Salvage Endotherapy (Stent and Suture) for Failed Thoracotomy Repair of Boerhaave Syndrome

Abstract

Introduction: Transmural esophageal perforation, or Boerhaave syndrome, is a life threatening emergency. Urgent surgical repair of the defect using a left thoracotomy is the standard of care. Occasionally surgical repair doesn't completely fix the injury, especially in cases with delayed presentation when tissues are friable. Endotherapy using temporary covered esophageal stent (ES) is often successful in healing such defects, but stent migration can occur. Case description: A 59 year old male with history of intermittent solid food dysphagia presented with epigastric pain after a violent retching episode. He developed odynophagia, dyspnea and fever. A thoraco-abdominal CT scan showed pneumomediastinum, bilateral pleural effusions and pneumoperitoneum within the lesser sac (Fig 1). Gastrograffin upper GI series showed a distal esophageal perforation. Esophagoscopy revealed a impacted food bolus in distal esophagus. Utilizing a left thoracotomy, a large purulent fluid collection was evacuated. The paraesophageal tissue was friable and the perforation was located immediately above the GE junction. It was repaired in 2 layers and buttressed with an intercostal muscle flap. Postoperatively the patient was intermittently febrile. Repeat CT scan showed a small residual left pleural effusion, fluid collection in the lesser sac and esophago-pleural fistula. The lesser sac collection was drained percutaneously. Esophagoscopy confirmed the esophago-pleural fistula, and a fully covered ES was deployed to cover the defect (Fig 2). Repeat imaging showed distal migration of the ES. The stent was repositioned during esophagoscopy, and its proximal end was anchored to the esophageal wall by endoscopic suturing, overstitch (Fig 3). The patient gradually improved with resolution of fluid collections in the chest and abdomen and was discharged. The ES was retrieved 6 weeks later and the fistula had completely healed.Figure 1Figure 2Figure 3Discussion: Our patient presented >48 hrs after onset of symptoms and had developed an empyema and fluid collection in the lesser sac for which surgical exploration was warranted. In cases that present early and tissue contamination is minimal, a covered ES may be sufficient in repairing the esophageal tear. When used in a non-obstructed esophageal lumen, a covered ES tends to displace and migrate distally necessitating some form of anchoring. While endoclips are likely to displace easily, endoscopic suturing appears to offer a better alternative.