Boerhaave's syndrome: Spontaneous full thickness esophageal perforation.

Sir,

I read with great interest the article entitled “Spontaneous esophageal-pleural fistula” by Vyas et al.[1] It is really an interesting and unusual case. Authors had concise topic very nicely. However, I would like to add some interesting points related to this condition. Spontaneous rupture of esophagus is popularly known as Boerhaave syndrome. Professor Hermann Boerhaave first documents this condition after an autopsy of an admiral of a Dutch navy in 1724.[2] It accounts only 15% of the causes of esophageal perforation. Boerhaave syndrome classically present as Mackler triad: Vomiting, subcutaneous emphysema, and lower thoracic pain. Iodinated water-soluble contrast media are suitable initial agents for study. The normal study with water-soluble contrast does not exclude the possibility the perforation as 22% of the patients who had a normal study with water-soluble contrast, a perforation was detected subsequently with the use of barium.[3] Some authorities including myself recommend barium as a contrast agent of choice for suspected lower esophageal perforation above gastro esophageal junction as barium is inert in the chest while aspiration of water-soluble contrast is associated with severe life-threatening pneumonitis. In this case, authors had performed upper gastrointestinal (GI) endoscopy to rule out associated inflammatory or malignant process. I would like to state here that endoscopy may be helpful when perforation is suspected but not proven and upper GI endoscopy is associated with risk of increasing the size and extend of perforation as well as may force the additional air in the pleural/mediastenal cavity. Endoscopy can be performed in those who require operative intervention with sensitivity of 100% and 85% specificity. The factors that decide the line of management are: Location of perforation, etiology, and the duration of injury.[4] Although standard of care is surgical, conservative management can be employed in following conditions: Minimal symptoms/clinical signs of infection, perforation that well drains back into the, and contained perforation within mediastinum. Primary repair is advised within first 24 h. After 24 h, edges of perforation are edematous and friable which makes the primary repair difficult. However, one study showed that primary repair may be considered as late as 72 h. Other alternative to primary repair are: Cervical esophagostomy, T-tube placement, and plastic covered self expandable metallic stents. Study performed by de Schipper et al. showed that the survival rates for conservative, surgical intervention and endoscopic management for spontaneous esophageal perforation are, respectively, 75%, 81%, and 100%.[5] They concluded that endoscopic management is recommended when the condition has been diagnosed within 48 h, provided that there is no evidence of sepsis.