Subtotal esophagectomy followed by subtotal gastric reconstruction for Boerhaave's syndrome: Case report with literature review

Boerhaave's syndrome, or spontaneous esophageal rupture, is a potentially fatal disease requiring prompt diagnosis and effective treatment. We report Boerhaave's syndrome in a patient who underwent subtotal esophagectomy and temporary cervical esophagostomy for esophageal perforation to the right thoracic cavity, followed by subtotal gastric reconstruction as the second step. A 70-year-old man with diarrhea and vomiting as chief complaints had underlying disease of reflux esophagitis. He experienced frequent hematemesis. Computed tomography (CT) at another hospital revealed right pleural effusion and abnormal mediastinal air and fluid retention around the esophagus, and he was transferred to our hospital. From the CT findings, he was diagnosed as having Boerhaave's syndrome with esophageal perforation into the right thoracic cavity. He was in shock, and emergency right thoracotomy was performed, revealing a severely purulent thoracic cavity, ruptured parietal pleura, and 5-cm perforation in the right front middle esophageal wall that was surrounded by mucosal necrosis. Subtotal esophagectomy, temporal cervical esophagostomy, and enteral feeding tube insertion were performed. After hospital discharge, he underwent subtotal gastric reconstruction 43 days postoperatively. His course was good, and he was transferred to another hospital for rehabilitation 36 days after reconstruction. In Boerhaave's syndrome, depending on the size of the perforation and fragility of the esophageal wall, subtotal esophagectomy may be feasible. Two-step reconstruction following esophageal rupture is possible after sufficient local infection control, and anastomosis can be performed if the patient's general condition is good, but only under conditions that guarantee no anastomotic leakage. •What is the best treatment strategy for severe mucosal necrotic esophageal rupture?•It is not necessary to hesitate to perform esophagectomy immediately even in a state of shock.•When we choose the two-step surgical method, a technique that guarantees secure anastomosis during reconstruction is required.