Endoscopic stenting as salvage therapy for high-risk Boerhaave's syndrome patients

Spontaneous oesophageal perforation (Boerhaave's syndrome) is a life-threatening emergency with significant morbidity and mortality. Surgical repair remains a key component of management for selected patients; however, many high-risk patients are unsuitable for operative management. This article discusses how, in these high-risk individuals, minimally invasive strategies such as the use of covered self-expanding metal stents (SEMS) offer a valuable alternative to surgery. Stent therapy aims to achieve rapid control of oesophageal leakage, limit mediastinal contamination, and facilitate early sepsis control. When applied in appropriately selected patients, this approach may reduce procedural morbidity while providing effective source control.

This retrospective cohort study analysed all patients diagnosed with spontaneous oesophageal perforation between 2012 and 2024 at a tertiary referral centre. Patients deemed unfit for surgical intervention following comprehensive clinical assessment and acute multidisciplinary team (MDT) discussion-incorporating physiological status, comorbidities, Charlson Comorbidity Index (CCI), Pittsburgh score, markers of infection, and end-organ function-were managed with covered SEMS. Clinical, biochemical, and outcome data were reviewed.

Of 102 patients with oesophageal perforation, 69 were diagnosed with Boerhaave's syndrome. Twenty-two high-risk patients underwent endoscopic stenting with covered SEMS. The in-hospital mortality rate was 45%, predominantly from sepsis and multiorgan failure, while no deaths were directly stent-related. The 1-year survival rate was 50%.

Endoscopic stenting offers a feasible and effective salvage option for high-risk Boerhaave's syndrome patients unsuitable for surgery. SEMS likely prevent otherwise inevitable fatalities in this cohort.