Background: Spontaneous esophageal perforation (SEP) or Boerhaaven Syndrome is a rare and life-threatening disease. Published series usually contain less than 10-15 patients treated variously during a long period of time. Therefore, the management of SEP is often based on personal experience and not on evidence-based results. Patient and
Methods: We scrutinized retrospectively the possible changes in the prognosis of 64 SEP patients (mean age 62 years) treated in a single institute between 1979-2007 by a team having special interest in esophageal surgery.
Results: There was no significant difference between decades in diagnostic delay. This delay was >24h in 43% and >48h in 34% of patients. The primary treatment strategy included aggressive conservative treatment of infection and homeostasis with the best possible available medical resuscitation in all 64 patients. Surgical strategy was primary repair through thoracotomy in 30 patients having vital esophagus (47%), and esophagectomy in 24 cases (38%) with severe wall necrosis or large esophageal damage making primary repair impossible. 10 patients (16%) with a small perforation and no/or very small pleural fistula or no empyema were treated non-operatively or with endoscopically installed esophageal prosthesis. Of treated patients, 29 (45%) had 1-4 reoperations.Mortality of SEP (30-d) decreased significantly from 28% (8/29) in 1980s-1990s to 3% (1/35) in the 21st century (p=0.029). Similarly, leak-rate after primary repair decreased significantly from 53% (8/15) to 7% (1/15). Median survival after discharge was 120 months, similar to general population.
Conclusions: The treatment of SEP has improved despite of similar strategies during 3 different decades. One reason is a decrease in leak-rate after primary repair. In this retrospective study, other factors are difficult to point out. These are probably multi-factorial including improved intensive care and team experience. Evidence-based results are needed in the treatment of SEP. Until then, the results of more conservative strategies including covered stents have to be compared to presented results.