Boerhaave’s Syndrome – Over 290 Yrs of Surgical Experiences. Surgical, Endoscopic and Conservative Treatment

Rokicki, Marek; Rokicki, W; Rydel, Mateusz

doi:10.1515/pjs-2016-0078

Cited by 10 publications

(38 citation statements)

References 15 publications

(32 reference statements)

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“…If the endoscopic or conservative approach fails, patients are usually reconsidered for surgical management. The estimated global mortality rate of patients with Boerhaave syndrome is 20–40% [2, 4] .…”

Section: Discussionmentioning

confidence: 99%

Boerhaave Syndrome in an Elderly Man

Pinto

Rodrigues

Almeida

et al. 2018

European Journal of Case Reports in Internal Medicine

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Boerhaave syndrome is rare, has an non-specific clinical presentation and most commonly develops after persistent vomiting. Septic shock dominates the clinical picture as a result of extensive infection of the mediastinum and pleural and abdominal cavities. The current management of Boerhaave syndrome includes conservative, endoscopic and surgical treatments. The authors present the case of a 94-year-old man admitted to hospital with community-acquired pneumonia with mild respiratory insufficiency complicated by oesophageal perforation after an episode of vomiting and the development of a large left pleural effusion. An endoscopic approach with the placement of an oesophageal prosthesis was chosen given the advanced age of the patient. The hospital stay was complicated by pleural effusion infection requiring broad-spectrum antibiotics and prosthesis substitution. The patient was discharged after 60 days of hospitalization, without the need for oxygen supplementation, and scoring 80% on the Karnofsky Performance Status Scale. The increase in average life expectancy requires a case-by-case approach, where the benefits of invasive manoeuvres and likelihood of discharge are weighed against an acceptable quality of life, aiming to prevent futile medical treatment.LEARNING POINTSBoerhaave syndrome is a complete rupture of the oesophageal wall secondary to a sudden increase in intraluminal oesophageal pressure, often in the lower third and left lateral position of the oesophagus.The management of Boerhaave syndrome depends on the time of diagnosis and clinical presentation and includes conservative, endoscopic and surgical approaches.Curative, aggressive approaches focused on the treatment of disease are often not appropriate for an aging population, hence the need for a case-by-case approach, where the benefits of invasive manoeuvres and likelihood of discharge are weighed against an acceptable quality of life, aiming to prevent futile medical treatment.

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Section: Discussionmentioning

confidence: 99%

Boerhaave Syndrome in an Elderly Man

Pinto

Rodrigues

Almeida

et al. 2018

European Journal of Case Reports in Internal Medicine

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“…Alguns cirurgiões acreditam que os danos iniciais acontecem nas primeiras 6 a 12 horas após a lesão 7 . A maioria dos cirurgiões aceitam o intervalo de tempo limite de 24 horas 4 . O tratamento da Síndrome deve ser iniciado durante a investigação diagnóstica, quando há suspeita, incluindo proibição de ingesta de água e alimentos, em alguns casos sem deglutir saliva, reposição de perdas volumétricas, correção de distúrbios de eletrólitos e início de antibióticos de amplo espectro por via endovenosa para evitar o choque séptico 4 .…”

Section: Discussionunclassified

“…A maioria dos cirurgiões aceitam o intervalo de tempo limite de 24 horas 4 . O tratamento da Síndrome deve ser iniciado durante a investigação diagnóstica, quando há suspeita, incluindo proibição de ingesta de água e alimentos, em alguns casos sem deglutir saliva, reposição de perdas volumétricas, correção de distúrbios de eletrólitos e início de antibióticos de amplo espectro por via endovenosa para evitar o choque séptico 4 . No caso do paciente em questão, devido à suspeita de úlcera péptica perfurada, excluindo hipóteses diagnósticas como infarto agudo do miocárdio, a conduta correta do mesmo ocorreu nas primeiras 24h do início dos sintomas, sendo considerado pela literatura como tratamento precoce, contribuindo para o sucesso do tratamento conservador.…”

Section: Discussionunclassified

“…O Manejo conservador geralmente consiste na exclusão esofágica com a colocação de uma sonda nasogástrica (descompressiva), nutrição enteral através de outra sonda distal, reposição intravenosa de perda de líquidos e eletrólitos, administração de antibióticos de amplo espectro, inibidores da bomba de prótons e drenagem mediastinal e pleural percutânea. O tratamento conservador é indicado para um número restrito de pacientes, especialmente quando apresentam poucos sintomas e o conteúdo extravasado retorna para o lúmem esofágico, sem comunicação do mesmo com o espaço pleural 4 .…”

Section: Introductionunclassified

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Tratamento conservador na síndrome de Boerhaave

Firme

Lima

Cordeiro³

et al. 2018

Rev. Med. (São Paulo)

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A Síndrome de Boerhaave, ruptura esofagiana espontânea, é uma doença de difícil diagnóstico, por não apresentar manifestações clínicas específicas e seus achados de sinais e sintomas sugerirem outros diagnósticos diferenciais. É uma síndrome que apresenta elevadas taxas de mortalidade e o principal fator para esse desfecho desfavorável é o atraso entre a perfuração do esófago e o tratamento adequado. Exames de imagem são fundamentais para elucidação diagnostica, contribuindo para o tratamento precoce. Diversas modalidades de tratamento estão descritas na literatura, dentre elas, o tratamento cirúrgico, endoscópico ou manejo conservador. A cirurgia ainda é considerada padrão-ouro no tratamento da maioria dos casos. Contudo, apesar de poucos casos descritos na literatura, o manejo conservador, sem necessidade de cirurgia em um primeiro momento, pode ser indicado para determinados grupos de pacientes, com sucesso. Relatamos um caso de paciente com diagnóstico de Síndrome de Boerhaave tratado conservadoramente, com excelente resultado. O tratamento conservador da perfuração esofágica é uma boa alternativa para determinados perfis de paciente e deve ser bem indicado para que se obtenha êxito.

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“…Boerhaave's syndrome is a life-threatening condition characterized by a disruption of the distal esophagus due to a barotrauma that results in contamination of the mediastinum and pleural cavity with gastric contents [1]. Symptoms may vary, and diagnosis can be challenging, as the classic triad of Mackler (vomiting, lower thoracic pain and subcutaneous emphysema) is present in a few cases [2].…”

Section: Introductionmentioning

confidence: 99%

Diagnostic challenge and surgical management of Boerhaave’s syndrome: three diagnosed cases of spontaneous esophageal rupture

Wang

Wang²,

Chen

2020

Preprint

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BACKGROUND: Boerhaave’s syndrome is the spontaneous rupture of the esophagus, caused by an increase of intraluminal pressure that is produced in the context of negative intrathoracic pressure. It has a high index of morbimortality, which is why it requires early diagnosis and treatment. Symptoms may vary, and diagnosis can be challenging.CASE PRESENTATION: Case one: A 54-year-old man presented to us with sudden-onset epigastric pain radiating to the back following hematemes. His previous medical history included gastric ulcer. His physical signs suggested early shock. Combined with his medical history and physical signs, emergency doctor suspected a diagnosis of peptic ulcer with hematemesis, and esophagegastroscopy was performed. However, upper gastrointestinal endoscopy revealed a full-thickness rupture of the esophageal wall. The subsequent computed tomography (CT) showed frank pneumomediastinum and heterogeneous pleural effusion. He was subsequently referred to us in view of suspected Boerhaave’s syndrome and clinical worsening. In view of hemodynamic instability with uncontrolled sepsis, he was planned for surgery. Esophageal perforation repair operation and jejunostomy was performed for him. The postoperative period was uneventful, and he was discharged.Case two: A 62-year-old man was admitted to the emergency department with thoracic dull pain and chest distress that started after he had been vomiting several hours before presentation. On physical examination, he presented rough bronchovesicular breathing sound, and crepitant rales in lungs prompting subcutaneous emphysema. Chest CT scan showed pneumomediastinum and large left-sided pleural effusion. Esophagus fistula was confirmed by contrast esophagography. Therefore, spontaneous esophageal perforation was suspected. Then, we performed thoracotomy to repair the esophageal tear as well as to debride and irrigate the left pleural space. His vital signs remained stable intraoperatively, and his postoperative periods were uneventful with no leakage or stricture. Case three: The patient was a 69-year old male presenting with a severe retrosternal and upper abdominal pain followed an episode of forceful vomiting. At admission, he was diaphoretic and in respiratory distress. Physical examination revealed extensive cervical and thoracic subcutaneous emphysema but was otherwise unremarkable. A thoracic CT scan revealed a rupture in the left distal part of the oesophagus, a pneumomediastinum and left-sided pleural effusions. Conservative treatment, with cessation of oral intake, nasogastric suction, administration of intravenous fluids and parenteral nutrition, intravenous broad-spectrum anti-biotics, proton pump inhibitors and drainage of the pleural effusion by left-sided thoracostomy, 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.

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Boerhaave’s Syndrome – Over 290 Yrs of Surgical Experiences. Surgical, Endoscopic and Conservative Treatment

Cited by 10 publications

References 15 publications

Boerhaave Syndrome in an Elderly Man

Boerhaave Syndrome in an Elderly Man

Tratamento conservador na síndrome de Boerhaave

Diagnostic challenge and surgical management of Boerhaave’s syndrome: three diagnosed cases of spontaneous esophageal rupture

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