Boerhaave syndrome: A rare complication of cosmetic surgery

1 Clínica Castellani, Itapeva, SP, Brazil. Conflicts of interest: none. Introduction: The objective of this case report is to alert surgeons to a possible postoperative complication of long cosmetic surgery under general anesthesia. Boerhaave syndrome is a serious life-threatening disease that requires diagnosis within 12 hours and proper treatment. Case report: A 58-year-old female patient presented with vomiting and nausea after abdominoplasty and mastopexy under general anesthesia. Results: The patient underwent dermolipectomy and mastopexy using the inferior pedicle technique under spinal anesthesia. Four hours after the operation, she presented several episodes of vomiting. Ten hours after the operation, she reported painful swallowing followed by generalized severe pain and presented severe dyspnea, sweating, pallor, and a 90/50 mmHg blood pressure. As the condition worsened, the patient was referred to the intensive care unit where she was intubated and underwent laboratory tests, thoracentesis, and radiological examinations. The patient currently uses an esophageal prosthesis. Conclusions: The literature suggests avoiding prolonged surgery, especially under general anesthesia, because of the risk of carbon dioxide retention, which may lead to postoperative emetic crisis in patients with a history of esophageal disease. It also suggests paying attention to symptoms, not excluding the possibility of Boerhaave syndrome. ■ ABSTRACT

considering the lack of studies on the association of Boerhaave syndrome with plastic surgery.
The objective of this study was to alert plastic surgery professionals about Boerhaave syndrome, which may occur after abdominoplasty under general anesthesia.

CASE REPORT
Patient A.M.R.L.P., a 58-year-old woman, visited our clinic to undergo abdominal dermolipectomy and mastopexy.
At physical examination: • Weight: 92 kg; • Gynecological history: 2PN2CP, gestational diabetes; • Cardiorespiratory system: denied dyspnea on exertion or in decubitus position, walked 30 to 40 minutes a day; • Genitourinary system: no complaints; • Gastrointestinal system: denied epigastric pain; • Motor system: rotator cuff tendon rupture in the right shoulder, with a prosthesis placed under general anesthesia; • Family history: maternal breast cancer;

INTRODUCTION
This is a case report study on the rare occurrence of Boerhaave syndrome in a patient who underwent abdominoplasty with general anesthesia.
The patient presented vomiting and nausea after abdominoplasty and mastopexy under general anesthesia, which, together with the use of an abdominal binder, resulted in the syndrome.It is important to emphasize that the location and sudden onset of pain may be confused with myocardial infarction or pulmonary embolism 1 .
Boerhaave syndrome or spontaneous rupture of the esophagus was first described in 1724 by Hermann Boerhaave 2 .It is a severe life-threatening disease that requires diagnosis within 12 hours and proper treatment.It is a relatively rare syndrome, but has a high mortality rate (35%).In fact, it is considered the most lethal type of rupture in the digestive tract 4 .
Boerhaave syndrome should be considered in the postoperative period of abdominal dermolipectomy under general anesthesia, which in this study was associated with mastopexy and postoperative vomiting and nausea.
• Habits: denied smoking or alcoholism; • Others: not using any medications; • Physical examination: abdominal apron with stretch marks in the hypogastric region, Pfannenstiel scar, and grade II breast ptosis (Regnault classification).Laboratory and radiological examinations, and preanesthetic consultation showed no abnormalities, and the patient was considered eligible for surgical dermolipectomy and mastopexy.
On May 25, 2007, she underwent abdominal dermolipectomy and mastopexy using the inferior pedicle technique under spinal anesthesia.The surgery lasted 4 hours with no complications.
Four hours after the end of surgery, the patient presented several episodes of vomiting alternating with periods of improvement after antiemetic medication.
Ten hours after surgery, she reported painful swallowing, which improved with xylocaine spray, and the patient passed the night without other complications.
At 6:45 am on May 26, 2007, she reported generalized severe pain and dyspnea, which improved with administration of corticosteroids and intravenous bronchodilator.The patient was discharged at 11:30 am with no complaints.
On the same date, at 2:30 pm, the patient returned with severe dyspnea, sweating, pallor, and a 90/50 mmHg blood pressure.She received supportive care, but the condition worsened, and she was referred to the intensive care unit, where she was intubated and underwent thoracentesis.The aspirated fluid had characteristics of gastric juice, and the amylase values were increased in the biochemical test (Table 1).The mediastinal shift worsened, but the diagnosis was not conclusive.The patient's general condition was poor, with sepsis and severe changes in laboratory parameters (Table 2).

PLEURAL FLUID TEST (collected
After these examinations, the general surgery team drained the left hemothorax (LHT) and requested computed tomography of the abdomen (Table 3) and chest (Table 4).After several examinations, the patient's condition continued to deteriorate, with LHT opacity 10 days later.
After several radiological examinations and laboratory tests, including upper digestive endoscopy, the patient was transferred to a hospital with a thoracic surgery service, where she underwent a thoracotomy for LHT decortication and was diagnosed intraoperatively at approximately 30 days after her plastic surgery.Currently, the patient is well recovered and uses an esophageal prosthesis.

DISCUSSION
Boerhaave syndrome is characterized by secondary esophageal perforation and a sudden increase in esophageal intraluminal pressure.It is common to find an etiological factor, which is often an internal pressure trauma.Although the classic definition of spontaneous rupture is incorrect, it is universally accepted.This syndrome results from increased intra-abdominal pressure due to vomiting, vomiting efforts, or other efforts.Pressure is rapidly transmitted to the esophagus, and a perforation may occur owing to distension of the mucosa and esophageal muscles, which cannot resist high pressure 5 .
In 80% of cases, the most common cause is vomiting or effort to vomit due to excessive food or alcohol ingestion 5 .
This perforation is often longitudinal and usually occurs on the left lateral wall 5 of the distal esophagus, above the esophagogastric transition and diaphragm.Thus, it may produce an esophageal-pleural fistula with subsequent pleural effusion and/or pneumothorax.
It is more frequent in men between 40 and 60 years of age 6 .The main symptom is severe, abrupt, progressive retrosternal pain.The classic Mackler's triad 7 , including vomiting, chest pain, and cervical emphysema, is uncommon.Hematemesis occurs in 22% of cases.Dyspnea occurs in 61% of cases, and cyanosis is also common.When an esophageal-pleural fistula is present, the typical pleural fluid presents nonspecific findings such as low pH and increased amylase 8 , and the diagnosis can be confirmed by finding food in the fluid.Other signs and symptoms include dysphagia, tachycardia, and hypotension, which may progress to sepsis and death.
Many diagnostic tools are available, including clinical diagnosis with history, physical examination, and radiological findings.Physical examination shows decreased vesicular murmur and fever in 30% of cases, with possible cervical crepitus and decreased airborne noises.Laboratory tests may show leukocytosis in some cases, without further changes 9 .
Chest radiography is useful for initial diagnosis, and the most common finding is pleural effusion, usually on the left side.Other findings include pneumothorax, often on the left side 5 , hydropneumothorax, pneumomediastinum, and subcutaneous emphysema.
Esophagography would reveal typical contrast extravasation into the pleural cavity and provide information on the size and location of the perforation, which are useful in choosing the most adequate surgical approach 9 .
Computed tomography can confirm the diagnosis or replace esophagography in intolerant patients.Early diagnosis and proper treatment are essential to prevent mediastinitis, sepsis, and shock, often associated with the second phase of the disease Choosing the surgical technique to treat the spontaneous esophageal perforation can be controversial, and time from onset is a decisive factor.When the diagnosis is established within the first 24 hours, cardiorespiratory stabilization, clinical support, and antibiotic therapy are recommended, as well as primary closure of the perforation through thoracotomy associated with mediastinal drainage.
After this period, the presence of edema, tissue necrosis, and mediastinal infection can make surgery extremely difficult.The most important complication of primary closure is the occurrence of fistulas.

Table 1 .
Pleural fluid test results

Table 3 .
Complete abdominal tomography result

Chest tomography (May 27, 2007)
Chest wallNo changes in subcutaneous tissue, chest muscles, intercostal area, and costal arches Anterosuperior thoracic drainage of the left hemothorax Subcutaneous emphysema in the chest wall

Table 4 .
Chest computed tomography results Source: ICU, Santa Casa de Itapeva