Boerhaave's syndrome: a review of management and outcome

Spontaneous oesophageal rupture (Boerhaave's syndrome) is an uncommon but serious condition. A retrospective review was undertaken of the management of 34 patients (age range 17-85 years) presenting between 1991 and 2006. Contrast swallow was possible in 22 patients, confirming the diagnosis in 17. Five patients showed pleural effusion on chest X-rays, with subsequent aspiration or chest drain insertion, confirming the diagnosis. Eleven needed CT scan, four of which showed evidence of a leak. Whilst some patients were referred immediately with the diagnosis, some waited up to 12 days (median delay four days). Whilst most patients were treated by operation on the day of diagnosis, diagnostic delay >24 h and delay in referral resulted in treatment delays of up to 24 days. Fifteen (44%) patients were suitable for primary surgical repair, ten were treated by aggressive conservative management with thoracotomy performed to visualise the perforation and assess suitability for primary repair, and hemithorax being debrided and drainage tubes and nasogastric tubes being accurately positioned under direct vision. One patient required an emergency oesophagectomy and eight patients were suitable only for surgical debridement, their initial diagnosis being delayed (median 2 days, range 2-18 days). The major factor determining treatment was the condition of the patient following initial resuscitation, there being a tendency for delayed referrals to be unsuitable for primary repair (P=0.03). Combined 30-day and in-hospital mortality was 17.6% (n=6). Median ICU stay was 1.5 (range 1-50) days with those with delayed diagnosis needing an average of 6.5 days (range 1-45). Median hospital stay was 21 (range 4-210) days.