UPPER gi Ann R Coll Surg Engl 2013; 95: 552–556 doi 10.1308/003588413X13629960049315
Minimally invasive endoscopic therapy for the management of Boerhaave’s syndrome JH Darrien, H Kasem NHS Lanarkshire, UK ABSTRACT INTRODUCTION Boerhaave’s syndrome represents the most lethal of all gastrointestinal perforations. In 2009 a treatment
algorithm was published based on current level 4 evidence indicating that all septic patients should be treated surgically, early presentations without sepsis endoscopically and delayed presentations without sepsis conservatively. No provision was made for septic patients unfit for surgical intervention. Using a case series, we demonstrate how minimally invasive endoscopic therapies can be used successfully to manage such a cohort. METHODS Between September 2008 and January 2010, five patients presented to Wishaw General Hospital with Boerhaave’s syndrome, all with an associated septic profile and none fit for surgery. They were managed using minimally invasive endoscopic therapies including endoscopic placement of oesophageal stents, elimination of mediastinal/pleural contamination using video assisted thorascopic lavage, management of subsequent collections using sinus tract endoscopy and minilaparotomy with transhiatal endoscopic drainage, and closure of oesophagocutaneous fistulas using the Surgisis® (Cook Surgical, Bloomington, IN, US) anal fistula plug sited endoscopically with a rendezvous technique. RESULTS Oesophageal re-epithelialisation and resolution of sepsis was achieved in all five cases on days 50, 50, 51, 59 and 103. Four patients are alive today. The fifth died on day 109 in hospital as a consequence of co-morbidity. Two patients required oesophageal dilatation for benign oesophageal strictures. CONCLUSIONS Minimally invasive endoscopic therapy can be used successfully to achieve oesophageal re-epithelialisation and resolution of sepsis in patients unfit for surgical intervention. It offers a feasible treatment for patients not accounted for in today’s literature and expands on currently described endoscopic therapies.
Keywords
Boerhaave’s syndrome – Oesophageal stent – Surgisis® anal fistula plug Accepted 16 July 2013 correspondence to Jennifer Darrien, c/o Hasan Kasem at Wishaw General Hospital, 50 Netherton Street, Wishaw, North Lanarkshire ML2 0DP, UK T: +44 (0)1698 361 100; F: +44 (0)1698 366 136; E: [email protected]
A spontaneous oesophageal rupture, also known as Boerhaave’s syndrome, is regarded as the most lethal of all gastrointestinal perforations. It carries a mortality rate of close to 100% without treatment.1 There is no treatment consensus in the literature, reflecting the rarity of the condition and also the spectrum of disease that it represents. In 2009 de Schipper et al published the only literature review and treatment algorithm for Boerhaave’s syndrome, based on level 4 evidence, highlighting the need for further multicentre trials to consolidate management.2 At present, early diagnosis in patients with a septic profile favours surgical management and in those without, endoscopic therapy.2 Conservative management is reserved for delayed presentations with contained, wide necked perforations without sepsis and for those who demonstrate tolerance to pleural contamination amenable to radiological drainage.3 Those failing to progress on conservative man552
1274 Darrien.indd 552
agement primarily owing to the evolution of sepsis should be reconsidered for surgical intervention. With regard to endoscopic therapy, the literature description is limited to oesophageal stents, for which there is a variable prognosis, and also to patients who present early without a septic profile.2 However, we describe the successful management of Boerhaave’s syndrome using minimally invasive endoscopic therapies to treat septic patients (presenting both early and late) who were deemed not fit for surgical intervention. Using a case series, we illustrate the successful technique of minimally invasive endoscopic therapy.
Case series Five patients presented to Wishaw General Hospital with a spontaneous oesophageal rupture between September 2008 and January 2010 (Table 1). Case 1 was a 30-year-old
Ann R Coll Surg Engl 2013; 95: 552–556
09/10/2013 13:50:18
Darrien Kasem
Minimally invasive endoscopic therapy for the management of Boerhaave’s syndrome
Table 1 Case series details Case
Age / sex
Co-morbidity
Presentation
Diagnosis
Sepsis
Organ failure
APACHE II points
APACHE II (predicted mortality)
1
30 M
Diabetes mellitus type 1 Asthma Chronic renal failure Alcohol excess Smoker Oesophagitis
>48 hours
>72 hours
Septic shock
Multiple organ failure
32
76.0%
2
31 F
Alcohol excess Smoker
>48 hours
>72 hours
Septic shock
Multiple organ failure
31
73.3%
3
74 F
Hypertension
Minimally invasive endoscopic therapy for the management of Boerhaave’s syndrome JH Darrien, H Kasem NHS Lanarkshire, UK ABSTRACT INTRODUCTION Boerhaave’s syndrome represents the most lethal of all gastrointestinal perforations. In 2009 a treatment
algorithm was published based on current level 4 evidence indicating that all septic patients should be treated surgically, early presentations without sepsis endoscopically and delayed presentations without sepsis conservatively. No provision was made for septic patients unfit for surgical intervention. Using a case series, we demonstrate how minimally invasive endoscopic therapies can be used successfully to manage such a cohort. METHODS Between September 2008 and January 2010, five patients presented to Wishaw General Hospital with Boerhaave’s syndrome, all with an associated septic profile and none fit for surgery. They were managed using minimally invasive endoscopic therapies including endoscopic placement of oesophageal stents, elimination of mediastinal/pleural contamination using video assisted thorascopic lavage, management of subsequent collections using sinus tract endoscopy and minilaparotomy with transhiatal endoscopic drainage, and closure of oesophagocutaneous fistulas using the Surgisis® (Cook Surgical, Bloomington, IN, US) anal fistula plug sited endoscopically with a rendezvous technique. RESULTS Oesophageal re-epithelialisation and resolution of sepsis was achieved in all five cases on days 50, 50, 51, 59 and 103. Four patients are alive today. The fifth died on day 109 in hospital as a consequence of co-morbidity. Two patients required oesophageal dilatation for benign oesophageal strictures. CONCLUSIONS Minimally invasive endoscopic therapy can be used successfully to achieve oesophageal re-epithelialisation and resolution of sepsis in patients unfit for surgical intervention. It offers a feasible treatment for patients not accounted for in today’s literature and expands on currently described endoscopic therapies.
Keywords
Boerhaave’s syndrome – Oesophageal stent – Surgisis® anal fistula plug Accepted 16 July 2013 correspondence to Jennifer Darrien, c/o Hasan Kasem at Wishaw General Hospital, 50 Netherton Street, Wishaw, North Lanarkshire ML2 0DP, UK T: +44 (0)1698 361 100; F: +44 (0)1698 366 136; E: [email protected]
A spontaneous oesophageal rupture, also known as Boerhaave’s syndrome, is regarded as the most lethal of all gastrointestinal perforations. It carries a mortality rate of close to 100% without treatment.1 There is no treatment consensus in the literature, reflecting the rarity of the condition and also the spectrum of disease that it represents. In 2009 de Schipper et al published the only literature review and treatment algorithm for Boerhaave’s syndrome, based on level 4 evidence, highlighting the need for further multicentre trials to consolidate management.2 At present, early diagnosis in patients with a septic profile favours surgical management and in those without, endoscopic therapy.2 Conservative management is reserved for delayed presentations with contained, wide necked perforations without sepsis and for those who demonstrate tolerance to pleural contamination amenable to radiological drainage.3 Those failing to progress on conservative man552
1274 Darrien.indd 552
agement primarily owing to the evolution of sepsis should be reconsidered for surgical intervention. With regard to endoscopic therapy, the literature description is limited to oesophageal stents, for which there is a variable prognosis, and also to patients who present early without a septic profile.2 However, we describe the successful management of Boerhaave’s syndrome using minimally invasive endoscopic therapies to treat septic patients (presenting both early and late) who were deemed not fit for surgical intervention. Using a case series, we illustrate the successful technique of minimally invasive endoscopic therapy.
Case series Five patients presented to Wishaw General Hospital with a spontaneous oesophageal rupture between September 2008 and January 2010 (Table 1). Case 1 was a 30-year-old
Ann R Coll Surg Engl 2013; 95: 552–556
09/10/2013 13:50:18
Darrien Kasem
Minimally invasive endoscopic therapy for the management of Boerhaave’s syndrome
Table 1 Case series details Case
Age / sex
Co-morbidity
Presentation
Diagnosis
Sepsis
Organ failure
APACHE II points
APACHE II (predicted mortality)
1
30 M
Diabetes mellitus type 1 Asthma Chronic renal failure Alcohol excess Smoker Oesophagitis
>48 hours
>72 hours
Septic shock
Multiple organ failure
32
76.0%
2
31 F
Alcohol excess Smoker
>48 hours
>72 hours
Septic shock
Multiple organ failure
31
73.3%
3
74 F
Hypertension
