Esophageal Perforation / Boerhaave Syndrome (WSES 2019)

Algorithm Steps

1. ▶

   Start

   Suspected Esophageal Perforation

   Chest/epigastric pain after vomiting, endoscopy, or foreign body

   1. ●

      Action

      Clinical Recognition

      Mackler Triad and other signs

      • MACKLER TRIAD:
      • • Vomiting
      • • Chest pain
      • • Subcutaneous emphysema
      • Other signs: fever, dysphagia, odynophagia
      • Hamman sign (mediastinal crunch)
      • Pleural effusion (often left-sided)
      1. ●

         Action

         Diagnostic Workup (WSES Level I)

         Confirm diagnosis and localize perforation

         • Labs: CBC, BMP, lactate, CRP (WSES Level I)
         • Imaging sequence:
         • 1. CXR: pneumomediastinum, pleural effusion, hydropneumothorax
         • 2. Water-soluble contrast swallow (Gastrografin)
         • 3. CT chest/abdomen with oral contrast (most sensitive)
         • CT sensitivity >90% for perforation
         1. ●

            Action

            Identify Etiology

            Guides management approach

            • SPONTANEOUS (Boerhaave): 15%
            • • Post-vomiting, large tear (3-8cm)
            • • Usually left lower esophagus
            • IATROGENIC: 60%
            • • Endoscopy, dilation, TEE
            • • Often smaller, better contained
            • TRAUMA/FOREIGN BODY: 25%
         2. ◆

            Decision

            Management Approach?

            Based on clinical status and leak containment

            • CONSERVATIVE criteria (all must be met):
            • • Well-contained leak (no mediastinal soiling)
            • • Drains back into esophagus
            • • Minimal symptoms
            • • No sepsis
            1. ●

               Action

               Conservative Management

               For contained perforations, minimal contamination

               • NPO, NG tube
               • Broad-spectrum IV antibiotics
               • Antifungals (consider)
               • PPI therapy
               • TPN for nutrition
               • Serial imaging to confirm healing
               • Consider endoscopic stent if:
               • • Small contained perforation
               • • No sepsis
               1. ●

                  Action

                  Endoscopic Options

                  Emerging alternatives

                  • Self-expanding stents (SEMS):
                  • • Bridge to healing or surgery
                  • • Best for contained leaks
                  • Endoscopic vacuum therapy (EVT):
                  • • Newer technique, promising results
                  • • Multicenter data emerging (2025)
                  • Clips/over-the-scope clips (OTSC):
                  • • Small acute perforations
                  1. ●

                     Action

                     ICU Care & Monitoring

                     Ongoing management

                     • Sepsis management
                     • Nutrition (TPN → enteral via J-tube)
                     • Repeat imaging in 5-7 days
                     • Contrast swallow before oral intake
                     • Watch for: empyema, abscess, fistula
                     1. ✓

                        Outcome

                        Healed / Reconstructed

                        Long-term: stricture surveillance

               2. ●

                  Action

                  Surgical Intervention

                  For uncontained leaks, sepsis, or failed conservative

                  • TIMING CRITICAL:
                  • • <24h: primary repair possible
                  • • >24h: tissue friable, drainage/diversion
                  • Approach: left thoracotomy (distal)
                  • or right thoracotomy (mid/proximal)
                  1. ●

                     Action

                     Surgical Options

                     Based on tissue quality and timing

                     • PRIMARY REPAIR (<24h, healthy tissue):
                     • • Debride edges, 2-layer closure
                     • • Buttress with pleural/intercostal flap
                     • • Wide drainage
                     • DRAINAGE ONLY (>24h or septic):
                     • • Decortication, drain mediastinum
                     • • Consider T-tube
                     • DIVERSION (severe contamination):
                     • • Cervical esophagostomy
                     • • Gastrostomy + feeding jejunostomy
                     • • Delayed reconstruction
            2. ⚠

               Warning

               ⚠️ TIME IS CRITICAL

               Mortality: <24h = 10-25%, >24h = 40-60%, untreated = nearly 100%