Negative Contrast Esophagography Does Not Exclude Dehiscence After Boerhaave Repair: Complementary Low-Insufflation Carbon Dioxide Endoscopy

After repair of Boerhaave syndrome, assessment of repair integrity is important because occult dehiscence may progress to mediastinitis or pleural sepsis. Water-soluble contrast esophagography is widely used before resuming oral intake, but absence of extravasation does not necessarily exclude a small or contained defect. We report a 59-year-old man with post-emetic distal esophageal rupture treated by emergency primary repair with pleural-flap buttress and drainage. Although clinically stable, contrast esophagography on postoperative day (POD) 7 showed no extravasation. Because feeding decisions required greater structural confidence, low-insufflation carbon dioxide esophagogastroduodenoscopy was performed on POD 9 and revealed focal suture-line dehiscence. Oral intake was deferred and conservative management continued. A regular diet was started only after POD 28 endoscopy showed marked interval healing; 3-month follow-up confirmed complete mucosal healing. Contrast esophagography remains the standard postoperative assessment; nevertheless, this hypothesis-generating case suggests that, in carefully selected, clinically stable patients with high-risk anatomic features, low-insufflation carbon dioxide endoscopy may provide complementary structural information when feeding decisions remain uncertain after a negative contrast study.