The current management of Boerhaave syndrome—a European multicenter case-vignette study

Boerhaave syndrome is a rare surgical emergency, defined as a spontaneous perforation of the esophagus. Treatment options include endoscopic intervention and/or surgery, but the morbidity and mortality associated with Boerhaave syndrome is high. No consensus-based treatment guidelines currently exist. The aim of this study was to evaluate the diversity in treatment strategies for different clinical scenarios of Boerhaave syndrome across Europe. Forty-four surgeons from 24 different esophageal tertiary centers across nine European countries, Australia and the United Kingdom were invited to participate in this case-vignette study. Each surgeon was presented with four different cases of patients with Boerhaave syndrome and asked for their choice of initial treatment using a multiple-choice questionnaire. A multivariable regression analysis was performed to identify predictors of treatment choice. Thirty-one surgeons from 21 centers (20 in Europe across 9 countries and 1 in Australia) participated in the study. The proportion of surgeons selecting endoscopic treatment varied across the four cases (45%-84%, P < 0.01). Endoscopic treatment was associated with younger patient age (OR 0.83, 95% CI [0.75, 0.92], P < 0.01), absence of sepsis (OR 0.11, 95% CI [0.00, 0.16], P < 0.01) and increased time to treatment (OR 1.97, 95% CI [1.17, 3.31], P = 0.01). All surgeons working at Nordic centers (N = 6) exclusively opted for endoscopic treatment. We found considerable diversity in treatment strategies among surgeons presented with identical cases of patients with Boerhaave syndrome. Notably, all surgeons working at a Nordic center selected endoscopic treatment as their initial treatment strategy in all four cases.