Perforation of the Esophagus (Boerhaave Syndrome): A Case Report

Abstract

Introduction: Esophageal perforation represents one of the most serious and difficult emergencies that the surgeon may be confronted with. Most often, these are iatrogenic perforations, especially since the advent of endoscopic therapies. However, in about 15% of cases, as in the case of our patient, it is a Boerhaave syndrome. It is defined as a spontaneous rupture with no known pre-existing pathology of the esophagus. We report a case of Boerhaave syndrome treated surgically and review the characteristics and the treatment in the literature. Aim: Our work is a retrospective case report with a descriptive aim concerning a patient operated for a perforation of the esophagus within the department of general surgery of CHU Ibn Rochd Casablanca. Case Report: A 55-year-old man, chronic smoker at 35 pack years, presented to the department with left basi-thoracic pain evolving for 4 days, associated with early food vomiting, without any transit disorder or externalized digestive hemorrhage, all evolving in a context of fever and alteration of general condition. On physical examination, the patient was conscious and stable on the respiratory and hemodynamic level. Abdominal examination found tenderness in the left hypochondrium and left flank. The thoracic examination revealed a globular thorax, with decreased perception of vesicular murmurs and vocal vibrations. The thoracoabdominal CT scan (Fig. 1) showed a bilateral pleural effusion, a pneumomediastinum and a left pneumothorax. It also showed digestive-like structures with air-fluid levels in the left hemithorax. The patient was rushed to the operating room. The operation consisted of a suture of a 5cm perforation of the abdominal esophagus by separate stitches with directed fistulization by Pezzer probe, with a feeding jejunostomy, a pre and retro esophageal drainage by 2 Delbet blades, a sub hepatic drainage by a Redon drain, a left phrenic drainage by a Joly drain, a biopsy of the perforation edges and a collection of the digestive fluid within the pleural cavity. The thoracic part of the operation consisted of an anterior thoracotomy through the 6th left intercostal space, which revealed the presence of digestive fluid within the pleural cavity, which was evacuated. Subsequently, an abundant saline lavage was performed with the placement of thoracic drains. Conclusion: Boerhaave syndrome is one of the most serious emergencies. The prognosis depends greatly on early diagnosis and proper treatment. Surgery remains the gold standard of treatment.