Endoscopic Stenting for the Treatment of Boerhaave’s Syndrome

Abstract

The spontaneous rupture of the esophagus, called Boerhaave’s syndrome, presents a critical medical condition that produces high mortality rates unless appropriate emergency medical care is provided. Endoscopic stenting has risen as a minimally invasive treatment option after surgical procedures lost their popularity for addressing this condition. The study reviews endoscopic stenting results in Boerhaave’s syndrome by examining treatment success rates and complication and mortality statistics. A systematic review based on the PRISMA guidelines that included studies from 2014 to 2024 obtained from PubMed, Scopus, and Web of Science was conducted. Patient demographics, intervention characteristics, and clinical outcomes were the primary targets for data extraction during the review process. A random-effects model statistical analysis confirmed endoscopic stenting as an effective treatment, achieving closure success in 72.4% of patients and leak occlusion in 93% of cases. A significant level of study methodological and patient diversity caused high heterogeneity (I² = 98.85%). Endoscopic stenting provided better outcomes for hospital stay duration and postoperative complications above surgical intervention, although publication bias shows a moderate risk (P = 0.1602). The major limitation related to migration in endoscopic stenting shows promise for improvement as current research develops both stent technology and patient selection methods. Testing outcomes from endoscopic stenting as an acceptable surgical option for Boerhaave’s syndrome patients exists, but additional randomized trials need to optimize treatment procedures.

Keywords

endoscopic stenting Boerhaave syndrome esophagus/foregut perforation

Introduction

Boerhaave’s syndrome is a crucial mechanical etiology of ischemic injury, which involves spontaneous rupture of the esophagus, generally in the lower part of the musculature.¹ The syndrome is associated with high morbidity and mortality rates of between 30% and 50% in any population within any given region in the world if not diagnosed early or left untreated.² Although Boerhaave’s syndrome requires surgical intervention with subsequent suturing of the lesion, an endoscopic stenting method has recently been described as an acceptable noninvasive management strategy.³ In addition to many other advantages, this approach has been shown to be even more beneficial in terms of quicker recovery time in comparison to the surgical intervention.⁴

Endoscopy with stent placement is a secure and less invasive method that has recently replaced surgical interventions because, besides the treatment of perforation, it offers fewer complications, shorter hospital stays, and fewer postoperative risks than that of surgical methods.⁴ However, the efficacy and durability of endoscopic stenting for managing Boerhaave’s syndrome continue to be controversial despite the availability of several reports in the recent literature.⁵ While there are individual studies exploring the clinical outcomes of the particular treatment, there is a need to conduct systematic reviews and meta-analyses in order to evaluate existing evidence effectively and compare the novel treatment to traditional surgery based on survival rates, complication rates, and other relevant factors.

There is a vast amount of literature that reviewed and discussed the different treatments for Boerhaave’s syndrome through the use of endoscopic stenting, and the outcomes of each may differ depending on patient-related factors, timing of stent intervention, and type of stent used.⁶ This would afford the chance to acquire more comprehensive data from those individual studies and analyze the treatment efficacy among the presented patient populations. Furthermore, it would allow for evaluating the risk of bias, defining the weaknesses and strengths of previous work, and determining more precise practice boundaries concerning this significant condition.

This meta-analysis was conducted to assess the current body of literature on the endoscopic stenting management of Boerhaave’s syndrome and the impact of this approach on morbidity, mortality, and overall treatment outcome. Thus, after completing a comprehensive analysis and comparing recent findings published in the last 10 years, the authors strive to contribute to clinical practice and conduct further research.

Methodology

The purpose of this meta-analysis is to assess the effectiveness of endoscopic stenting in the management of Boerhaave’s syndrome. The guidelines chosen to test the methodology of this systematic review were those presented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following research proposal was constructed before the beginning of the study: the description of the research problem, inclusion criteria for the participants, sources with potential articles to be included in the review, and statistical tools to be used. The objective of this meta-analysis is to evaluate the clinical results of endoscopic stenting for the treatment of Boerhaave’s syndrome in terms of survival, complications, and outcome in general.

Eligibility Criteria

Specific criteria for including or excluding studies into the meta-analysis were defined to obtain high quality, and only relevant articles required for the analyses were considered. Studies were included if they met the criteria provided in Table 1.

Table 1.

Eligibility Criteria for Study Selection.

Criteria	Inclusion	Exclusion
Population	Research based on the surgical patient population over the age of 18 with Boerhaave’s syndrome and who were treated through endoscopic stenting.	Research articles that did not meet inclusion criteria 1 = focused solely on Boerhaave’s syndrome or 2 = did not include endoscopic stenting as one of the management strategies. Animal models
Intervention/ exposure	Studies evaluating endoscopic stenting in Boerhaave’s syndrome.	Research studies on Boerhaave syndrome using other than endoscopic stenting, for example, endoscopic vacuum.
Outcome	Clinical results including survival, esophageal perforation management, morbidity, and mortality, as well as infections, fistula formation, and follow-up results.
Study design	No restrictions on type of study: cohort studies, case-control studies, clinical controlled trials (having more than n = 5), and miscellaneous controlled trials on endoscopic stenting in Boerhaave’s syndrome.	Editorials and/or letters case study.
Type of publication	Peer-reviewed clinical studies, articles, or journals.	Books, theses, conference proceedings, editorials, and opinions.
Publication date	Studies published between 2014 and 2024	Any study before 2014
Language	Studies published in the English language.	Studies published in languages other than English

Both the title and abstract of the studies identified from the database search were reviewed by two authors individually to eliminate those articles that did not fit the eligibility criteria of the study. The articles were then further screened based on their availability in the full text. Where there was any disagreement between the reviewers, then it was handled through a discussion or resolved through consultation with a third reviewer. Articles that were screened but did not meet the inclusion criteria or were subsequently excluded have been described, and the reasons for their exclusion have been presented in the form of a PRISMA flow diagram.

Search Strategy

The search strategy to obtain the relevant literature was designed and carried out to warrant a comprehensive and evidence-based systematic review according to the PRISMA guidelines. An appropriate use of keywords and Boolean operators was made to ensure sensitivity and specificity. The goal was to identify the studies with the greatest potential utility in addressing the research question and focusing on the endoscopic stent application for Boerhaave’s syndrome regarding clinical outcomes such as survival rates, complications, and general efficacy.

The papers were collected from PubMed, Scopus, and Web of Science databases for the core articles. These were identified from the core aspects of the research question, especially endoscopic stenting, Boerhaave’s syndrome, and clinical outcomes such as survival rate, complications, and treatment effectiveness. The search terms were as follows: To locate literature on the intervention, the search terms “[ENDOSCOPIC STENTING],” “[ESOPHAGEAL STENTING],” “[ENDOSCOPIC TREATMENT],” “[ENDOSCOPIC THERAPY],” and “[STENT PLACEMENT]” were used. The terms used for Boerhaave’s syndrome included “[BOERHAAVE’S SYNDROME],” “[SPONTANEOUS RUPTURE OF THE OESOPHAGUS],” “[OESOPHAGEAL PERFORATION],” and [OESOPHAGEAL TEAR].” For outcome, sources were searched using the keywords such as “[SURVIVAL RATE],” “[TREATMENT EFFICACY],” “[COMPLICATION],” “[MORTALITY],” “[SUCCESS RATE],” “[TREATMENT OUTCOME],” and “[COMPLICATION RATE]” in order to include study reporting the clinical results.

Data Extraction

Data from each examined paper was collected using a data sheet in Excel. All the data was entered into an Excel spreadsheet to minimize bias. The following data was extracted from each study.

Study Characteristics

Author’s identity, the year of publication, the country of the study, or the type of research method used were collected.

Parameters of the Sample

Number of patients included in the sample and their demographics.

Mechanisms of Intervention

Treatment characteristics (eg, used stent type and the treatment course duration).

The outcome measures include parameters obtained from the treatment results (such as mortality, stent migration, closure of perforation, and organ failure).

Any number or character data, including average (mean and standard deviation), risk (odds ratio), and measure of uncertainty (confidence interval).

Data extraction was done by two reviewers, and any disagreements that arose were resolved by coming to a consensus. In case data were either missing or not entirely clear, the authors of the particular research were asked for additional information (Table 2).

Table 2.

Study Table.

Study ID	Sample Size	Intervention	Outcome
Anundsen et al (2024)⁷	17	Stent	Persistent leakage 23%
Ashbrook et al (2024)⁸	385	Stent	Mortality 11%
Berlth et al (2019)⁹	76	Metal stent	Closure rate 72.4%
Bick et al (2017)¹⁰	101	Sutured FC-SEMS Stent	Stent migration 63.2%
Freeman et al (2014)¹¹	5	Stent	Postoperative complications 60%
Kamarajah et al (2020)¹²	29	Plastic/ metal stent	Leak occlusion occurred in 93%
Schweigert et al (2013)¹³	13	Stent	Mortality 15%
Willems et al (2023)¹⁴	12	Stent	Empyema formation 42%

Critical Appraisal

The quality of the related studies included in this synthesis was evaluated using standardized checklists. To assess the RCTs, the Cochrane Risk of Bias tool was used to evaluate the risk of bias across seven sources: selection, performance, detection, attrition, reporting, and other sources. The Newcastle-Ottawa Scale (NOS) assessed the methodological quality of the observational studies, comparing selection, comparability, and outcome assessment. To do this, each study received a score depending on these quality assessment tools, which was later used in the meta-analysis to determine the effect of the quality of the studies on the result.

Statistical Analysis

R-Studio was used for testing random-effect meta-regression, for bias analysis through funnel plot, and for conducting Eggers’ test. The random-effects model was used in performing the meta-analysis because it deals with the heterogeneity of study participants and results. The pooled effect size was computed for variables like survival, rate of complications, and the closing of esophageal perforation. The heterogeneity statistics I² test was also used to determine heterogeneity between the subgroups.

The overall effect sizes for each outcome measure and their confidence interval have been presented in the form of forest plots. Finally, the risk of bias for all the individual studies was assessed to identify the extent to which bias might have affected these findings.

PRISMA Flow Diagram

A PRISMA flow diagram was used to present the detailed flow of the studies through the screening and selection process, including the final meta-analysis.

This PRISMA flow diagram in Figure 1 will assist in explaining the quantitative results since the identification of the studies, as well as the exclusion and inclusion process, will follow the PRISMA guidelines.

Results

Outcomes with Esophageal Stenting

The following features were established while using the random-effects model in the study on esophageal stenting in Boerhaave syndrome (refer to Figure 2). The model was based on 7 meta-analyses (k = 7) and the tau² estimator, while the total heterogeneity was 0.1134 with its SE 0.0712. This implied that there was a fair amount of heterogeneity between the studies selected in the present meta-analysis.

The fixed-effect model (I² = 98.85) suggested substantial variance due to the high heterogeneity between studies. The estimate of the model for the effect size is 0.4303, while the standard error was 0.1329. By calculating the z-value of 3.2377 and P-value equal to 0.0012, the authors have claimed that this estimate is statistically significant for the postoperative prognosis of Boerhaave syndrome through esophageal stenting.

Accordingly, the random-effects model indicated that esophageal stenting had a clinically significant impact on the management of Boerhaave syndrome. However, the high I² and significant Q-test values of the studies confirmed the existence of substantial heterogeneity between the studies.

Analysis of Study Bias

Funnel Plot

A funnel plot testing publication bias in studies related to esophageal stenting reveals slight asymmetry, which might stem from both publication bias and variation between studies. Research with smaller sample sizes shows wider-ranging effect measurements, but larger investigations tend to group closer to the average.

The distribution patterns detected possible variations in study sizes and research methodologies among the investigations, as shown in Figure 3.

Egger’s Test

When Egger’s test was conducted, the P-value equal to 0.1602 (P ≥ .05) implied no significant bias. Also, the funnel plot was not significantly asymmetrical, thus suggesting that there was no publication bias. The test statistic (τ² = 50.6826) shows a small degree of heterogeneity among the studies included, and the limit estimate for smaller standard errors (3.7739) signifies a null or smaller effect size. The evidence generally points to moderate to low-level publication bias in our data set.

Discussion

Endoscopic stenting treatment for Boerhaave’s syndrome proves effective according to the analysis results presented in this study. The spontaneous rupture of the esophagus, which is Boerhaave’s syndrome, requires instant medical treatment to prevent disability and death. Endoscopic stenting represents a promising noninvasive treatment option, providing promising results despite traditional surgical therapy remaining the conventional approach.¹⁵ Endoscopic stenting in the treatment of Boerhaave’s syndrome allows endoscopists to implement it without great difficulty while showing variable results, according to the analysis from a few research studies. Our meta-analysis showed a 72.4% clinical success rate along with a 93% successful delivery of leak reduction. Spontaneous migration of stents happened to 36.6% of patients during the treatment, which required further interventions occasionally. Endoscopic stenting serves as a feasible surgical replacement, but effective patient selection stands as the key requirement for maximizing treatment results.

The findings of this analysis demonstrated that endoscopic stenting represents an effective surgical substitute suitable primarily for specific patient groups. Our findings are in line with previous studies that have shown that placing stents successfully treats colonic obstruction and shortens hospital stays.¹⁶ The analysis reported by Kamarajah et al (2020) revealed 93% leak occlusion success, along with Berlth et al (2019) demonstrating 72.4% closure rates to verify endoscopic intervention effectiveness. The observed evidence confirms similar systematic reviews, which showed that minimal intervention approaches contribute to shorter recovery times while diminishing total health care expenses.^17,18

Endoscopic stenting offers crucial benefits, yet surgical intervention stands as an essential treatment option for patients who have severe esophageal tissue damage, delayed medical interventions, or non-response to traditional therapy. The mortality rate of 11% presented by Ashbrook et al (2024) shows endoscopic stenting raises survival rates, yet some patients need surgical intervention to survive. Primary surgical repair demonstrates better clinical results for patients who present with severe mediastinitis or extensive tissue necrosis, according to Vodička et al.¹⁹ Among postoperative complications, endoscopic stenting demonstrates an increased occurrence of infection. These findings align with the observation of fistula formation and anastomotic leakage, as reported by Rosianu et al.²⁰ Multiple factors causing patient variation warrant using customized treatment methods that combine either surgical or endoscopic approaches for best outcomes.

Endoscopic stenting has demonstrated its increasing importance as a treatment method for Boerhaave’s syndrome in needy surgical patients. Endoscopic stenting delivers high technical success and enhanced postoperative recovery. However, questions remain about both device migration and the frequency of subsequent procedures. The combination of endoscopic stenting with surgical interventions and vacuum therapy shows promise for minimizing complications in patients with extensive types of esophageal damage.

A substantial amount of heterogeneity emerges in this meta-analysis (I² = 98.85) because different methodologies and various patient groups and stent types were used. Follow-up duration and time points for intervention seem to affect the observed variations between studies significantly. Multiple studies indicate early intervention holds significance because treatment delay leads to higher morbidity and mortality rates, according to Freeman et al (2014).

Egger’s test indicated moderate publication bias risk with a value of P = .1602. The success rates appear skewed because researchers published limited findings from smaller studies showing positive results. The primary source of weakness for research comes from retrospective study design, which introduces selection bias. Standardized randomized controlled trials need to be conducted to establish the precise function of endoscopic stenting for Boerhaave’s syndrome treatment.

More studies are needed to test biodegradable stents that would support the structures during a short period but eliminate both migration issues and complications with removal. Long-term functional outcome analyses of dysphagia and esophageal motility will determine optimal treatment methods for sustaining persistent patient treatment.

Conclusion

Endoscopic stenting can be performed to treat Boerhaave’s syndrome, which offers both minimal invasive properties and safe outcomes compared with surgery. Endoscopic stenting yields significant benefits through reduced mortality and enhanced recovery, but the high incidence of stent migration alongside the need for secondary procedures constrain its effectiveness. Future research must optimize stenting technology through improved designs while refining patient assessment methods to establish clinical protocols using randomized controlled trial results.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Piyush Manoria

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