Boerhaave’s syndrome is a rare life-threatening condition, usually requiring urgent surgical treatment.
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Thoracic drainage may confirm diagnosis rapidly.
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Debridement and drainage of pleural space and mediastinum are essential in sepsis control.
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Damage control approach with oesophageal T-tube drainage may help in sepsis control, allowing delayed definitive oesophageal repair.
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The outcome is determined by rapid diagnosis and timely and effective treatment.
Abstract
Introduction
Boerhaave’s syndrome is a life-threatening oesophageal perforation that carries a high mortality rate (20–50%). Diagnosis is difficult by its rarity and the absence of typical symptoms. Treatment of this condition usually requires surgical intervention.
Presentation of case
We report the case of a 77-year-old man that resorted to the emergency room with dyspnoea and thoracic pain after vomiting. CT scan revealed pneumomediastinum, left collapse lung and loculated pleural effusion. A left intercostal chest tube was inserted with food drainage. Hence, Boerhaave’s syndrome was suspected. Thoracotomy with mediastinum debridement, pleural drainage and oesophageal T-tube drainage was performed. Patient was admitted on the Intensive Care Unit with septic shock, with need for ventilatory support and vasopressor therapy. Two days later, a second look thoracotomy was done with definitive oesophageal repair and pleural patch. The post-operative course was complicated by pneumonia and stroke. Patient was discharged home on the 38th day and remains well at 3 month of follow-up.
Discussion
Delayed diagnosis and treatment are the principal causes of high mortality in Boerhaave’s syndrome. The classic Mackler’s triad (vomiting, lower thoracic pain and subcutaneous emphysema) is present in less then 50% of cases. A thoracic drainage may be useful to confirm diagnosis promptly. There is no standard treatment option. In this case report, the authors used a damage control approach to control sepsis, allowing for a delayed definitive oesophageal repair.
Conclusion
Prompt diagnosis with thoracic drainage and a damage control treatment plan might lead to good prognosis for patients with this rare and potentially fatal condition.
