LETTERS TO THE EDITOR

 

Atypical localization in Boerhaave's syndrome

Síndrome de Boerhaave de localización atípica

 

 

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Key words: Boerhaave's syndrome. Esophageal perforation.

Palabras clave: Síndrome de Boerhaave. Perforación esofágica.

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Dear Editor,

A 70-year-old man was an elite athlete and had no significant past medical history. After 12 hours with epigastric pain and dyspnea after sudden vomiting, the patient was admitted to hospital. Physical examination showed cold sweats, tachycardia (147 beats/min) and hypotension (82/57 mmHg). Examination of the abdomen was normal. Laboratory values: 8,200 leukocytes/mm³ with neutrophilia (89% N). Cervical-thoracic-abdominal computed tomography (CT) showed a perforation of 6-7 cm in the right posterior wall of the lower esophagus, with important hydropneumothorax and cervical emphysema (Fig. 1A). Surgical treatment was indicated. Through a right thoracotomy a primary suture of the perforation was performed (Fig. 1B) and two chest tubes and a nasojejunal tube were placed. During postoperative period, the patient developed esophageal suture dehiscence and a Wallflex^® type coated stent was placed in the 8^th postoperative day. Due to migration of the prior stent a new Hanarostent^® type coated stent was necessary (Fig. 1C). After thirty days, both stents were removed and the esophagogram was normal (Fig. 1D). The patient resumed oral feeding smoothly and was discharged 82 days after admission. After three and a half months of outpatient follow-up, the patient is asymptomatic.

 

 

Discussion

Boerhaave's syndrome is an esophageal rupture due to increased intraluminal pressure during vomiting in the absence of the upper esophageal sphincter relaxation. The most common location is in the left lateral wall of the distal esophagus (90%) (1). It is a relatively rare disease with high mortality rate from 20 to 40% (2). In fact, it is considered the most lethal of all penetrations of the digestive tract.

The presence of retrosternal pain and subcutaneous emphysema after episode of vomiting (Mackler triad) is a set of symptoms suggestive of acute esophageal perforation (3). The differential diagnosis includes perforated ulcer, myocardial infarction, pulmonary embolism, dissecting aortic aneurysm, and acute pancreatitis (4). Although X-ray can show the existence of pneumomediastinum, subcutaneous emphysema or mediastinal widening, CT with contrast is the test of choice for demonstrating esophageal perforation (5). A delay in diagnosis increases morbidity and mortality and worse prognosis (6).

Aggressive treatment of the perforation by direct suture appears to be the most effective, as well as its combination with endoscopic techniques increase success rates (7-9), as occurred in our patient. Good results with a conservative approach have been described in esophageal perforations of more than 48 hours of evolution (10). In our particular case, we report that the patient had no spontaneous esophageal perforation in the left lateral wall of the distal esophagus, as usual, but it was rarely located in the right posterior wall of the esophageal segment. It was resolved with surgical and endoscopic treatment.

 

Antonio Rodríguez-Infante, Pablo Granero-Castro, José Antonio Álvarez-Pérez,
Estrella Turienzo-Santos and Lino Vázquez-Velasco
Department of General Surgery. Hospital Universitario Central de Asturias. Oviedo, Asturias. Spain

 

References

1. Vial CM, Whyte RI. Boerhaave's syndrome: diagnosis and treatment. Surg Clin North Am 2005;85:515-24.         [ Links ]

2. Sutcliffe RP, Forshaw MJ, Datta G, Rohatgi A, Strauss DC, Mason RC, et al. Surgical management of Boerhaave's syndrome in a tertiary oesophagogastric centre. Ann R Coll Surg Eng 2009;91:374-80.         [ Links ]

3. Schmidt SC, Strauch S, Rösch T, Veltzke-Schlieker W, Jonas S, Pratschke J, et al. Management of esophageal perforations. Surg Endosc 2010; 24:2809-13.         [ Links ]

4. Korczynski P, Krenke R, Fangrat A, Kupis W, Orlowski TM, Chazan R. Acute respiratory failure in a patient with spontaneous esophageal rupture (Boerhaave Syndrome). Respir Care 2011;56:347-50.         [ Links ]

5. Vallböhmer D, Hölscher AH, Hölscher M, Bludau M, Gutschow C, Stippel D, et al. Options in the management of esophageal perforation: analysis over a 12-year period. Dis Esophagus 2010;23:185-90.         [ Links ]

6. Eroglu A, Turkyilmaz, Aydin Y, Yekeler E, Karaoglanoglu N. Current management of esophageal perforation: 20 years experience. Dis Esophagus 2009;22:374-80.         [ Links ]

7. García-Cano J, Jimeno-Ayllón C, Morillas-Ariño MJ. Iatrogenic esophageal perforation sealed by means of a self-expanding metal stent. Rev Esp Enferm Dig 2011;12:648-9.         [ Links ]

8. Salminen P, Gullichsen R, Laine S. Use of self-expandable metal stent for the treatment of esophageal perforations and anastomotic leaks. Surg Endosc 2009;23:1526-30.         [ Links ]

9. Álamo Martínez JM, Galindo Galindo A, López Bernal F, Bernal Bellido C, Belda Laguna O, Sousa Vaquero JM, et al. Tratamiento endoscópico con selladores biológicos de fístulas esofágicas residuales tras cirugía del síndrome de Boerhaave. Rev Esp Enferm Dig 2003;95:366-8.         [ Links ]

10. de Shipper JP, Pull ter Gunne AF, Oostvogel HJ, Van Laarhoven CJ. Spontaneous ruptures of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm. Dig Surg 2009;26:1-6.         [ Links ]