Cardiothoracic and Vascular Surgery Podium Presentation: Survival after distal esophageal rupture: a case report of prolonged intrathoracic complications after conversion from Mallory Weiss tear to Boerhaave’s syndrome during a pandemic.

Introduction/Purpose: This report details a case of a right pleural effusion after esophageal rupture with a protracted course ultimately leading to successful patient discharge.

Methods or Case Description: We present a 42 year-old male with chronic alcoholic cirrhosis who was admitted to the intensive care unit during the COVID-19 pandemic with altered mental status, agonal respirations, and hematemesis. He was a person under investigation for COVID-19 with gastroenterology evaluation of reported retching with hematemesis. There was no evidence of ongoing bleed and endoscopy was deferred in the setting of his critical condition. A large right pleural effusion was identified and initially drained 2 liters of “dirty dishwater” fluid via a pigtail thoracostomy tube. Over three weeks, the patient had pigtail catheter exchanged for a larger chest tube as the effusion became empyema. Once the patient was stabilized and downgraded from the ICU, he was transitioned to an oral liquid diet, which was observed to drain into his chest tube.

Outcomes: The patient underwent endoscopy with covered stent placement, venting percutaneous endoscopic gastrostomy tube placement, and eventual jejunostomy feeding tube placement. Nearly 3 months after initial admission, he underwent thoracotomy with decortication and washout, after which he recovered well and was discharged home on liquid diet.

Conclusion: This case is uniquely interesting given our patient's remarkable outcome despite the significant published mortality of Mallory Weiss tear conversion to Boerhaave’s syndrome in a patient with Child-Pugh class B cirrhosis and critical condition at presentation, superimposed on the significantly altered resource profile available during the height of the COVID-19 pandemic.