Endoscopic Vacuum Therapy in Boerhaave Syndrome: A Contemporary Narrative Review

Boerhaave syndrome remains a life-threatening condition due to rapid mediastinal contamination and sepsis, prompting growing interest in minimally invasive alternatives to surgery. Alongside surgery and endoscopic stenting, endoscopic vacuum therapy (EVT) has emerged over the past decade as an organ-preserving treatment option that combines defect closure with continuous internal drainage—an advantage over conventional stents, which often migrate and fail to control underlying contamination. This narrative review synthesizes current evidence on the role of EVT and hybrid vacuum–stent technologies in the management of spontaneous esophageal rupture. Across recent multicenter cohorts, observational studies, and case series, EVT demonstrates high defect closure rates (80–90%), particularly when applied early in contained perforations and in patients at increased operative risk. Comparative data suggest that, while stents provide effective luminal sealing, EVT offers a distinct advantage in controlling sepsis through active drainage, thereby reducing the need for adjunctive interventions in selected cases. Hybrid systems such as the VACStent further integrate luminal patency, sealing, and negative pressure, allowing nutritional intake while maintaining effective drainage. However, the available evidence remains heterogeneous and largely non-randomized, and EVT appears less effective in the presence of extensive contamination, large chronic cavities, or advanced sepsis. Current data support EVT as a central component of individualized, multimodal management strategies for Boerhaave syndrome, complementing rather than replacing surgical and stent-based approaches. Further prospective and comparative studies are required to refine patient selection and optimize treatment algorithms.