Spontaneous transmural rupture of esophagus--Boerhaave's syndrome.

Spontaneous transmural esophageal perforation is a rare condition with high morbidity and mortality. It is traditionally associated with alcohol abuse. Experience of the syndrome at a large medical center in Israel, a country where alcohol is not a national problem, is reviewed, and eight cases are described. The clinical picture was varied and confusing, only one patient presenting with the classic triad of vomiting, chest pain and subcutaneous emphysema, though abdominal pain occurred in six cases. The diagnosis consequently was delayed (average 2.8 days) in three patients and two died undiagnosed. Contrast studies, when performed, were diagnostic. Early rupture (less than 24 hours) was treated with primary repair (n = 3). Late rupture (greater than 24 hours) was successfully managed by drainage alone (without esophageal exclusion) in three cases, but required long hospital stay (mean 52 days). Five of the six patients diagnosed ante mortem survived. Late reconstructive procedures were not required. The key to successful outcome is awareness of the condition, with early diagnosis and aggressive surgical intervention--repair or drainage.