Boerhaave Syndrome: Challenges Faced to Achieve Positive Outcomes.

Boerhaave syndrome, the spontaneous barogenic rupture of the oesophagus, is lethal when unrecognised and its cardiorespiratory mimicry frequently delays diagnosis. Optimal management remains debated. We retrospectively reviewed four consecutive patients with spontaneous oesophageal perforation managed over two years at a tertiary surgical-gastroenterology unit. Diagnosis was confirmed by water-soluble oral-contrast computed tomography; presentation, operative findings, complications and outcomes were analysed and compared with the contemporary literature. The four patients were initially assessed by non-surgical services, with an intercostal drain placed for a presumed effusion or pneumothorax before food or purulent fluid in the drain revealed the diagnosis. The perforation was left-sided in three and right-sided in one. Management was individualised: laparoscopy converted to laparotomy with transhiatal primary repair and omental buttress; laparotomy with transhiatal repair and thoracoscopic lavage; a thoraco-abdominal approach; and a right posterolateral thoracotomy. A postoperative leak occurred in two patients and was managed by endoscopic vacuum therapy and by transhiatal oesophagectomy with gastric conduit, respectively. All four patients survived. Food-stained or purulent output from a chest drain placed for a presumed effusion should prompt immediate contrast computed tomography. An individualised, multidisciplinary strategy combining timely source control, thoracoscopic pleural lavage and modern endoscopic rescue achieved survival in every patient, including a rare right-sided rupture.