Stepwise endoscopic and surgical management of spontaneous esophageal rupture with severe mediastinal contamination:...

Spontaneous esophageal rupture (Boerhaave syndrome) is a rare and life-threatening condition caused by a sudden increase in intraesophageal pressure, most commonly following forceful vomiting. The early diagnosis of Boerhaave syndrome remains challenging due to its nonspecific clinical presentation. The present study reports the case of a 54-year-old man who presented with severe vomiting after alcohol consumption and overeating, followed by intense chest and back pain, fever and subsequent development of septic shock. Initial computed tomography imaging revealed high-density soft tissue surrounding the lower esophagus within the mediastinum, raising suspicion for esophageal rupture. Due to severe hemodynamic instability, definitive intervention was delayed until day 5 of illness, when bedside gastroscopy confirmed a large transmural perforation communicating with the mediastinal cavity. Through the perforation, necrotic tissue, exposed blood vessels and a pulsatile pericardial structure were directly visualized. Endoscopic debridement and irrigation were performed, followed by the placement of a transesophageal drainage tube as a bridging intervention. On day 8 of illness, the patient underwent video-assisted thoracoscopic surgery for definitive mediastinal debridement and primary esophageal repair. After comprehensive antimicrobial therapy and supportive care, the patient recovered and was discharged. The present case highlights the diagnostic and therapeutic value of bedside gastroscopy as a temporizing bridge to definitive surgery, illustrating the effectiveness of a stepwise, multidisciplinary approach in managing Boerhaave syndrome with severe mediastinal contamination.