Management of Boerhaave syndrome in Australasia: a retrospective case series and systematic review of the Australasian literature

Abstract

Background Boerhaave syndrome is a rare and life‐threatening condition characterized by a spontaneous transmural tear of the oesophagus. There remains wide variation in the condition's management with non‐operative management (NOM) and surgery being the two main treatment strategies. The aim was to review the presentation, management and outcomes for patients treated for Boerhaave syndrome at our institution and to compare these data with that previously reported within the Australasian literature. Methods A retrospective case series was performed for consecutive patients diagnosed with Boerhaave syndrome at our institution between January 2000 and January 2020. A systematic review of the Australasian literature was also performed. Results In case series, 15 patients were included (n = 2 NOM, n = 13 operative). The most common operative technique was primary repair with intercostal drainage via thoracotomy. Major complications occurred in 11 (73%) patients. Median Comprehensive Complication Index was 53.4 (interquartile range: 50). There was a significantly lower Comprehensive Complication Index associated with primary repair when compared to oesophageal resection (P = 0.01). There was one death, in the operative management group. Median length of hospital stay was 33 days (interquartile range: 58). In systematic review, 11 articles were included; four case series and seven case reports. From these, 23 patients met inclusion criteria. The majority of patients (83%) were managed operatively, with only four undergoing NOM. Seven patients died, representing an overall mortality rate of 30%. Conclusions We provide an updated overview of the management of Boerhaave syndrome within Australasia. Aggressive operative management is associated with reasonable outcomes.

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

“…Spontaneous esophageal perforation is a rare esophageal pathology. The rarity of this condition results in very scarce data even in specialist centers and the level of evidence is limited to retrospective case series and expert opinions [ 12 , 13 ]. No consensus has been reached on the most suitable treatment.…”

Atypical presentation of Boerhaave’s syndrome in a remote Australian setting

“…There are only 12 other known cases of Boerhaave’s syndrome presenting with tension pneumothorax in the literature, in which 5 patients survived, 4 died and 3 had unknown/unreported outcomes 4. The classical presentation for Boerhaave’s syndrome is Mackler’s triad (chest pain, vomiting, subcutaneous emphysema) and occurs in only 20% of patients 5. Differential diagnoses include cardiorespiratory disorders such as myocardial infarction, pericarditis, spontaneous pneumothorax and pneumonia.…”

“…In this case, CT was done later due to the immediate need to stabilise the patient’s cardiorespiratory system. The majority of patients are managed operatively with oversewing of the tear, although endoscopic therapies with chest drainage are occasionally used 5. Given the mortality rate is so high, postprocedure intensive care unit admission is required and is standard practice 7…”

Efficacy of esophageal stents as a primary therapeutic option in spontaneous esophageal perforations: a systematic review and meta-analysis of observational studies

“…The ensuing rupture is usually on the left side of the lower intrathoracic portion of the esophagus [ 1 ]. If not promptly recognized and treated, it is often fatal, with contemporary series reporting a mortality rate between 15-42% [ 2 - 5 ]. Traditional treatment includes urgent surgical intervention in the form of primary repair, T-tube placement, or resection and diversion, with best results accomplished when patients are operated early after the insult [ 6 - 9 ].…”