An endoscopic approach to therapy for spontaneous esophageal rupture. These are our disclosures. Spontaneous esophageal perforations were first described in 1724 by Hermann Borchow after an autopsy of a man who complained of three days of abdominal pain, not abated by remedies or vomiting, and was found to have an esophageal perforation. Borchow syndrome is the most lethal gastrointestinal tract disorder with a reported mortality rate of up to 40%. Rupture most commonly occurs in the left posterolateral wall of the distal esophagus with extension into the left pleural cavity. These ruptures are formed by a sudden increase in intraesophageal pressure that leads to complete transmural injury, causing mediastinal inflammation, subcutaneous emphysema, or necrosis secondary to spillage of gastric reflux. Our case will demonstrate an approach to an endoscopic technique for successful management of a patient presenting with Borchow syndrome. A 35-year-old otherwise healthy man presented with severe substernal chest pain after self-induced vomiting, attempting to resolve a food impaction. In the ED, a CT chest showed a complex heterogeneous air and fluid-filled mediastinal collection suggestive of esophageal rupture. To confirm the suspicion of esophageal perforation and given his hemodynamic stability, the patient was referred for emergent inpatient endoscopic evaluation and therapy. On upper endoscopy, a 2.5-centimeter distal left posterolateral perforation of the esophagus was noted with extension to the gastroesophageal junction. Given the size of this acute perforation, the decision was made to perform a sutured repair of the esophagus. The endoscopic suturing device was attached to a double-channel therapeutic endoscope loaded with a 2.0 polypropylene suture, and the esophagus was carefully intubated without the use of an overtube. Note that the first full thickness bite at the distal aspect of the perforation is approached by first puncturing the mucosal side of the esophageal wall rather than starting the suturing from inside of the perforation. This is done to prevent placement of the final securing cinch on the extraluminal side of the perforation. A tissue helix or rat-tooth forceps may be used to aid in tissue grasping as needed when closing a smaller perforation. A running suture pattern is followed progressing proximally up the esophageal perforation until the final bite of the suturing worm is taken passing from within the perforation cavity out through the mucosa of the esophagus. This ensures that the steel T-tag of the suture is not placed on the extraluminal side of the esophagus similar to the paradigm of the first bite. The T-tag is then released from the endoscopic suturing device and a suture cinch is advanced over the suture which is tightened taking care not to over tighten the suture which could lead to tissue ischemia and failure of the repair. The cinch is then fired placing a plastic T-tag at the mucosal surface upon the suture where it was first passed through the esophageal wall. An additional layer of suture repair may be performed again progressing from distal to proximal to reinforce the perforation repair. In our practice we also proceed with fully covered esophageal stent placement which is performed using either a through the scope as shown or traditional esophageal stent placement technique using fluoroscopy with or without endoscopic guidance. Care is taken to select a stent which is both appropriately sized to the esophageal lumen caliber as well as the length needed to fully cover the area of perforation as well as several centimeters above and below the perforation repair site generally extending slightly into the stomach beyond the gastroesophageal junction. As may be recommended with any fully covered esophageal stent stay sutures should be placed to prevent early migration of the stent during its dwell time. Many sutures are generally not full thickness bites and our favorite method is to first bite the mucosa then pass the suture through the interstices of the stent then back to the mucosa. The suture is then dropped and cinched loosely so that the suture is visible and accessible during later stent removal procedures. As in perforation repair, over tightening the suture likely leads to tissue ischemia and failure of the suture to perform its intended function. The stent fixation suturing technique may be repeated with an additional one to three sutures depending on the size of the esophagus and stent but generally at least two sutures are used. Finally, to allow for antero-bypass of the injured area and to allow for rested healing of the esophagus, a 12 French nasojejunal feeding tube is placed coaxially to the esophageal stent and to the duodenum under fluoroscopic guidance for 10 to 14 days after the repair. After performing the primary and secondary endoscopic closure using suturing and esophageal stenting, a chest tube was placed by thoracic surgery colleagues to aid in negative pressure drainage of the measurable fluid and air-filled mediastinal cavity with extension into the pleural space. The patient was also instructed to take a twice daily proton pump inhibitor through the nasojejunal feeding tube to prevent symptomatic acid reflux related to the stent crossing the gastroesophageal junction and to sleep with an elevated head of the bed. The esophagram was repeated weekly in addition to a CT scan for 21 days. At day 21, the collection was resolving and the chest tube was successfully removed. Immediately thereafter, a repeat endoscopy was performed to remove the esophageal stent and to examine the impaired esophagus. In this case, rotatable and disposable endoscopic scissors were used to cut the stay sutures from the esophageal stent which was then grasped with a rat tooth forcep and removed trans-orally. The site of tissue repair showed complete resolution of the perforation with good healing of this area. Given the patient's history of prior recurrent food impactions, esophageal biopsies were taken and came back negative, ruling out eosinophilic esophagitis as an underlying cause of his symptoms and presentation. He remains well and asymptomatic on a once daily proton pump inhibitor per his 6 month follow up. Medical Implications Hemodynamically stable patients presenting with esophageal rupture may be treated endoscopically. A large mediastinal or pleural space collection requires percutaneous drainage. Placing a nasojejunal feeding tube permits esophageal rest and repair after injury. In conclusion, endoscopic suturing is one option for primary closure of acute esophageal perforations. In the esophagus, secondary protection with a fully covered metal stent may be useful. Endoscopic stay sutures prevent stent migration. Given the high morbidity associated with Borhoff syndrome, working in a multidisciplinary approach is required.

endoscopic approach

spontaneous esophageal rupture

Borchow syndrome

endoscopic suturing device

fully covered esophageal stent