Tulip-bundle technique for suture dehiscence in a Boerhaave syndrome

A 55-year-old-woman was admitted to the emergency department with hematemesis and abdominal pain. Her physical examination was unremarkable. Laboratory results without anemia. The upper gastrointestinal endoscopy revealed a deep large tear between 36 and 39 cm with transmural perforation. A diagnosis of Boerhaave syndrome was made. Thoraco-abdominal CT-scan revealed a laceration in the left posterolateral side of the esophagus, measuring 6.5 cm proximal to the esophagogastric junction (GEJ), associated with a pneumomediastinum, pneumoperitoneum and a mediastinal air fluid collection anteriorly to the GEJ. The patient was submitted to laparoscopic surgery with closure of the perforation, Graham patch confection. Nine days after, the esophago-gastric transit showed luminal contrast leakage to the posterior mediastinum. An endoscopic evaluation showed a 2 cm suture dehiscence. We applied a hemostatic clip in the distal end of the tear to bring the edges closer, but it was impossible to put additional ones. It was decided to perform a tulip-bundle technique with a single-channel endoscope in a sequential two-step maneuver and another two clips were placed in the borders of the tear with an endoloop applied over the clips with success. One month later, an endoscopic revaluation was performed, revealing the clips involved by the endoloop and no signs of leakage. After that, she started oral diet without any complications.