The evolving management of Boerhaave syndrome: a hybrid approach in patients with an elevated risk of fistula recurrence

Boerhaave syndrome (BS) is a transmural esophageal tear caused by an abrupt rise in intraluminal esophageal pressure, most commonly due to a neuromuscular incoordination during retching or vomiting. The typical presentation, known as the Mackler’s triad, is only found in a minority of patients. Patients instead typically present with vague signs and symptoms, such as chest or epigastric pain, tachycardia, tachypnea, dyspnea, hypotension and fever. Gastrografin or barium contrast esophagography or CT scan with oral contrast can directly demonstrate the leakage of contrast medium from the site of the perforation into the surrounding spaces. Because of the rarity of this condition and its vague clinical picture, the barogenic rupture of the esophagus, compared to other causes of esophageal perforation, is more commonly associated with a diagnostic delay, that severely affects its prognosis. This thesis reports the case of a 64-year-old woman that was admitted to the emergency room for dyspnea, retrosternal and epigastric pain and history of a single episode of vomiting after cold fluids ingestion, occurred the day before. The suspicion of a post-emetic esophageal rupture came when biliary fluid appeared from the chest drainage on the following day. The diagnosis was than confirmed by a CT scan with oral contrast. The patient first underwent a primary repair of the lesion, then needed reoperation on the 6th postoperative day, due to the recurrence of the fistula. Endoscopic stent placement was used as a salvage procedure in combination with surgical debridement and drainage for the containment of the sepsis, and with the fixation of the stent with a surgical stich crossing all the esophageal layers in order to reduce the risk of migration. Currently the most effective treatment option for BS is primary repair, especially when performed within 24 hours although recently, the use of endoscopic and hybrid techniques is increasing, improving the outcomes. Endoluminal stent placement is not without risks, but these can be reduced with the application of preventive measures. The fixation of the stent with a surgical could drastically reduce the risk of stent migration, which represents the main complication of this procedure. In patients with a delayed diagnosis, combining stent placement with primary repair could prevent the recurrence of the fistula, which has an increased risk of occurrence in this group of patients.