ENDOSCOPIC TREATMENT OF BOERHAAVE'S SYNDROME IN A PATIENT WITH PREVIOUS HELLER'S MIOTOMY AND GASTRIC BYPASS: “CHIKEN SOUP IS NOT GOOD FOR THE HEART”

Aims:

Boerhaave's Syndrome or spontaneous rupture of the esophagus is a critical event with high mortality if untreated in the first 24 hours. Endoscopic management has been described.

Methods:

We present a case of a 66 year old male patient who had Heller's Myotomy for Achalasia 15 years ago and gastric bypass for morbid obesity 1 year before the current event. After an episode of overindulgence in food (Chiken soup) presented vomiting followed by dyspnea, retrosternal chest pain and diaphoresis. Was admited in poor clinical conditions with pneumothorax, large left Pleural effusion, mediastinal collection and contrast leakage at distal esophagus in CT Scan. Under general anesthesia and endotracheal intubation, CO2 Upper Endoscopy was performed using a 9.8 mm gastroscope. An oriffice greater than 1 cm was identified communicating to the mediastinum. The endoscope was advanced through it and endoscopic drainage completed (450 ml of chicken soup and rest of solids). Ribs, colapsed lung and heart were fully recognized and flushed with saline to complete cleansing of the area. In the mean time the thoracic surgeon placed a chest tube. Double pig-tail 10 Fr stents were placed between medistinum and gastric pouch. A 12 cms partially covered Self-expanding esophageal metal stent was placed from distal esophagus to the gastric pouch. A naso yeyunal feeding tube was advanced.

Results:

Inmediate adequate clinical response was observed. Naso-yeyunal feeding tube was removed at 7 days. Chest tube was removed at 9 days and discharge from hospital was decided after 11 days. Upper endoscopy allowed pig-tail stents removal at 3 weeks and SEMS removal at 6 weeks achieving complete healing of the perforation. The patient has been followed up for two years and remains asymptomatic.

Conclusion:

Endoscopic drainage combined with self-expanding stent and adequate thoracic drainage is and alternative for Boerhaave's Syndrome.