Multimodal Treatment of a Complicated Esophagopleural Fistula After Boerhaave's Syndrome: Successful Resolution With Endoscopic Vacuum Therapy.

Esophagopleural fistulas are rare complications associated with high morbidity and mortality, often resulting from spontaneous or iatrogenic esophageal perforations. We report a case of a 60-year-old male presenting with acute respiratory failure and empyema after spontaneous esophageal rupture (Boerhaave's syndrome). Despite thoracotomy with pleural decortication, surgical closure of the fistula was not feasible due to its proximity to the descending aorta. We report a technically complex case of esophagopleural fistula located near the descending aorta, in which delayed diagnosis and extensive inflammatory reaction obscured the tissue planes, precluding safe surgical dissection and repair. Endoscopic vacuum therapy (EVT) was therefore employed as a successful rescue strategy. A multimodal approach was adopted, including intensive care, broad-spectrum antibiotics, drainage procedures, and subsequent EVT. EVT was performed using a handmade sponge system constructed with gauze attached to a nasogastric tube, initially positioned intracavitarily, and exchanges were performed every seven days. After 14 days of EVT, complete closure of the fistula was confirmed endoscopically and radiologically. This case highlights EVT as an effective rescue strategy for complex esophagopleural fistulas, underscoring the importance of individualized, multidisciplinary management.