracic computed tomography scan revealed a rupture in the left distal part of the esophagus, a pneumomediastinum, and left-sided pleural effusions. Conservative treatment failed to improve disease conditions. Open thoracic surgery was performed with debridement and drainage of the mediastinum and the pleural cavity, after which he made a slow but full recovery. Conclusions We highlight that early diagnosis and appropriate surgical treatment are essential for optimum outcome in patients with esophageal rupture. We emphasize the importance of critical care support, particularly in the early stages of management.

EP.WE.1015Management of Boerhaave Syndrome

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.

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.