Hubert J. Stein, Holger Bartels, Burkhard H. A. v. Rahden, J. Ruediger Siewert, Chirurgische Klinik und Poliklinik TU Muenchen, Munich, Germany

Background: Despite emergency surgery the reported mortality rates of emetogenic esophageal rupture (Boerhaave's syndrome) are high. We report our experience with an individualized treatment strategy in the largest so far reported single center series of patients with Boerhaave's syndrome. Material and Methods: Over a period of 21 years a total of 35 patients (27 male, 8 female, median age 69 years) with Boerhaave's syndrome were treated at a center for esophageal surgery. After confirmation of the diagnosis all patients received immediate endotracheal intubation, shock therapy, drainage of pleural effusions, placement of esophageal and gastric tubes, and systemic antibiosis. Surgical therapy was only performed after stabilisation of vital parameters and based on length/location/containment of the rupture, time interval to diagnosis, intraoperative aspect of the esophagus, and general condition of the patient. Results: Median length of the rupture was 3.8 cm (range 1.8-8 cm). Time interval between rupture and initiation of treatment was < 24 hours in 19 patients and > 24 hours in 16. In 15/35 patients a primary closure and covering with fundoplication was possible. In 18/35 patients an esophagectomy was performed because of length of the rupture or destroyed esophageal wall. Reconstruction after esophagectomy was delayed until complete recovery (4-46 weeks after esophagectomy) and was performed with gastric pull-up (n=10) or colon interposition (n=8). In 2/35 patients with delayed diagnosis (> 3 days) and covered rupture a successfull non-operative management was possible. Despite a substantial morbidity (empyema 47%, septic multiorgan failure 27%, peritonitis 17%) with a median ICU stay of 23 days only 1 patient died (mortality 2.9%). Summary: In a center for esophageal surgery Boerhaave's syndrome can be managed successfully with a mortality below 5%. Key to success are preoperative intensiv care management until stabilisation, individualized surgical and conservative strategies and aggressive therapy of complications.