Diagnosis and Management of Boerhaave Syndrome

Educational Objectives

The goal of this program is to improve the diagnosis and management of Boerhaave syndrome. After hearing and assimilating this program, the clinician and surgeon will be better able to:

1. Use various imaging modalities to diagnose Boerhaave syndrome.
2. ptimize risk stratification for patients with Boerhaave syndrome.

Summary

Anatomy of the esophagus: the esophagus is a 20- to 30-cm-long muscular tube; begins at the posterior pharynx at the edge of the cricoid cartilage and ends at the stomach; lateral border of the cervical esophagus are the carotid sheath, anteriorly bordered by the trachea and thyroid, and posteriorly by the spine and spine musculature; the vagus nerve runs close to the esophagus in the thoracic region, and is apposed at the tracheal bifurcation; 1 to 2 cm of the intra-abdominal esophagus is normally present, an important factor for the clinical symptoms of spontaneous esophageal perforation; the esophagus has an inner circular and outer longitudinal layer of musculature; the upper one-third part of the esophagus has 50% smooth muscle, increasing to 100% at the gastroesophageal (GE) junction; in the neck the esophagus is supplied by the inferior thyroid arteries, in the upper thorax by the bronchial arteries, and in the lower thorax by the branches of aorta; veins of the abdominal esophagus are bordered by the systemic and portal drainage systems

Boerhaave syndrome: is spontaneous perforation of the esophagus; first described in 1724 by Hermann Boerhaave; constitutes 15% of all causes of esophageal rupture; usual site is the left posterior lateral wall of the distal third of the esophagus; manifests with the typical clinical triad also known as the Mackler triad; it includes vomiting, chest pain, and subcutaneous emphysema; some cases are less symptomatic or asymptomatic; esophageal perforation is rare (3.1 per 1 million patients per yr); usually iatrogenic etiology and caused by instruments and procedures, and with a high (≤40% of patients) mortality; in the case of repairs, there is recurrence of leaks (≤30% of patients) after the original presentation; prognosis is variable but early diagnosis and treatment within 24 hr can improve outcomes

Diagnosis of esophageal perforation: diagnosed clinically by finding subcutaneous emphysema via physical examination, but typically from history of sudden onset of forceful vomiting after a large meal, alcohol intoxication and violent retching, and sudden excruciating chest pain; plain radiography may show subcutaneous emphysema or air in the mediastinum (more common); preferred test for the latter is a contrast study; computed tomography (CT) with oral water-soluble contrast with or without intravenous (IV) contrast is preferred vs an upper gastrointestinal (GI) contrast X-ray; key findings on CT are contrast extravasation, mediastinal air, and associated findings such as pleural effusions, atelectasis, or free intraabdominal air; a continuous, active extravasation or hemodynamic instability is treated differently from a case in which there is no active extravasation and patient is hemodynamically stable; predisposing factors include diverticula, distal obstruction from benign conditions like esophageal motility disorders, or esophageal lesions causing obstruction, or large paraoesophageal hernias with relative distal obstruction caused by the compression of the stomach at the level of the GE junction; once diagnosed, treat as emergency

Stratification of risk: perforation severity scores predict the natural history and prognosis after interventions; the parameters used by the University of Pennsylvania include ≥75 yr of age, tachycardia >100 beats per min, >10,000 leukocytes/mm³ of blood, presence of pleural effusions, fever ≥38.5°C, active extravasation, respiratory compromise, time of diagnosis >24 hr from onset, presence of esophageal cancer (ie, malignant distal obstruction), or hypotension indicating sepsis; later diagnosis determines longer length of stay, chances of re-intervention, intensive care unit (ICU) admission, or mortality; early treatment means 19% fewer re-interventions, 35% chance of shorter hospital stays, and ≥6% decrease in mortality; in 90% of cases perforations are in distal esophagus, more commonly on the left side and the posterior aspect

Management: start IV fluids, IV antibiotics, nil per os (NPO), and immediate referral to an appropriate center; severity score of 0 to 2 with a contained leak can be managed conservatively assuming it is sealed; intervene for active leaks; endoscopic stenting is a recent procedure, although not a standard of care yet; does not guarantee a complete seal; surgery involves primary repair with buttressing of surrounding tissue, eg, an intercostal flap; it is the procedure of choice vs drains; traditionally approached with a left posterior lateral thoracotomy based on the location; approach perforations in other locations like midesophagus (rare) with a right-sided thoracotomy; minimally invasive thoracoscopic or laparoscopic transabdominal approach are options for intraabdominal esophagus, by experienced laparoscopic foregut surgeons with suturing skills; establish enteral access with myotomy for postoperative nutrition; always treat distal obstruction; a medium perforation score of 3 to 5 should be individualized; if the patient has esophageal cancer, understand prognosis; if no other esophageal pathology, perform primary repair with intercostal flap; for a high perforation score ≥5 with esophageal cancer, individualize treatment based on staging of cancer; discuss prognosis with the patients and family before extensive esophagectomies; manage operatively if nonmalignant and the patient is fit for aggressive treatment; choice of procedure is based on the extent of injury, pre-existing pathology, and site of perforation

Readings

Elliott JA et al. Minimally invasive surgical management of spontaneous esophageal perforation (Boerhaave's syndrome). Surg Endosc. 2019;33:3494-3502; doi: 10.1007/s00464-019-06863-2; Han D et al. The role of operation in the treatment of Boerhaave’s syndrome. Biomed Res Int. 2018;2018:8483401; doi: 10.1155/2018/8483401; Ivey TD et al. Boerhaave syndrome: successful conservative management in three patients with late presentation. Am J Surg. 1981;141:531-533; doi: 10.1016/0002-9610(81)90040-4; Kaman L et al. Management of esophageal perforation in adults. Gastroenterology Res. 2010;3:235–244; doi: 10.4021/gr263w; Kuehn F et al. Endoscopic vacuum therapy for various defects of the upper gastrointestinal tract. Surg Endosc. 2017;31:3449-3458; doi: 10.1007/s00464-016-5404-x; Sulpice L et al. Conservative surgical management of Boerhaave's syndrome: experience of two tertiary referral centers. Int J Surg. 2013;11:64-67. doi: 10.1016/j.ijsu.2012.11.013; Sutcliffe RP et al. Surgical management of Boerhaave's syndrome in a tertiary oesophagogastric centre. Ann R Coll Surg Engl. 2009;91:374–380; doi: 10.1308/003588409X428298; Tonolini M, Bianco R. Spontaneous esophageal perforation (Boerhaave syndrome): diagnosis with CT-esophagography. J Emerg Trauma Shock. 2013;6:58–60; doi: 10.4103/0974-2700.106329.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Lo Menzo reported nothing to disclose. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Lo Menzo was recorded exclusively for Audio Digest using virtual teleconference software, in compliance with current social-distancing guidelines during the COVID-19 pandemic. Audio Digest thanks the speakers for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification pro

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS681702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.