Enhanced Recovery Protocol for Boerhaave Syndrome: Our Experience

Abstract

From its first description in 1724, the diagnosis and management of Boerhaave syndrome remain challenging till date. We share our management protocol for enhanced recovery in patients presenting more than 24 h following spontaneous esophageal rupture at a tertiary care center in India. A retrospective review of all patients diagnosed with Boerhaave syndrome and managed by the chief investigator in the Department of General Surgery at our institution in the last 3 years (2016–2019) was performed. After hemodynamic stabilization, an intercostal drainage (ICD) tube was inserted on the side of empyema to drain the collection. This was followed by an upper GI (UGI) endoscopy to confirm the site and size of perforation. No attempt at a therapeutic intervention was made during the procedure. A triple lumen tube was inserted under imaging at the same time for gastric decompression and advanced to the jejunum for enteric feeding. In patients with sepsis and persistent collection, a video-assisted thoracoscopic (VATS) drainage was performed. Twelve patients were admitted for Boerhaave syndrome. ICD was inserted for 9 patients and managed by us as per our enhanced recovery protocol. Three patients referred from other setup came with an ICD in situ showing signs of sepsis. Debridement and drainage by VATS was performed for these patients. No patient required prolonged ventilatory assistance, and there was no mortality. Gastric decompression, adequate and timely drainage of collection/s, and enteral nutrition form the pillars of enhanced recovery protocol for management of Boerhaave syndrome.