Treatment of Boerhaave Syndrome with Hemodynamic Instability, Non-Contained Perforation, or Severe Sepsis
Spontaneous esophageal perforation (Boerhaave syndrome) is a life-threatening emergency. When the clinical picture includes hemodynamic instability, non-contained contrast extravasation, or systemic signs of severe sepsis, non-operative management is not appropriate and a surgical approach is required.
This protocol addresses spontaneous (Boerhaave) esophageal perforation presenting with one or more of: hemodynamic instability, non-contained extravasation of contrast material, or systemic signs of severe sepsis — any of which excludes non-operative management.
Approach overview
Surgical management is directed at immediate control of mediastinal and pleural contamination and primary repair of the thoracic esophagus, with further steps to reinforce the repair and ensure adequate drainage and nutritional support…
References
DOI: 10.1186/s13017-019-0245-2
- Spontaneous esophageal perforation (Boerhaave syndrome) is most often due to an abrupt increase in the esophageal pressure following a vomiting effort in the absence of relaxation of the superior esophageal sphincter.
- Surgery should be undertaken in all patients who do not meet NOM criteria (Grade 1C).
- Primary repair is the treatment of choice for EP with free perforation of the thoracic esophagus (Grade 1C).
- Management of perforation of the thoracic esophagus relies on immediate interruption of mediastinal and pleural contamination, debridement of the perforation to healthy tissue, tension-free primary repair, and adequate external drainage.
- Buttressing the esophageal repair with surrounding viable tissue (intercostal muscle flap, pleural or pericardic patch) has been recommended to decrease the risk of leakage.
- Drainage of the mediastinum and pleural cavity is required and enteral nutrition remains an essential component of the treatment plan.
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