Minimally invasive surgical management of spontaneous esophageal perforation (Boerhaave's syndrome)

Background Spontaneous esophageal perforation (Boerhaave's syndrome) is a highly morbid condition traditionally associated with poor outcomes. The Pittsburgh perforation severity score (PSS) accurately predicts risk of morbidity, length of stay (LOS) and mortality. Operative management is indicated among patients with medium (3-5) or high (> 5) PSS; however, the role of minimally invasive surgery remains uncertain. Methods Consecutive patients presenting with Boerhaave's syndrome with intermediate or high PSS managed via a thoracoscopic and laparoscopic approach from 2012 to 2018 were reviewed. Demographics, clinical presentation, management, and outcomes were analyzed. Results Ten patients (80% male) with a mean age of 61.3 years (range 37-81) were included. Two patients had intermediate and eight had high PSS (7.9 +/- 2.8, range 4-12). The mean time from onset of symptoms to diagnosis was 27 +/- 12 h and APACHE II score was 13.6 +/- 4.9. Thoracoscopic debridement and primary repair was performed in eight cases, with two perforations repaired primarily over a T-tube. Laparoscopic feeding jejunostomy was performed in all patients. Critical care LOS was 8.7 +/- 6.8 days (range 3-26), while inpatient LOS was 23.1 +/- 12.5 days (range 14-46). Mean comprehensive complications index was 42.1 +/- 26.2, with grade IIIa and IV morbidity in 60% and 10%, respectively. One patient developed dehiscence at the primary repair, which was managed non-operatively. In-hospital and 90-day mortality was 10%. Conclusion Minimally invasive surgical management of spontaneous esophageal perforation with medium to high perforation severity scores is feasible and safe, with outcomes which compare favorably to the published literature.