Spontaneous esophageal perforation within a hiatal hernia: A case report

Abstract

Introduction: Spontaneous esophageal perforation, also commonly referred to as Boerhaave's syndrome, is one of the most lethal diseases causing an acute abdomen. Though rare, emergent surgical intervention is often required and management can be various based upon the site of the perforation. This literature has been written in line with the SCARE criteria (Agha et al., 2020) [1].

Presentation of case: A 76-year-old man presented with acute abdominal pain. Computed tomography (CT) revealed and an emergent esophagogastroduodenoscopy (EGD) was performed carefully, which revealed a 7 cm all-layer esophageal laceration in the left lower esophageal wall. In our case, a hiatal hernia was protruding into the mediastinum, and the perforation site was inside of it, but there was no invasion into the thoracic cavity, thus a transabdominal approach was performed without thoracotomy.

Discussion: This type of esophageal perforation within a hiatal hernia is quite rare and provides a unique clinical challenge. In addition, A review reported the average length of spontaneous esophageal perforation to be around 2 cm while our case had a perforation with a length of 7 cm. We chose the combination of the simple suture with omental buttress and wide drainage, but a complete fundoplication was impossible due to its large size of perforation.

Conclusion: We chose the open abdominal approach because the case had high inflammation, a hiatal hernia and possibility of retro-gastric perforation. However, MIS should have been considered first if a situation or human resources allow it.

Keywords: Boerhaave's syndrome; Hiatal hernia; Spontaneous esophageal perforation; Transabdominal approach.