S2324 Multimodality Endoscopic Treatment of Boerhaave Syndrome

Abstract

INTRODUCTION: We present a case of Boerhaave syndrome successfully treated with endoscopic suturing followed by esophageal stent placement. CASE DESCRIPTION/METHODS: A 54-year-old male presented with chest pain after repeated episodes of retching. CT showed pneumomediastinum and pleural effusions. The patient went into septic shock requiring vasopressors and mechanical ventilation. Bilateral chest tubes were placed. Fluid draining from the chest tubes was high in amylase. An urgent EGD was performed at the bedside in the ICU. Endoscopy revealed a 6 cm esophageal perforation (Figure 1). The patient was deemed a poor surgical candidate secondary to hemodynamic instability, and thus we proceeded with endoscopic treatment. Given the large defect size, we attempted primary closure with endoscopic suturing using three interrupted sutures and achieved excellent tissue apposition (Figure 2). This was followed by placement of a 15 cm × 20 mm, through the scope, fully covered self-expanding metal stent across the sutured defect site. The upper flare of the stent was then sutured endoscopically to the esophageal wall to minimize the risk of distal migration. An esophagram two weeks later showed no leakage of contrast. The patient improved clinically, tolerated a soft diet, and was discharged. Repeat EGD was performed 3 months later to remove the stent. The perforation site had healed (Figure 3). DISCUSSION: We used a combination of endoscopic techniques to successfully treat a patient with Boerhaave syndrome. Temporary placement of esophageal stents have been reported for this condition. This works not by directly closing the perforation site but rather by preventing oral and GI secretions from passing through the defect and thereby allowing a natural inflammatory response to ultimately seal the perforation. We were concerned that the large size of the defect may not allow the esophageal stent to sufficiently appose the entire defect. We believe that endoscopic suturing mimics primary surgical closure and also facilitates stent fixation, which may minimize the risk of stent migration. We advocate that if endoscopic suturing tools and expertise are available and if endoscopic suturing is considered for stent fixation, efforts should be made to primarily close the defect by endoscopic suturing before placing and anchoring the esophageal stent. Finally, this case also highlights that this procedure can be performed at the ICU bedside without the need for fluoroscopy, which may be ideal in unstable patients.Figure 1.: The endoscopic view reveals a large 6 cm perforation in length.Figure 2.: Endoscopic view showing complete closure of the defect using OverStitch Endoscopic Suturing System (Apollo Endosurgery. Austin, TX) prior to placement of a through the scope, fully covered self-expanding metal stent (Taewong Medical. Seoul, Korea) across the sutured defect site. Yellow triangle tip at the level of the most proximal suture.Figure 3.: Endoscopic view after stent removal. The perforation site has completely closed 3 months after the initial intervention.