Successful endoscopic treatment of Boerhaave syndrome using an over-the-scope clip.

Boerhaave syndrome, a rare condition involving esophageal perforation and associated with high mortality, has traditionally required surgical repair [1]. In most cases of Boerhaave syndrome, the tear extends several centimeters, because of which it is difficult to completely close with hemoclips. More recently, treatment with self-expandable metal stents has been attempted for Boerhaave syndrome. However this method has a limited success rate and safety concerns have been reported [2]. We have described elsewhere the utility of the over-the-scope clip (OTSC) in patients with perforations and fistulas of the gastrointestinal tract [3–5]. Here, we present the first patient with Boerhaave syndrome successfully treated nonoperatively with OTSC. A 62-year-old man presented with hematemesis and substernal pain after an episode of vomiting. Enhanced computed tomography (CT) revealed intraluminal hematoma in the middle esophagus and pneumomediastinum (●" Fig.1). The patient was diagnosed as having Boerhaave syndrome with spontaneous esophageal perforation. The patient declined surgical repair, and we carried out endoscopic treatment after obtaining informed consent. Endoscopy revealed a 10-cm long tear on the middle to lower esophagus and exposed muscularis propria with perforation in lower esophagus (●" Fig.2 and ●" Video1). Closure usinghemoclips failed because of the extended length of the tear. Another attempt was made to close the tear in the lower esophagus using OTSC, which was successful. Subsequently, owing to the reduction in the length of the tear by using OTSC, we could easily close the defect in the middle esophagus with hemoclips, resulting in successful closure of the whole tear (●" Fig.3 and●" Video1). A CT scan taken 2 days after the treatment revealed disappearance of pneumomediastinum (●" Fig.4). The clinical condition of the patient improved and he was discharged 25days later. On follow-upendoscopy 24 days later, the tear site was completely healedwith the scarring (●" Fig.5). Our patient had an excellent outcome with complete healing of the defect withFig.1 Enhanced computed tomography (CT) scan in a 62-year-old man with hematemesis and substernal pain after an episode of vomiting, showing intraluminal hematoma (white arrows) in the middle esophagus, pneumomediastinum (black arrows), and pleural effusion.