A 48-year-old man develops sudden severe epigastric pain followed by vomiting after a heavy meal with alcohol consumption. He is febrile and tachycardic. Chest radiograph shows a left pleural effusion and pneumomediastinum. CT confirms a full-thickness tear of the distal esophagus with mediastinal contamination within 12 hours of onset. What is the preferred management?
- A Primary surgical repair with drainage within 24 hours ✓
- B Conservative management with broad-spectrum antibiotics and nil per os
- C Immediate esophagectomy with gastric pull-up
- D Fully covered self-expanding metallic stent as first choice
Correct answer: A. Primary surgical repair with drainage within 24 hours
Explanation
Boerhaave syndrome presenting early, within 24 hours, in a stable patient is best treated with primary closure of the perforation reinforced with a vascularized flap such as intercostal muscle, combined with wide drainage of the pleura and mediastinum. Conservative management carries high mortality in a free perforation with mediastinal contamination. Esophagectomy is reserved for necrotic esophagus or failed repair. Stenting is an alternative when surgery is contraindicated.
Reference: Bailey and Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.