Our experience on management of Boerhaave's syndrome with late presentation

Abstract

A retrospective review of 18 patients treated for Boerhaave's syndrome in our center from 1954 to 2006 was undertaken. The patients were divided into two groups: group 1, the time delayed before treatment was less than 24 hours; group 2, the time delayed was more than 24 hours. The time interval between perforation and the onset of treatment in group 2 was from 50 hours to 30 days. Roentgenograms of the chest and esophagogram with a water-soluble contrast medium are able to reveal the perforation in most cases, and thoracentesis or thoracic drainage after swallow methylene blue may provide help as well. Surgical intervention was adopted in all three patients in group 1 and 12 in group 2, and conservative intervention in three in group 2. In group 1, two patients recovered uneventfully, the other one developed a postoperative respiratory infection, and he recovered after the infection was controlled. The mortality in group 2 was 33.3% (5/15), and the mortality in patients with conservative intervention was 100% (3/3). Five complications occurred after surgical intervention in group 2, including four fistulae and one incision infection. In conclusion, it may be appropriate to manage patients aggressively with primary repair and adequate mediastinal and pleural drainage when patients present late. Because of the syndrome's initial severity and a tendency to postoperative complications, patients should be closely monitored, and correct antibiotic therapy and adequate nutrition are very important in treatment.

A Case of Rapid Diagnosis of Boerhaave Syndrome by Thoracic Drainage

“…Delayed diagnosis and treatment of Boerhaave syndrome, especially more than 24 h after symptom onset, is reportedly fatal (2)(3)(4)(5)(6)(7)(8). The patient in this case received immediate thoracic drainage that confirmed the diagnosis of Boerhaave syndrome, and she was treated rapidly and recovered.…”

“…However, a relatively high false-negative rate (15-25%) has been reported, and furthermore, esophagography is not performed immediately after admission (10). The other technique to confirm the diagnosis, thoracentesis or thoracic drainage, has been reported in the literature (4,6). We report here a case of Boerhaave syndrome that was rapidly diagnosed and treated by immediate thoracic drainage, which drained off food particles such as broccoli that were visible with the naked eye.…”

“…The time between symptom onset and the correct diagnosis and its relationship to the mortality rate of Boerhaave syndrome are discussed in recent reviews listed in Table 2 (2-8). These articles demonstrate that the mortality rate for patients diagnosed within the first 24 h is significantly lower than for those patients diagnosed after the first 24 h (2)(3)(4)(5)(6)(7)(8).…”

“…Boerhaave syndrome is rare and occurs mainly in males and at the left posterolateral wall of the distal esophagus without any apparent precipitating factor. Previous case reports have focused on clinical features, work-up, and prognosis without any description of how to diagnose and rapidly treat it (2)(3)(4)(5)(6)(7)(8). Delayed diagnosis and treatment are closely associated with prolonged morbidity and increased mortality.…”

Predicting operative mortality in patients undergoing coronary artery bypass surgery

“…The dominance of coronary artery system, the degree of luminal obstruction, the number of diseased coronary vessels and calcification of coronaries and the aorta should be taken into consideration in the risk stratification of patients undergoing coronary artery bypass grafting (CABG). The above points are addressed in the SYNTAX scoring system (developed in May 2009), [1][2][3] which is a unique scoring system to assess the severity and the anatomical complexity of coronary artery disease and provides a guide to revascularisation options to the cardiologists. Incorporating the SYNTAX score into the Euroscore will provide an additive value in predicting outcome after CABG.…”