Clinical profile and treatment outcomes of Boerhaave's syndrome: A 13-year experience from an upper gastrointestinal surgical unit/Boerhaave sendromunun klinik profli ve tedavi sonuclari: Bir ust gastrointestinal cerrahi unitesinin 13 yillik deneyimi

• Published in: Turkish Journal of Surgery Vol. 39; no. 3; p. 177
• Main Authors: Surendran, Suraj, Victor, Coelho, Yacob, Myla, Paul, Negine, Chandran, Sudhakar, John, Anoop, Simon, Ebby George, Samarasam, Inian
• Format: Journal Article
• Language: English
• Published: AVES 01.09.2023
• Subjects: Care and treatment; Diagnosis; Esophageal diseases; Esophagus; Injuries; Intestines; Patient outcomes; Surgery; India
• ISSN: 2564-6850
• DOI: 10.47717/turkjsurg.2023.5830

Objective: Boerhaave's syndrome (BS) is a rare, but potentially fatal condition, characterized by barogenic esophageal rupture and carries a high mortality. We aimed to study our institutional experience of managing patients with BS. Material and Methods: A retrospective review of patients with BS presenting to a tertiary care centre from 2005 to 2018 was carried out in this study. Clinical presentation, diagnostic evaluations, treatments received, and treatment outcomes were studied. Perforations were classified as early (<24 hours) and delayed (>24 hours), based on the time elapsed. Surgical complications were graded using Clavien-Dindo grade.The Pittsburgh perforation severity score was correlated with short-term treatment outcomes. Results: Of the 12 patients [male, 75%; mean (range) age, 53 (28-80) years] included, 10 patients had a delayed (>24 hours) presentation. Chest pain was the dominant symptom (58.3%); six patients presented either in shock (n= 1) or with organ failure (n= 3) or both (n= 2). All the perforations were sited in the lower thoracic esophagus, of which three were contained and nine were uncontained. The seal of the perforation was achieved by surgical repair in four patients (primary repair, 2; repair over a T-tube, 2) and endoscopic techniques in four patients (clipping, 1; stenting, 3). Sepsis drainage [surgical, 7 (open-5, minimally-invasive-2); non-surgical, 5] and feeding jejunostomy were performed in all patients. Five (41.7%) patients received a re-intervention. Median (range) hospital stay was 25.5 (12-101) days, 30-day operative morbidity was 50%, and there was one in-hospital death. The Pittsburgh perforation severity score was as follows: 2-5 in two patients and >5 in 10 patients; there were more delayed presentations, increased surgical interventions, post-procedure morbidity, and in-hospital mortality in the latter group, but the differences were statistically not significant. In 11 patients followed-up [median (range):1507 (17-5929) days], there was no disease recurrence, symptomatic reflux or dysphagia. Conclusion: Favourable treatment outcomes, including reduced mortality and organ preservation can be achieved for Boerhaave's perforations, through a multimodality approach. Minimally invasive, endoluminal or open surgical techniques may be safely utilized in its management. The Pittsburgh severity score can be a useful clinical tool that can be used to select the initial intervention and to predict treatment outcomes. Keywords: Boerhaave's syndrome, spontaneous esophageal perforation, surgery, therapeutic endoscopy, Pittsburgh perforation severity score Giris ve Amac: Boerhaave sendromu (BS), barojenik ozofagus rupturu ile karakterize, nadir fakat potansiyel olarak olumcul bir durumdur ve yuksek mortalite tasir. BS'li hastalari yonetme konusundaki kurumsal deneyimimizi incelemeyi amacladik. Gerec ve Yontem: Bu calismada 2005'ten 2018'e kadar ucuncu basamak bir bakim merkezine basvuran BS'li hastalarin retrospektif bir incelemesi yapilmistir. Klinik prezentasyon, tanisal degerlendirmeler, alinan tedaviler ve tedavi sonuclari incelendi. Perforasyonlar gecen sureye gore erken (<24 saat) ve gecikmis (>24 saat) olarak sinifandirildi. Cerrahi komplikasyonlar Clavien-Dindo derecesine gore derecelendirildi. Pittsburgh perforasyon siddeti skoru, kisa vadeli tedavi sonuclari ile korele idi. Bulgular: Dahil edilmis 12 hastanin [erkek, %75; ortalama (aralik) yas, 53 (28-80) yil] 10'unda gecikmis (>24 saat) basvuru vardi. Gogus agrisi baskin semptomdu (%58.3); alti hasta ya sokta (n= 1) ya da organ yetmezligi (n= 3) ya da her ikisi (n= 2) ile basvurdu. Tum perforasyonlar alt torasik ozofagusa yerlestirilmis olup, bunlarin ucu kontrollu ve dokuzu kontrolsuz idi. Perforasyonun kapatilmasi dort hastada cerrahi onarim (primer onarim, 2; T-tupu uzerinden onarim, 2) ve dort hastada endoskopik teknikler (klipsleme, 1; stentleme, 3) ile saglandi. Sepsis drenaji [cerrahi, 7 (acik-5, minimal invaziv-2); cerrahi olmayan, 5] ve beslenme jejunostomisi tum hastalara uygulandi. Bes (%41,7) hasta yeniden girisim aldi. Ortanca (aralik) hastanede kalis suresi 25,5 (12-101) gundu, 30 gunluk operatif morbidite %50 idi ve bir hastane ici olum meydana geldi. Pittsburgh perforasyon siddeti skoru iki hastada 2-5 ve 10 hastada >5; ikinci grupta daha fazla gecikmis basvurular, artmis cerrahi mudahaleler, islem sonrasi morbidite ve hastane ici mortalite vardi ancak farkliliklar istatistiksel olarak anlamli degildi. Takip edilen 11 hastada [medyan (aralik): 1507 (17-5929) gun] hastalik nuksu, semptomatik refu veya disfaji gorulmedi. Sonuc: Boerhaave perforasyonlari icin cok yonlu bir yaklasimla, azaltilmis mortalite ve organ korumasi da dahil olmak uzere olumlu tedavi sonuclari elde edilebilir. Tedavisinde minimal invaziv, endoluminal veya acik cerrahi teknikler guvenle kullanilabilir. Pittsburgh siddet skoru, ilk mudahaleyi secmek ve tedavi sonuclarini tahmin etmek icin kullanilabilecek yararli bir klinik arac olabilir. Anahtar Kelimeler: Boerhaave sendromu, spontan ozofagus perforasyonu, cerrahi, terapotik endoskopi, Pittsburgh perforasyon siddet skoru