Minimally invasive endoscopic therapy for the management of Boerhaave's syndrome.

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 mini-laparotomy 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.