Navigating management dilemmas in late-presenting Boerhaave’s syndrome: a case report and literature review

Abstract

Boerhaave’s syndrome is a serious surgical emergency, especially when patients present late (typically defined as more than 24 hours after the onset of symptoms). The best management approach in these situations is debated, as it involves weighing the need for effective decortication through a thoracic approach against the conventional practice of esophagectomy. This case report explores the challenges related to choosing between thoracic and abdominal methods, the sufficiency of decortication, and the choice to preserve the oesophagus instead of opting for resection in cases of lower esophageal rupture. We present a case involving a patient with a late-presenting lower esophageal rupture due to Boerhaave’s syndrome and septic shock. The preoperative strategy focused on preserving the oesophagus, which led to the early preparation of an intercostal muscle flap (created before the placement of Finochietto retractors). A left thoracotomy was conducted to enable thorough decortication of the infected pleural cavity and to support a careful, multilayer primary repair of the oesophagus under magnification. This approach resulted in a watertight and airtight closure, leading to a swift resolution of sepsis and successful preservation of the oesophagus.