Successful multistage surgical management of Boerhaave syndrome: a case report and review of the literature

BACKGROUND: Boerhaave's syndrome is a rare cause of spontaneous transmural esophageal perforation and carries high morbidity and mortality, as its classical presentation (such as Mackler's triad of vomiting, chest pain, and subcutaneous emphysema) is infrequent and diagnosis is often delayed. Early diagnosis and urgent intervention are needed. CASE PRESENTATION: This case report presents a 36-year-old Asian male admitted to the emergency department with acute chest pain and respiratory distress after multiple episodes of vomiting. Thoracic computed tomography (CT) revealed distal esophageal perforation with right hydropneumothorax. The patient was managed surgically, initially with pleural drainage and endoscopic esophageal stenting as an organ-preserving strategy, but migration of the stent with mediastinitis and sepsis necessitated esophagectomy and feeding jejunostomy. Definitive management with retrosternal gastric conduit pull-up and esophageal reconstruction was performed once sepsis was controlled and nutritional status improved, and after a prolonged stay in the long-term care unit and intensive care unit (ICU), the patient was discharged in good clinical condition on oral feeding. CONCLUSIONS: Boerhaave's syndrome is a rare but potentially life-threatening cause of esophageal perforation, particularly when complicated by massive hydropneumothorax and mediastinitis. This case illustrates that aggressive, multidisciplinary, multistage management-including early thoracic drainage and sepsis control, followed by delayed reconstruction after nutritional rehabilitation-can achieve good long-term outcomes.