Utility of endoscopic therapy in the management of Boerhaave syndrome

Abstract

Background/aims: The optimal intervention for Boerhaave perforation has not been determined. Options include surgical repair with/without a pedicled muscle flap, T tube placement, esophageal resection or diversion, or an endoscopic approach. All management strategies require adequate drainage and nutritional support. Our aim was to evaluate outcomes following Boerhaave perforation treated with surgery, endoscopic therapy, or both. Patients and methods: We performed a 10-year review of our prospectively maintained databases of adult patients with Boerhaave perforations. We documented clinical presentation, extent of injury, primary intervention, “salvage” treatment (any treatment for persistent leak), and outcome. Results were analyzed using the Fisher’s exact and Kruskal – Wallis tests. Results: Between October 2004 and October 2014, 235 patients presented with esophageal leak/fistula with 17 Boerhaave perforations. Median age was 68 years. Median length of perforation was 1.25 cm (range 0.8 – 5 cm). Four patients presented with systemic sepsis (two treated with palliative stent and two surgically). Primary endotherapy was performed for eight (50 %) and primary surgery for eight (50 %) patients. Two endotherapy patients required multiple stents. Median stent duration was 61 days (range 56 – 76). “Salvage” intervention was required in 2/8 (25 %) endotherapy patients and 1/8 (13 %) surgery patient (stent). All patients healed without resection/reconstruction. There were no deaths in the surgically treated group and two in the endotherapy group (stented with palliative intent due to poor systemic condition). Readmission within 30 days occurred in 3/6 of alive endotherapy patients (50 %) and 0/8 surgery patients. Re-intervention within 30 days was required for one endotherapy patient. Conclusion: Endoscopic repair of Boerhaave perforations can be useful in carefully selected patients without evidence of systemic sepsis. Endoscopic therapy such as stenting is particularly valuable as a “salvage” intervention. The benefits of endoscopic therapy and esophageal preservation are offset against an increased risk of readmission in patients primarily treated endoscopically.

Esophageal Stenting in Clinical Practice: an Overview

“…Early diagnosis, within 24 h, is crucial for successful outcome and can be challenging in patients with BS because the symptom onset usually sets off in an out of hospital setting [ 18 , 61 ]. Esophageal stent placement to treat BS has been shown to be feasible and may have a role in the treatment algorithm [ 62 , 63 ].…”

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

“…The point of importance to note here is that this challenges current belief that endoscopic therapy should be reserved for patients who present early and in whom there is no associated sepsis, as Dickinson et al 10 conclude in their recently published study. They compared endoscopic therapy to surgery for BS in 2 groups of patients.…”

Boerhaave Syndrome Causing Bilateral Empyemas

“…11 Ongoing debates exist regarding best practices based on a patient's presenting clinical scenario, with the current literature suggesting that endoscopic therapy be reserved for early presenters, those with a defect less than 1 cm and without evidence of sepsis, thus indicating a promising role for endoscopy in a carefully selected population with Boerhaave syndrome. 15,16…”