How Far Can We Go to Avoid Surgery? Successful Management of a 4 cm Esophageal Perforation

Boerhaave syndrome is a critical condition characterized by transmural esophageal perforation secondary to increased intraesophageally pressure. Most common clinical scenario is secondary to forceful emesis. It requires prompt intervention to prevent potentially fatal consequences and ensure better patient outcomes.

We present the case of an 84-year-old male patient with no significant past medical history, admitted to our hospital with a high clinical suspicion of esophageal perforation. X-ray revealed hydropneumothorax. A left pleurostoma was promptly performed, and within six hours, endoscopic evaluation confirmed Boerhaave syndrome, revealing a large distal esophageal defect measuring 4 cm on the left lateral-posterior wall. A nasogastric tube was inserted, and the patient was transferred to ICU for further management. Clinical status was deteriorating due to respiratory failure [1].

A joint decision by the multidisciplinary team facilitated the prompt initiation of endoscopic treatment. The defect was subsequently managed by placing a Lockado clip at the proximal region of the lesion and two Padlock clips distally. Finally, a fully covered self-expanding metal stent (SEMS) measuring 120 mm×24 mm was deployed, ensuring complete closure of the defect.

Endoscopic clipping and stenting are minimally invasive techniques that have significantly reduced mortality and morbidity in esophageal perforations and while formal guidelines are continuously improving these methods have proven effective for treating a variety of perforation causes and locations.

• References

• 1 Shaqran TM, Engineer R, Abdalla EM, Alamoudi AA, Almahdi R, Aldhahri A, Alghamdi AM, Abufarea BM, Almutairi RF, Al-Suliman AA.. The Management of Esophageal Perforation: A Systematic Review. Cureus. 2024; 16 (7): e63651 PMID: 39092389; PMCID: PMC11293018