Surgical versus endoscopic management of Boerhaave’s syndrome: a systematic review and meta-analysis

INTRODUCTION: Boerhaave's syndrome, a spontaneous full-thickness oesophageal perforation, is rare but life-threatening, largely because of delayed diagnosis and mediastinal contamination. Despite advances in surgical, endoscopic and perioperative care, the optimal management strategy remains uncertain. This study systematically reviewed outcomes following surgical and non-surgical treatment of Boerhaave's syndrome. METHODS: MEDLINE, Embase and CENTRAL were searched from January 2000 to January 2025 for studies reporting outcomes in adults with confirmed Boerhaave's syndrome. The primary outcome was early mortality (in-hospital or 30-day). Secondary outcomes included leak rate, re-intervention and length of hospital stay. Random-effects meta-analyses were performed. Risk of bias was assessed using ROBINS-I. The review was registered with PROSPERO (CRD42024546970). FINDINGS: Twenty-eight observational studies including 881 patients were analysed (mean age 59.5±14 years; 78% male). Of 870 patients receiving active treatment, 80.5% underwent surgery and 19.5% non-surgical management. Primary repair was most common (52.7%), followed by T-tube repair (14.8%) and oesophagectomy or exclusion-diversion (3.4%). Endoscopic therapy accounted for 8.9% and conservative management for 8.7%. Overall early mortality was 16.3% (95% confidence interval [CI] 12.7-20.6%). Mortality was lowest after endoscopic therapy (12.0%) and primary repair (13.3%), and highest after T-tube repair (27.4%) and oesophagectomy or exclusion-diversion (31.2%). Leak rates were similar between surgical repair and endoscopic therapy, but re-intervention was more frequent after endoscopic treatment (odds ratio 4.55, 95% CI 2.63-7.87). Delayed treatment (>24h) showed a non-significant trend towards higher mortality. CONCLUSIONS: Primary repair remains the cornerstone of management for Boerhaave's syndrome. Endoscopic therapy offers comparable survival but is associated with high re-intervention rates. Early diagnosis and individualised treatment selection are essential.