Background/aims: The optimal intervention for Boerhaave perforation has not been determined. Options
include surgical repair with/without a pedicled muscle flap, T tube placement, esophageal
resection or diversion, or an endoscopic approach. All management strategies require
adequate drainage and nutritional support. Our aim was to evaluate outcomes following
Boerhaave perforation treated with surgery, endoscopic therapy, or both.
Patients and methods: We performed a 10-year review of our prospectively maintained databases of adult
patients with Boerhaave perforations. We documented clinical presentation, extent
of injury, primary intervention, “salvage” treatment (any treatment for persistent
leak), and outcome. Results were analyzed using the Fisher’s exact and Kruskal – Wallis
tests.
Results: Between October 2004 and October 2014, 235 patients presented with esophageal leak/fistula
with 17 Boerhaave perforations. Median age was 68 years. Median length of perforation
was 1.25 cm (range 0.8 – 5 cm). Four patients presented with systemic sepsis (two
treated with palliative stent and two surgically). Primary endotherapy was performed
for eight (50 %) and primary surgery for eight (50 %) patients. Two endotherapy patients
required multiple stents. Median stent duration was 61 days (range 56 – 76). “Salvage”
intervention was required in 2/8 (25 %) endotherapy patients and 1/8 (13 %) surgery
patient (stent). All patients healed without resection/reconstruction. There were
no deaths in the surgically treated group and two in the endotherapy group (stented
with palliative intent due to poor systemic condition). Readmission within 30 days
occurred in 3/6 of alive endotherapy patients (50 %) and 0/8 surgery patients. Re-intervention
within 30 days was required for one endotherapy patient.
Conclusion: Endoscopic repair of Boerhaave perforations can be useful in carefully selected patients
without evidence of systemic sepsis. Endoscopic therapy such as stenting is particularly
valuable as a “salvage” intervention. The benefits of endoscopic therapy and esophageal
preservation are offset against an increased risk of readmission in patients primarily
treated endoscopically.
