Abstract H.Sakthivel

Challenges in the Management of Complicated Boerhaave’s Syndrome

Presenting Author :

H.Sakthivel ,Chennai , India ( shakthivel.hsurgeon@gmail.com)

Co – Authors : M Kanagavel, Apsara Chandramohan, Professor Balaji Singh, Professor SM Chandramohan

Background:

Spontaneous esophageal perforation (Boerhaave’s Syndrome) is one of the rare causes of esophageal perforation. The rate of misdiagnosis is as high as 50 % because of its nonspecific symptoms. It is a true surgical emergency with high morbidity and mortality. Varied modalities of treatment are available (Endoscopic / Surgical) for the management of the same. Here we discuss the challenges faced in the management of 16 cases of Complicated Boerhaave’s Syndrome in our department.

Methods:

16 cases of complicated Boerhaave’s syndrome managed by a single surgical team were analyzed. Patients demographic variables, average time of presentation, evaluation done, modalities of treatment adopted and outcomes were analyzed.

Results:

We analyzed 16 patients of complicated Boerhaave’s Syndrome managed in our department. 11 patients were initially diagnosed as Cardiac or pleuritic chest pain and evaluated for cardiac, pulmonary or non-esophageal thoracic cause. 5 patients were managed outside as Boerhaave’s syndrome and referred to us. All patients were male patients.

Age range was 22- 81 years (Mean – 42.4). The most common initial presenting symptom was chest pain followed by dyspnea. History of ethanol use was present in 6 patients.  Initial presentation was pyothorax in 7 patients, pleural effusion in 7 patients and unstable angina in 2 patients. The median delay in diagnosis was 16 days (Range – 11– 40 days). All patients but one had perforation in the lower third of esophagus. The perforation was into the right pleural cavity in 6 patients, left pleural cavity in 8 patients and both in 2 patients. 1 patient was managed conservatively, Transhiatal esophagectomy was done in 8 patients, abdominal and right thoracic approach esophagectomy was done in 6 patients and left thoracoabdominal approach esophagectomy was done in 1 patient. Average length of hospital stay was 18 days and there was no mortality. In the follow up 1 patient developed anastomotic stricture for which revision of anastomosis was done. After a median follow up of 30 months all our patients are symptom free.

Conclusion:

Boerhaave’s syndrome is a surgical emergency and needs immediate intervention

(Endoscopic / Surgical). For delayed presentation surgery is the mainstay of treatment

with good outcomes after esophagectomy. Patients who survive the acute insult have good outcomes after the surgical intervention.