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Ann Thorac Surg 1999;67:1482-1483
© 1999 The Society of Thoracic Surgeons

Case Reports

Expanding mesh stent in the emergency treatment of Boerhaave’s syndrome

Andrew P. Davies, MRCSa, Roger Vaughan, FRCSa

a Department of Thoracic Surgery, Norfolk and Norwich Hospital, Norwich, United Kingdom

Accepted for publication October 22, 1998.

Address reprint requests to Mr Vaughan, Department of Thoracic Surgery, Norfolk and Norwich Hospital, Brunswick Rd, Norwich, NR1 3SR, UK


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Boerhaave’s syndrome, or spontaneous esophageal perforation, is a life threatening condition demanding early diagnosis and rapid aggressive management to prevent fulminant mediastinitis and death. We describe a patient treated in an emergency situation with an expanding esophageal mesh stent to bridge the esophageal rent together with chest and mediastinal drainage, resulting in complete recovery and return to the community. We also describe the partial recovery of the stent in the convalescent period.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Boerhaave’s syndrome is potentially lethal and presents not only a diagnostic but also a therapeutic challenge. Most series report a substantial morbidity and mortality rate [1, 2]. The accumulation within the mediastinum and pleural spaces of corrosive gastric juices, enzymes, and food results in fulminant mediastinitis and severe cardiorespiratory embarrassment. Patients are, therefore, extremely unwell on admission and require urgent resuscitation prior to the emergency operation to drain the mediastinal and pleural spaces and to effect a repair of the esophageal perforation. What is required, therefore, is a fast, efficient means of sealing the esophageal rent.

A previously independent, but rather frail, 85-year-old lady was presented as an emergency with severe epigastric pain of sudden onset after a bout of vomiting. The diagnosis was confirmed by contrast swallow that showed a long, left-sided tear in the distal third of the esophagus draining into a large sliding hiatus hernial sac. The patient’s condition deteriorated rapidly and she was transferred to the intensive care unit where her condition was optimized. She was then transferred to the operating theaters where she underwent drainage and lavage of both pleural cavities and the mediastinal cavity via an upper midline laparotomy with siting of wide bore drainage tubes to each of these three spaces. A feeding jejunostomy was sited and a covered Wall stent endoprosthesis (Schneider SA, Bulach, Switzerland) was placed across the esophageal rent under x-ray control, above the hiatus hernia. The hernia was not repaired, because the patient was too unstable under anesthesia. The total time in the operating theater was 80 minutes. The patient was then transferred back to the intensive care unit.

A contrast swallow performed on the 15th postoperative day showed the wall stent correctly located and contrast flowing freely through it with no continuing evidence of a leak (Fig 1A ). The patient was then started on a soft diet and was discharged from the hospital on the 18th postoperative day. Four weeks later using a rigid esophagoscope under general anesthetic, the stent was retrieved in a piecemeal fashion until no further evidence of it could be seen. A contrast swallow performed the following day (Fig 1B) showed that the majority of the stent had indeed been removed, although clearly some strands of it still remained. Ten weeks after her admission this patient is symptom-free and living back in the community.



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  		Fig 1. (A) Stent in situ with no evidence of leak. (B) After retrieval of stent.

 

   Comment
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 Abstract
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References
 
Boerhaave’s syndrome is a relatively rare, but life threatening condition that may mimic a large number of medical and surgical diagnoses. The incidence of diagnostic error can be 50% or higher [3, 4].

Despite numerous reports documenting a wide range of potential treatments for esophageal perforation, controversy still surrounds the most effective therapy [5]. Patients are usually shocked and this may be hard to correct until the mediastinum is opened and tamponade is relieved. Options for surgical management include primary closure, esophageal resection, drainage alone, or exclusion and diversion. The use of self-expanding mesh stents has been well described for the treatment of benign esophageal stricture [6] and also malignant dysphagia [7]. The use of expanding mesh stents has also been described to treat iatrogenic esophageal perforation resulting from the treatment of malignant strictures, either by dilator or laser therapy [8]. Our experience with the use of the self-expanding stent in the emergency situation of Boerhaave’s syndrome confirms that the procedure is both rapid and effective in sealing the esophageal rent to prevent further leakage of gastric contents. We have also demonstrated that the judicious removal of such a stent is possible during the convalescent period, thus allowing the patient to go back onto a normal diet. Removal also avoids future potential complications of stent migration and uncontrolled stent expansion.

The use of the self-expanding wall stent endoprosthesis offers a rapid, safe and effective treatment of the esophagal rent in Boerhaave’s syndrome. The relative speed with which the tear can be sealed in this manner is of particular benefit to patients who are frail or elderly and cannot tolerate prolonged anesthesia.


   References
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 Abstract
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 References
 

  1. Walker W.S., Cameron E.W.S., Walbaum P.R. Diagnosis and management of spontaneous transmural rupture of the esophagus. Br J Surg 1985;72:204-207.[Medline]
  2. Pillay S.P., Ward M., Cowen A., Pollard E. Esophageal ruptures and perforations – a review. Med J Aust 1989;150:246-252.[Medline]
  3. Keighley M.R.B., Girdwood R.W., Ionescu M.I., Wooler G. Spontaneous rupture of the esophagus: avoidance of post operative morbidity. Br J Surg 1972;59:649-652.[Medline]
  4. Levine P.H., Kelley M.L. Spontaneous perforation of esophagus simulating acute pancreatitis. JAMA 1965;191:343-345.
  5. Bladergroen M.R., Lowe J.E., Postlethwait R.W. Diagnosis and recommended management of esophageal perforation and rupture. Ann Thorac Surg 1986;42:235-239.[Abstract]
  6. Foster D.R. Self-expandable esophageal stents in the management of benign peptic esophageal strictures in the elderly. Br J Clin Pract 1997;51:199.[Medline]
  7. Ellul J.P., Watkinson A., Khan R.J., Adam A., Mason R.C. Self expanding metal stents for the palliation of dysphagia due to inoperable esophageal carcinoma. Br J Surg 1995;82:1678-1681.[Medline]
  8. Watkinson A., Ellul J., Entwistle K., Farrugia M., Mason R., Adam A. Plastic covered metallic endoprostheses in the management of esophageal perforation in patients with esophageal carcinoma. Clin Radiol 1995;50:304-309.[Medline]



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