Supplementary Material for: Endoluminal Vacuum Therapy for the Management of Boerhaave Syndrome: A Case Series

Introduction
Boerhaave syndrome is a rare condition associated with high morbidity and mortality. Prompt intervention greatly improves outcomes, with surgery traditionally being the mainstay of management. Recent advances in therapeutic endoscopy have led to increasing interest in endoluminal vacuum therapy (EVT); a minimally invasive technique, allowing wound debridement and drainage, encouraging granulation tissue formation. EVT has been associated with positive clinical outcomes, including lower mortality rates compared to surgery and stenting for the management of anastomotic leaks, and to a lesser extent, oesophageal perforations. EVT has been adopted into practice across Europe, however, only few cases have been reported from the UK.

Case Presentations
We report three cases of Boerhaave syndrome, successfully managed with EVT, using the EsoSPONGE ® (B.Braun, Medical Ltd, Sheffield, UK). EVT involves the placement of a polyurethane sponge into the wound cavity. The cavity is initially assessed, then an overtube is introduced through which the sponge is inserted, and then the overtube is removed. Sponge position is confirmed and adjusted if necessary. The sponge is connected via a trans-nasal drain to continuous negative pressure suction and is changed every 3–5 days. Having been deemed surgically unfit, all three patients were referred for EVT. All patients made excellent recovery and were discharged home.

Conclusion
EVT is an effective management strategy for surgically unfit Boerhaave syndrome patients. EsoSPONGE use aided drainage of the septic focus and closure of the defect; leading to complete recovery. Our findings support the existing evidence that EVT is a promising solution for Boerhaave syndrome.