Successful Late Endoscopic Stent-Grafting in a Patient with Boerhaave Syndrome

Patient: Male, 53-year-old Final Diagnosis: Spontaneous esophageal rupture Symptoms: Chest pain • dyspena • hydropneumothorax • purulent discharge from the umbilicus • vomiting Medication: — Clinical Procedure: Endoscopic stent-grafting • enteral feeding • pleural drainage Specialty: Gastroenterology and Hepatology • Surgery OBJECTIVE: Unusual setting of medical care BACKGROUND: Boerhaave syndrome is a rare esophageal injury associated with a high mortality rate of 14.8%. Immediate diagnosis and treatment have been associated with a better outcome. Surgery remains the mainstay of treatment for those who present early with widespread septic contamination. One of the most difficult dilemmas in the treatment of Boerhaave syndrome is selection of the most appropriate management for late perforations with severe septic complications. In this situation, aggressive surgical approach with esophagectomy and immediate or postponed reconstruction is usually recommended. CASE REPORT: We report a patient with spontaneous esophageal rupture successfully treated by late endoscopic stent-grafting. The patient was transferred from a rural hospital after initial non-effective conservative treatment. Endoscopic stent-grafting was performed 7 days from the onset of symptoms. A self-expanding plastic stent-graft (Polyflex) used initially very early migrated to the stomach. The plastic stent-graft was then replaced by a fully covered self-expandable metal stent-graft (EndoMAXX), which was wider and equipped with anti-migration struts. Implantation of the EndoMAXX stent-graft resulted in clinical success, with the closure of esophageal rupture confirmed 8 weeks after stent-grafting. CONCLUSIONS: Our case indicates that even late after spontaneous esophageal perforation, less invasive treatment by endoscopic stent-grafting with adequate drainage of septic contamination may be an attractive option for preserving the esophagus in selected patients in stable hemodynamic condition. Our case also supports implantation of wider metallic stent-grafts to seal benign esophageal perforation above the esophago-gastric junction to prevent early migration to the stomach.