Challenges faced in the management of complicated Boerhaave syndrome: a tertiary care center experience.

Spontaneous esophageal perforation is rare and is associated with high morbidity and mortality. A spectrum of various surgical modalities ranging from primary surgical repair to esophagectomy is available for its management. The optimal management of patients presenting late in a hemodynamically stable condition is not clearly defined in the literature. A retrospective review of all patients with Boerhaave syndrome managed by a single surgical team in a tertiary care center between 2008 and 2019 was performed (n = 16). Eleven patients were initially managed in the medical intensive care unit (MICU) as non-esophageal cause and 5 patients were referred after failed management (conservative/endoscopic). Demographics, clinical presentation, characteristics of perforation, initial diagnosis, and treatment were analyzed. All patients were males with a mean age of 42.2 years. A history of ethanol use was present in 6 patients. The median delay in diagnosis and referral was 16 days (range: 11-40 days). The common presenting symptoms were chest pain (n=11), dyspnoea (n=10), vomiting (n=4) and cough (n=2). The perforation was directed into right, left, and bilateral pleural cavities in 6, 8, and 2 patients respectively. The location of perforation was distal esophagus except for one patient. One patient was successfully treated with conservative management. The remaining patients underwent esophagectomy as a definitive surgical procedure. There was no significant postoperative morbidity and mortality. Esophagectomy can be done as a one-stage definitive procedure for patients with Boerhaave syndrome who present late in a hemodynamically stable condition with acceptable morbidity and good long term outcome.

Pathophysiology of Vomiting and Esophageal Perforation in Boerhaave's Syndrome.

BACKGROUND AND AIMS: Boerhaave's syndrome, involving esophagus rupture, is considered a pathological response to vomiting that may occur just before perforation. However, the mechanism of vomiting and occurrence of this disease have not been clearly demonstrated. METHODS: We identified patients with esophageal perforation between 1995 and 2017 and reviewed endoscopic findings at retching during upper gastrointestinal endoscopy. Finally, we proposed a theory for the underlying pathological mechanism. RESULTS: We retrospectively investigated 10 patients with esophageal perforation between 1995 and 2017. All patients presented after vomiting associated with large volumes of food and alcohol intake. Nine were treated by primary closure of the perforation and drainage of the thoracic cavity, and one was conservatively treated. In all cases, the perforations were longitudinal tears (1-4 cm) and located in the left of the esophagus, just above the gastric cardia. CONCLUSIONS: We hypothesize that vomiting occurred by retrograde propagation of gastrointestinal motor contraction from the jejunum to the gastric antrum, followed by prolapse of the gastric fornix mucosal into the esophagus. Subsequent esophageal perforation probably resulted from excessive prolapse due to strong contraction and destruction of the muscularis mucosa of the left side of abdominal esophagus, with longitudinal stretching of the whole left esophageal wall due to traction. We also propose that Boerhaave's syndrome is defined as "post-emetic esophageal perforation" to ensure broader recognition and more expedient diagnosis and treatment. Remaining conditions without any definite causes may be labeled "idiopathic" or "spontaneous" rupture of the esophagus.

Esophageal perforation in eosinophilic esophagitis: A systematic review on clinical presentation, management and outcomes.

There is evidence of an increased fragility in the inflamed esophagus of patients with eosinophilic esophagitis (EoE). We performed a systematic review on presentation, management and outcomes of and surgical interventions for esophageal perforation in these patients, by searching in the MEDLINE, Embase and Scopus databases. Of the 599 references identified, 41 full-papers and 9 abstract met the inclusion criteria. Overall, 76 esophageal perforation episodes in 70 individual patients aged between 9 and 65 years were reported. 51 patients had not been diagnosed with EoE at the time of perforation; 14 patients had an untreated disease and the remaining were non responsive to therapy. Acute or progressive pain after long-lasting dysphagia and food impaction was the most common symptom leading to diagnosis in 42 patients who presented with Boerhaave syndrome. Pushing impacted food into the stomach led to perforation in 5 cases. Eight episodes appeared after dilation. CT scans demonstrated perforation in 82.4% of patients. Conservative management (including esophageal stenting) was used in 67.1% patients. The 25 remaining patients underwent surgery. Recovery was uneventful in the vast majority of patients. No death was reported. Active inflammation due to undiagnosed or untreated EoE was present in most cases of esophageal perforation. Conservative treatment of perforation should always be considered in EoE.

[Boerhaave syndrome: update on physiopathology, diagnosis and early management]. / Syndrome de Boerhaave : mise au point sur la physiopathologie, le diagnostic et le traitement précoce.

Boerhaave syndrome is a rare condition, usually associated with a delay in diagnosis. It is fatal in the absence of therapy. The nonspecific nature of the clinical signs contributes to the poor outcome. This syndrome should be suspected in patients with severe chest or abdominal pain, associated with a history of vomiting, clinical signs of pneumomediastinum (subcutaneous emphysema, pleural effusion) and rapid clinical deterioration. Prompt diagnosis and initial management by the primary care physician and the emergency department physician are key elements of a better outcome. This article will review the pathogenesis, clinical manifestations, diagnosis and treatment of Boerhaave syndrome in adults.

Le syndrome de Boerhaave est une entité rare, de diagnostic difficile, dont l'évolution est potentiellement fatale en l'absence d'une prise en charge rapide. Le manque de spécificité des signes cliniques participe au retard diagnostique et au mauvais pronostic. Le syndrome doit être évoqué lors d'une symptomatologie thoracique ou abdominale aiguë, avec une anamnèse de vomissements, des signes cliniques de pneumomédiastin (emphysème sous-cutané, épanchements pleuraux) et l'apparition de signes de choc. Le pronostic étant conditionné par la rapidité du diagnostic et de la prise en charge, le rôle du médecin de premier recours et de l'urgentiste est crucial. Cet article a pour but de faire le point sur la physiopathologie, les manifestations cliniques, le diagnostic et le traitement de cette pathologie chez l'adulte.

Boerhaave's syndrome complicated by a Saccharomyces cerevisiae pleural empyema. Case report and review of the literature.

Objective and Importance Boerhaave's syndrome is a sudden and rare form of oesophageal rupture and is often complicated by local or systemic infection of the mediastinum or pleural cavity. Several micro-organisms are documented as cause of pleural empyema in patients with Boerhaave's syndrome. Intervention (& Technique) We report on a previously healthy 74-year-old male who was admitted at a regional hospital with severe retrosternal and abdominal pain after an episode of vigorous vomiting the morning after ingestion of large quantity of beer. A CT-scan confirmed the diagnosis of Boerhaave's syndrome, an oesophageal stent was placed and a left-sided pleural empyema necessitated chest tube drainage. Pleural fluid samples were cultured every two days and were positive for Proteus mirabilis on day 2 after admission and for Saccharomyces cerevisiae on day 8 after admission. Intravenous fluconazole 800 mg per day was added to the antibacterial treatment. Pleural fluid culture became negative for P. mirabilis on day 23 and for S. cerevisiae on day 13. Recurrent empyema necessitated intrapleural thrombolysis. The patient could be discharged from the ICU after 43 days, from the normal ward to a rehabilitation centre after an additional 13 days. Conclusion Pleural empyema caused by S. cerevisiae, commonly known as 'Brewers' yeast', has never been described in such patients. Our case illustrates that clinicians should be aware of infection with S. cerevisiae after oesophageal perforation, soon after ingestion of beer. Adequate antimycotic treatment was successful and led to negative culture of pleural fluid after 5 days.

Pneumomediastinum following a prolonged second stage of labor - an emphasis on early diagnosis and conservative management: a case report.

BACKGROUND: Esophageal rupture is an extremely rare condition to occur to a pregnant or postnatal woman. Esophageal ruptures have been previously described in the literature; however, they are most common in the setting of hyperemesis gravidarum. CASE PRESENTATION: This case report describes a 27-year-old white woman who began complaining of central chest pain and shortness of breath 3 hours after a normal vaginal delivery, with no history of vomiting antenatally or intrapartum. A chest X-ray and computed tomography pulmonary angiogram confirmed surgical emphysema and pneumomediastinum, and a diagnosis of esophageal rupture was made based on these findings. She was stable and conservative management was initiated; she improved over 4 days. Resolution of surgical emphysema was demonstrated on serial chest X-rays without requiring contrast swallow or surgical intervention. CONCLUSIONS: This case exemplifies the importance of a timely diagnosis of esophageal rupture in ensuring a positive outcome for the patient. Delay in diagnosis can lead to an increase in morbidity and mortality.

Causes and Outcomes of Esophageal Perforation in Eosinophilic Esophagitis.

GOALS: To characterize patients who suffer perforation in the context of eosinophilic esophagitis (EoE) and to identify predictors of perforation. BACKGROUND: Esophageal perforation is a serious complication of EoE. MATERIALS AND METHODS: We conducted a retrospective cohort study of the University of North Carolina EoE clinicopathologic database from 2001 to 2014. Subjects were included if they had an incident diagnosis of EoE and met consensus guidelines, including nonresponse to a PPI trial. Patients with EoE who had suffered perforation at any point during their course were identified, and compared with EoE cases without perforation. Multiple logistic regression was performed to determine predictors of perforation. RESULTS: Out of 511 subjects with EoE, 10 (2.0%) had experienced an esophageal perforation. Although those who perforated tended to have a longer duration of symptoms before diagnosis (11.4 vs. 7.0 y, P=0.13), a history of food impaction (odds ratio, 14.9; 95% confidence interval, 1.7-129.2) and the presence of a focal stricture (odds ratio, 4.6; 95% confidence interval, 1.1-19.7) were the only factors independently associated with perforation. Most perforations (80%) occurred after a prolonged food bolus impaction, and only half of individuals (5/10) carried a diagnosis of EoE at the time of perforation; none occurred after dilation. Six patients (60%) were treated with nonoperative management, and 4 (40%) required surgical repair. CONCLUSIONS: Esophageal perforation is a rare but serious complication of eosinophilic esophagitis, occurring in ∼2% of cases. Most episodes are due to food bolus impaction or strictures, suggesting that patients with fibrostenotic disease due to longer duration of symptoms are at increased risk.

Esophagectomy in esophageal perforations: an analysis.

This study aimed to study the factors that are associated with urgent esophagectomy for the treatment of esophageal perforations and the impact of this therapy. A retrospective review of all esophageal perforations treated at a tertiary care hospital from January 1984 to January 2012 was performed. Compiling demographics, cause and site of perforations, time to presentation, comorbidities, radiological tests, the length of perforation, the hemodynamic status of the patient, type of treatment required, and outcomes were performed. Univariate, multivariate, and Cox regression analyses were conducted. Of 127 cases of esophageal perforation, it was spontaneous in 44 (35%), iatrogenic in 53 (44%), foreign body ingestion in 22 (17%), and traumatic perforation in 7 (6%) cases. Overall, 85 of the 127 (67%) patients were managed operatively, 35 (27.6%) patients were treated conservatively, and 7 (6.3%) patients were treated by endoscopic stent placement. Of the 85 patients who were managed operatively, 21 (16.5%) required esophagectomies, 13 (15.3%) had esophagectomy with immediate reconstruction, 5 (5.9%) patients had esophagectomy followed by delayed reconstruction, and 3 (3.5%) patients failed primary repair and required an esophagectomy as a secondary definitive procedure. Multivariate analysis revealed that esophagectomy in esophageal perforations was associated with the presence of benign or malignant esophageal stricture (P = 0.001) and a perforation >5 cm (P = 0.001). Mortality was mainly associated with the presence of a benign or malignant esophageal stricture (P = 0.04). The presence of pre-existing benign or malignant stricture or large perforation (>5 cm) is associated with the need for an urgent esophagectomy with or without immediate reconstruction. Performing esophagectomy was not found to be a significant prognosticator for mortality.

Pharyngoesophageal perforation 3 years after anterior cervical spine surgery: a rare case report and literature review.

Pharyngoesophageal perforation after anterior cervical spine surgery is rare and the delayed cases were more rarely reported but potentially life-threatening. We report a case of pharyngoesophageal perforation 3 years after anterior cervical spine surgery. The patient presented with dysphagia, fever, left cervical mass and developing dyspnea 3 years after cervical spine surgery for trauma. After careful examinations, he underwent an emergency tracheostomy, neck exploration, hardware removal, abscess drainage and infected tissue debridement. 14 days after surgery, CT of the neck with oral contrast demonstrated no contrast extravasation from the esophagus. Upon review of literature, only 14 cases of pharyngoesophageal perforation more than 1 year after anterior cervical spine surgery were found. We discussed possible etiology, diagnosis and management and concluded that in cases of dysphagia, dyspnea, cervical pain, swelling and edema of the cervical area even long time after anterior cervical spine surgery, potential pharyngoesophageal damage should be considered.

Hamman and Boerhaave syndromes - diagnostic dilemmas in a patient presenting with hyperemesis gravidarum: a case report.

INTRODUCTION: Hyperemesis gravidarum describes persistent vomiting leading to fluid and electrolyte imbalance. It is the commonest reason for admission in the first half of pregnancy. We describe a case of Hamman syndrome secondary to hyperemesis gravidarum. We also discuss Boerhaave syndrome: a particularly rare condition with only a handful of cases being described in the literature. CASE PRESENTATION: A 17 year old admitted with hyperemesis gravidarum was diagnosed with Hamman syndrome after complaining of chest pain due to the presence of subcutaneous emphysema and pneumomediastinum on chest radiograph. She was treated conservatively for potential ruptured oesophagus but then self-discharged against medical advice. CONCLUSION: Subcutaneous emphysema is an alarming finding in any pregnancy and should be treated in a timely and cautious manner. This case report adds weight to the previous literature advocating a conservative versus surgical approach to the management of a woman with Hamman syndrome secondary to hyperemesis gravidarum.

Endoscopic band ligation for closure of GI perforations in a porcine animal model (with video).

BACKGROUND: GI perforations occur rarely during endoscopy but have life-threatening implications. OBJECTIVE: To evaluate endoscopic band ligation (EBL) for closure of acute GI perforations by using a porcine model. DESIGN: Investigator-initiated interventional pilot study by using an in vivo porcine model. SETTING: Tertiary-care institution. SUBJECTS: Ten domestic pigs. INTERVENTION: Each animal underwent a single endoscopic procedure, with creation of a single GI lumen perforation. Perforations of 10 to 20 mm were created in the esophagus, stomach, duodenum, and colon. EBL was used for closure. Fourteen days later, the pigs were killed, microbial cultures were obtained, and histologic review was done. MAIN OUTCOME MEASUREMENTS: Immediate and delayed endoscopic closure of the perforation site, evidence of clinical peritonitis during the 14-day follow-up. RESULTS: Ten pigs completed the protocol and survived without clinical peritonitis during the 14-day follow-up. Endoscopic closure of a 15-mm esophageal perforation failed, thus, no attempt was made to close a 20-mm esophageal perforation. Closure of all other perforations was successful. At necropsy, fibrinous peritonitis was suspected in one animal with a 10-mm duodenal perforation. Chronic inflammation and fibroplasia at the perforation sites were the most common histologic findings. LIMITATIONS: The applicability of widespread use in humans remains unknown despite successful case reports in the medical literature. CONCLUSION: EBL can be used successfully to close 10 to 20 mm perforations within normal stomach, duodenum, and colon and can prevent clinically relevant intra-abdominal infections. However, for esophageal perforations, closure may be limited to small (≤10 mm), iatrogenic perforations.

Looking at the frame after the picture: "retrocardiac echocardiography".

We report three cases of mediastinal structures encroaching on the left atrium without haemodynamic compromise. These cases emphasize the potential role of echocardiography for the diagnosis and the management of several extracardiac mediastinal abnormalities.