Approach Considerations
Ideal management for Boerhaave syndrome involves a combination of both conservative and surgical interventions.
Mainstays of therapy include the following:
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Intravenous volume resuscitation
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Administration of broad-spectrum antibiotics
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Prompt endoscopic and/or surgical intervention
The decision to use a conservative (medical intervention only) or an aggressive (medical plus surgical intervention) approach depends on the following factors:
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Time delay in presentation and diagnosis
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Extent of perforation
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Overall medical condition of the patient
Surgical intervention is the standard of care in most cases, but Cameron et al established a set of criteria in which conservative (nonsurgical) management might be appropriate. [10] These include the following:
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The esophageal disruption should be well contained in the mediastinum.
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The cavity should be well drained back into the esophagus.
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Few symptoms should be present.
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Evidence of clinical sepsis should be minimal.
Conservative management consists of the following:
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Intravenous fluids should be administered.
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Antibiotics: Imipenem/cilastatin or ticarcillin/clavulanate offer good broad-spectrum coverage.
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Nasogastric suction should be applied.
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Keep the patient nil per os (NPO).
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Adequate drainage with tube thoracostomy or formal thoracotomy is vital.
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Early use of nutritional supplementation: Evidence suggests that for hastening recovery, a jejunostomy tube feeding may be favored over hyperalimentation.
Consultations
Consultation with a thoracic or general surgeon and gastroenterologist is indicated as soon as the diagnosis is suspected.
An infectious disease specialist should be consulted for assistance with antimicrobial therapy.
Surgical Care
Barrett described the first successful surgical repair of the esophagus in 1947. Prior to this, Boerhaave syndrome had a virtually 100% mortality.
Most physicians advocate surgical intervention if the diagnosis is made within the first 24 hours after perforation. Direct repair of the rupture and adequate drainage of the mediastinum and pleural cavity provide the best survival rates.
A left thoracotomy is the preferred approach, although laparotomy may be necessary if the tear extends into the distal esophagus. Various techniques, such as the use of an omental flap, may be used to support the primary closure. Gastrostomy and jejunostomy tubes are often placed to aid in drainage and nutrition, respectively.
The vitality of the surrounding tissue is an important factor in selecting the surgical procedure. For patients in whom a delay in diagnosis occurred, (>24 h) primary repair may not be possible. After 24 hours, the wound edges are frequently edematous, stiff, and friable.
Various alternatives to primary repair are available, including the following:
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The most common procedure includes the creation of an esophageal diversion through the use of a loop or end-cervical esophagostomy. This allows the wound to heal by secondary intention.
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The use of T-tubes also has been described. T-tube use results in the formation of a controlled fistula and a route for drainage of esophageal secretions and refluxed gastric materials.
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One study noted that the option of primary repair may be considered for perforations as old as 72 hours.
Newer techniques involve the use of plastic-covered, self-expanding metal stents. [11, 12] Note the following:
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These techniques are considered acceptable alternatives only when all other interventional options have been exhausted.
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The use of stents in Boerhaave syndrome is recommended for cases that involve extreme delays in diagnosis or a failure of conservative management.
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Expandable metal stents are most commonly used as palliative interventions for unresectable malignant esophageal obstruction.
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These devices bridge the esophageal tear.
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Several types of stents are available, with varying flexibility. Research holds the promise of biodegradable stents, obviating the necessity for removal.
Late complications of surgical intervention may include the following:
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Empyema that often requires tube drainage or decortication
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Esophagotracheal or esophagobronchial fistulas
Based on a review of published literature, de Schipper et al recommended endoscopic treatment of Boerhaave syndrome in certain cases. [3] The authors determined that the survival rates for conservative, surgical, and endoscopic treatments for Boerhaave syndrome are, respectively, 75%, 81%, and 100%. They concluded that patients should be treated endoscopically when the condition has been diagnosed within 48 hours of the esophageal rupture, provided there are no signs of sepsis. If the diagnosis is made within 48 hours of rupture but the patient has a septic profile, the investigators recommended that thoracotomy with hemifundoplication and pleural/mediastinal drainage be performed. [3]
de Schipper et al also indicated that intra-abdominal leakage necessitates local repair via laparotomy [3] In addition, they recommended that patients who are diagnosed more than 48 hours after esophageal rupture should undergo conservative therapy, with surgical treatment employed in these patients only when they have a septic profile.
More recently, endosocopic vacuum therapy has been under investigation for the management of esophageal perforation or leaks. [13, 14] This therapy has been shown to be successful in a few case reports or case series.
