From the Guidelines
Boerhaave syndrome is a medical emergency that requires immediate attention, as delayed treatment is associated with high mortality rates, ranging between 10% and 20% 1. The condition is characterized by spontaneous rupture of the esophagus, typically following forceful vomiting, and is often located on the left border of the lower third of the thoracic esophagus with a large wall defect 1.
Key Characteristics
- Spontaneous esophageal perforation accounts for 15% of esophageal perforations 1
- The tear is usually 3-8 cm in size 1
- Forceful retching or vomiting is the most common cause, and the term "Boerhaave syndrome" is often used to describe this condition 1
Diagnosis and Treatment
- Diagnosis requires imaging studies such as CT scan with oral contrast or esophagography
- Treatment depends on the extent of the rupture and the patient's condition, but generally involves:
- Surgical repair of the esophageal tear
- Broad-spectrum antibiotics
- Intensive supportive care, including nil by mouth status, IV fluids, and possibly mechanical ventilation
- For contained leaks in stable patients, conservative management with antibiotics, nasogastric drainage, and parenteral nutrition may be considered 1
Prognosis
- Delay in treatment is the most important survival predictor, with mortality rates increasing significantly if treatment is delayed 1
- Prompt medical attention is essential to reduce the risk of severe sepsis and death 1
From the Research
Definition and Characteristics of Boerhaave Syndrome
- Boerhaave syndrome is a rare, life-threatening condition characterized by spontaneous esophageal rupture 2, 3, 4, 5, 6
- It has no specific symptom, making diagnosis difficult 3
- The condition requires urgent intervention 3
Treatment Options for Boerhaave Syndrome
- Treatment options include primary operative management, endoscopic stent insertion, and a hybrid minimally invasive approach combining esophageal endoscopic stenting with video-assisted thoracoscopic surgery (VATS) 2, 4, 5
- Endoscopic stent insertion offers a promising alternative to traditional surgery 4
- The hybrid minimally invasive approach has shown relatively low mortality rates, even among patients with high perforation severity scores 5
Outcomes and Mortality Rates
- Overall mortality rates for Boerhaave syndrome are significant, with rates ranging from 14% to 25% 2, 5
- Mortality is significantly higher in late-diagnosed patients compared to those diagnosed early 2, 4
- The odds for fatal outcome are higher in the stent group than in the surgery group, although this may depend on various factors including patient comorbidity and time to diagnosis 4
Factors Influencing Treatment Outcomes
- Time to diagnosis and treatment is a critical factor influencing outcomes, with delayed diagnosis associated with higher risk for fatal outcome 2, 4
- Patient factors, including advanced age and comorbidity, should be considered when selecting a treatment approach 2, 4
- The combined approach of rapidly sealing the defect and decontamination of the thorax may contribute to relatively low mortality rates 5