Treatment

The treatment of Boerhaave's syndrome often consists of a combination of medical and surgical interventions. (1) The mainstay of treatment includes avoidance of all oral intake, volume replacement, broad-spectrum antibiotic coverage, nutritional support (usually parenteral), source control of any leaks, and prompt surgical or endoscopic intervention as indicated. Ideally, this should be instituted within six hours of diagnosis and with stabilization of the patient: after this time, the metabolic effects and damage to the oesophagus make survival less likely.

Medical management includes avoidance of all oral intake for at least 7 days, parenteral nutrition, broad-spectrum IV antibiotics for 7 to 14 days, and drainage of any fluid collections.

Surgery entails draining the pleural cavity, searching for concomitant pathology at thoracotomy, e.g. tumours, oversewing the lesion, and closing the chest with an underwater seal drain. Oesophagectomy may be required for extensive stenosing lesions. Parenteral feeding or a feeding gastrostomy may be required.

Surgery has a 36% mortality, whereas medical management has a 65% mortality within 24 hours and a 100% mortality after one week.

Advanced endoscopic techniques can provide patients with a minimally invasive therapeutic intervention. Endoscopic approaches for managing oesophageal perforation include placement of fully covered oesophageal stents, through-the-scope clips, over-the-scope clips, and endoscopic suturing, oesophageal resection and diversion. (2)

Reference

1. Carrott PW, Low DE. Advances in the management of esophageal perforation. Thorac Surg Clin. 2011 Nov;21(4):541-55.
2. Barakat MT, Girotra M, Banerjee S. (Re)building the Wall: Recurrent Boerhaave Syndrome Managed by Over-the-Scope Clip and Covered Metallic Stent Placement. Dig Dis Sci. 2018 May;63(5):1139-1142