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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 167-169

Endoscopic management of failed surgical repair of Boerhaave's syndrome


1 Department of Gastroenterology, Care Hospitals, Nagpur, Maharashtra, India
2 Department of Gastroenterology, Aureus Hospital, Nagpur, Maharashtra, India
3 DSC Enterprises, Endoscopic Technician, Affiliated to Care Hospital, Nagpur, Maharashtra, India

Date of Submission25-Apr-2021
Date of Acceptance12-Aug-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Shankar Zanwar
Care Hospitals, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_17_21

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  Abstract 


We present a case of failed surgical repair of Boerhaave's syndrome managed with minimally invasive care and first of its kind use of Padlock Clip for Boerhaave's syndrome.

Keywords: Boerhaave's syndrome, endoscopic management, Padlock Clip


How to cite this article:
Zanwar S, Gupta V, Patle N, Ganjare A, Rajput A, Chaware S. Endoscopic management of failed surgical repair of Boerhaave's syndrome. Gastroenterol Hepatol Endosc Pract 2021;1:167-9

How to cite this URL:
Zanwar S, Gupta V, Patle N, Ganjare A, Rajput A, Chaware S. Endoscopic management of failed surgical repair of Boerhaave's syndrome. Gastroenterol Hepatol Endosc Pract [serial online] 2021 [cited 2021 Oct 24];1:167-9. Available from: http://www.ghepjournal.com/text.asp?2021/1/4/167/326628




  Introduction Top


We present a case of 60-year-old male who had an episode of a forceful vomiting after having dinner at a wedding in the month of December 2019 in Mumbai. He had no comorbid illness and addictions. After that vomiting, he developed severe breathlessness and chest pain. He was evaluated there and was found to have surgical emphysema, hydropneumothorax, and pneumomediastinum. Endoscopy was done and he was diagnosed to have Boerhaave's syndrome – lower esophageal tear of approximately 1.5 cm was noted. Chest drains were placed; initially, he was managed conservatively for 3 days. His general condition worsened and endotracheal intubation with invasive ventilation was initiated. After 4 days of vomiting, thoracotomy with esophageal perforation repair and mediastinal drainage was done. Five days after surgery, he had persistent high-output drainage from the intercostal drains. He was managed with IV antibiotics and antifungals with NJ tube feeding next 2 weeks, he showed no consistent improvement.

After 25 days, he was shifted to our center. At the presentation he had fever. On examination, he was moderately built, had tachycardia and tachypnea with in situ endotracheal tube, and was requiring ventilator support. He also had chest drain in situ, nasojejunal tube, and a central line in the internal jugular vein. He had good urine output and was responding well to commands. Laboratory evaluation revealedthat leukocytosis, liver, and renal profiles were near normal. He was on total parenteral nutritional support. Blood, urine, tracheal aspirate, and chest tube fluid cultures were sent and antibiotics changed empirically according to local sensitivity patterns. Contrast-enhanced computerized tomography (CECT) of the thorax and upper abdomen was done with oral contrast. This showed a leak from the lower esophagus communicating to the mediastinum. The impression made was esophagomediastinocutaneous fistula. Multidisciplinary team opinions were sought and relatives were explained step-up approach plan, an attempt of endoscopic treatment and maintaining drainage, if failed to be followed by surgical intervention.

On January 6, 2020, i.e., 27 days after the index episode, endoscopy [Figure 1] was done and a large rent in the lower esophagus of 2.5 cm approximately one cm above the gastro esophageal (GE) junction was noted. The scope could easily enter into the mediastinum. The edges of the defect appeared epithelialized. Endoscopic closure of the defect was done using a Padlock Clip which closed the defect except for the distal 5 mm opening – which was closed using hemoclip (Resolution clip). Over this, a fully covered self-expanding metal stent of size 26 mm × 110 mm was placed and the upper end of the stent was secured with hemoclips [Figure 2]. Laparoscopic surgeon did lavage from the chest tube and placed a feeding jejunostomy (FJ). The patient was monitored in the intensive care unit (ICU) – nutritional support with FJ and antibiotics according to blood cultures was continued. Over a period of 3 weeks, the patient had a stable condition with no further worsening. Serial imaging was done with X-rays [Figure 3]. X-ray after 2 weeks showed stent displacement and the stent was replaced in position. After 4 weeks, there was a small leak seen in the oral contrast computerized tomography (CT) and he had a smaller remnant collection. Thus, relook endoscopy was done and the lower esophageal defect was smaller in size compared to index endoscopy. The edges of the defect now showed cut areas due to spikes of the Padlock Clip. The Padlock Clip had freshened the edges. Padlock Clip and stent were removed and healing by primary intention promoted since granulation tissue was now apparent. Venting percutaneous endoscopic gastrostomy (PEG) was done. He was managed in ICU for the next 1 week; over this time, his ventilator requirements reduced significantly, the chest tube drain and pleural effusion also reduced. He was shifted to ward after 1 week. Nutritional supplementation and antibiotics were continued. After period of 25 days, he was discharged with chest tube, venting PEG tube, and FJ in situ. After 45 days, repeat CT was done which showed no leak of oral contrast, thus the chest tube was removed, endoscopy was done, and no defect was noted. After 64 days, his FJ was also removed. He is now fully ambulatory gained 15 kg weight and needs no medical support for activities of daily living.
Figure 1: Endoscopic appearance of the tear above the OG junction

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Figure 2: Image intensifier view during the procedure

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Figure 3: Post procedure X ray chest showing Padlock clip and stent in situ

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As above, we present a case of Boerhaave's syndrome initially managed surgically that did not yield, later shifted to our center. We did endoscopic management with Padlock Clip and stenting which not only reduced the output from the fistula but also freshened the edges of the epithelialized esophageal opening. With a multidisciplinary approach, the patient could recover completely. To the best of our knowledge based on an extensive literature search, this is the only case of Boerhaave's syndrome being managed with a Padlock Clip from India.


  Discussion Top


Boerhaave's syndrome was first described in 1724.[1] The postulated hypothesis for esophageal rupture in Boerhaave's syndrome is an abrupt increase in intraluminal pressure formed during vomiting due to failure in relaxation of the cricopharyngeus muscle.[2] The tear is commonly located in the distal esophagus and involves the left posterolateral wall roughly 2–3 cm above the GE junction. The patient presents classically with repeated bouts of retching and vomiting, with too much food and alcohol intake usually in a middle-aged man. Meckler's triad of vomiting, lower chest pain, and surgical emphysema is seen in only 14% of patients.[3]

CECT of the thorax and upper abdomen with oral contrast is an investigation of the choice. Mortality of patients with this syndrome is 10% when diagnosed early and 50% when delayed.[4] Endoscopic therapy can be a salvage treatment for patients not responding to initial surgical management as in our case.[5]

In our case, primary surgery was delayed by 4 days, thus sutures could not hold the edges, and probably, the sepsis had set in by then which added to poor healing. Also at initial hospitalization, only a nasogastric tube was placed which contributed to the worsening of mediastinal contamination. This was corrected at our center by creating a FJ.

Endoscopic therapy in this patient with hemoclips or mere placement of covered metal stent would not have sufficed as the edges of the opening appeared epithelialized after 27 days of index episode. Thus, the use of Padlock Clips helped not only in apposing the edges, but the penetrating spikes freshened the mucosa and incited growth of the granulation tissue which hastened healing. Despite this, the patient had some persistent leaks. A venting PEG was done and leak decreased. A venting PEG is a recommendation in poststenting esophageal leaks.[6] The clip was removed later as granulation tissue was visualized and keeping clip any further would prevent adequate healing due to presence of foreign body in the fistula.

A constant and scrupulous support from intensive care and surgical team is mandatory in management of patients with Boerhaave's syndrome to circumvent the infective and mechanical respiratory complications. This included ensuring complete drainage of the mediastinal leak with frequent reassessments. The most important aspect of careful monitoring of nutritional status cannot be undermined for an ultimate successful outcome.

Based on our experience in this case, Padlock Clip, esophageal stenting, and a venting PEG can be attempted in a patient with Boerhaave's syndrome when a multidisciplinary team is available.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Adams BD, Sebastian BM, Carter J. Honoring the admiral: Boerhaave-van Wassenaer's syndrome. Dis Esophagus 2006;19:146-51.  Back to cited text no. 1
    
2.
Bjerke HS. Boerhaave's syndrome and barogenic injuries of the esophagus. Chest Surg Clin N Am 1994;4:819-25.  Back to cited text no. 2
    
3.
Woo KM, Schneider JI. High-risk chief complaints I: Chest pain--the big three. Emerg Med Clin North Am 2009;27:685-712.  Back to cited text no. 3
    
4.
Klin B, Berlatzky Y, Uretzky G. Boerhaave's syndrome: Case report and review of the literature. Isr J Med Sci 1989;25:113-5.  Back to cited text no. 4
    
5.
Dickinson KJ, Buttar N, Wong Kee Song LM, Gostout CJ, Cassivi SD, Allen MS, et al. Utility of endoscopic therapy in the management of Boerhaave syndrome. Endosc Int Open 2016;4:E1146-50.  Back to cited text no. 5
    
6.
Stephens EH, Correa AM, Kim MP, Gaur P, Blackmon SH. Classification of esophageal stent leaks: Leak presentation, complications, and management. Ann Thorac Surg 2014;98:297-303.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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