Diagnostic approach and therapeutic management of spontaneous esophageal peroration (Boerhaave’s syndrome): a case-based meta-analysis.

Boerhaave’s syndrome (BS) is a rare but life-threatening clinical entity, characterized by spontaneous esophageal perforation resulting from sudden distal esophageal pressurization, most frequently precipitated by forceful vomiting, in the context of negative intrathoracic pressure. Although it was first described in 1724 by Hermann Boerhaave, successful surgical management was not reported until more than two centuries later by Barrett et al. BS accounts for approximately 15% of all esophageal perforations with an age-standardized incidence of 0.31 cases per 100.000 population per year. Despite advances in diagnosis and treatment, mortality rates remain high, ranging from 15% to 50% largely driven by mediastinal contamination and the development of sepsis. The principles of treatment include hemodynamic stabilization, definitive closure of the esophageal defect, and adequate drainage of pleural collections. While surgical treatment has traditionally been the mainstay of treatment, the introduction of endoscopic therapy has changed the therapeutic landscape of esophageal perforation. Endoscopic approaches, comprising self-expandable metal stent placement and endoscopic vacuum therapy (EVT), have emerged as organ-preserving alternatives to surgery. Recent evidence from a large multinational retrospective cohort study suggests comparable short-term outcomes among endoscopic, surgical, and combined approaches, with no significant difference in in-hospital and 90-day mortality. Nevertheless, the existing evidence is largely derived from retrospective single-center series, frequently combining different etiologies of esophageal perforation. Consequently, the optimal management of BS remains uncertain, and current guideline recommendations are constrained by low-quality evidence. This heterogeneity limits the comparability of reported outcomes, complicating clinical decision-making. This systematic review and meta-analysis aim to synthesize current evidence on the clinical presentation, diagnostic and therapeutic strategies, and outcomes of BS in adults to identify management patterns and delineate gaps in contemporary management.