Diagnostic Approach and Therapeutic Management of Spontaneous Esophageal Perforation (Boerhaave's Syndrome): A Systematic Review and Individual Patient-Level Pooled Analysis.

Background/

Objectives

Boerhaave's syndrome (BS) is a rare, life-threatening condition associated with high mortality. This systematic review aimed to summarize the clinical presentation, management, and outcomes of adult patients with BS.

Methods

PubMed and Scopus were searched through 12 June 2026 for case reports and case series reporting individual patient-level data. Demographic, clinical, diagnostic, therapeutic, and outcome data were extracted. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist, and factors associated with in-hospital mortality were explored using logistic regression.

Results

A total of 427 studies comprising 694 patients were included. Mean age was 57.1 years and 523 patients (80.6%) were male. Vomiting (79.5%) and chest pain (60.7%) were the most common symptoms, while 263 patients (67.6%) met SIRS criteria at diagnosis. The distal esophagus was involved in 83.5% of cases, and computed tomography was the predominant diagnostic modality (55.5%). Surgery was the most common first-line treatment (62.8%). In-hospital and 30-day mortality were 18.2% and 15.4%, respectively. In exploratory analyses, increasing age and SIRS were associated with in-hospital mortality. Risk of bias assessment identified methodological concerns across studies predominantly due to selective and incomplete outcome reporting. Certainty of evidence for in-hospital mortality was very low according to GRADE.

Conclusions

BS remains associated with substantial morbidity and mortality. Surgery remains the most frequently applied treatment, while conservative and endoscopic strategies are used in selected patients. Case-based evidence precludes reliable comparative assessment of treatment effectiveness. The association between SIRS and mortality remains hypothesis-generating.