The Pittsburgh Perforation Severity Score Guides Surgical Decision-Making in Delayed-Presentation Boerhaave’s Syndrome: A Retrospective Cohort Study

Background The management of Boerhaave’s syndrome presenting beyond the traditional 24-hour “golden period” remains controversial. This study evaluated whether the Pittsburgh Perforation Severity Score (PSS) could identify which delayed-presentation patients might still benefit from aggressive surgery. Methods We conducted a single-center retrospective cohort study (2020–2025). Among 20 patients, 14 underwent surgery and were analyzed for outcomes relative to surgical timing (early [< 24h] vs. delayed [≥ 24h]). Crucially, all patients were risk-stratified by PSS (low-intermediate: ≤5; high: ≥6). The primary outcome was 90-day mortality. Results The delayed surgery group (n = 6) had higher baseline severity (age, Charlson Index, PSS) than the early group (n = 8). Overall 90-day mortality was 7.1% (1/14), with the sole death occurring in the delayed group (16.7% vs. 0%, P = 0.429) in a patient with PSS = 13. PSS-stratified analysis revealed all adverse outcomes concentrated in the high-risk (PSS ≥ 6) subgroup. Notably, among high-risk patients (n = 10), surgical intervention (n = 6) yielded significantly lower mortality than non-surgical management (n = 4) (16.7% vs. 100%, P = 0.048). Conclusions For Boerhaave’s syndrome presenting late, the PSS provides critical risk stratification. While early surgery is preferable, selected high-risk patients (PSS ≥ 6) may still achieve survival benefit from surgical intervention. Our findings support using PSS to inform an individualized, “risk-adapted” surgical strategy over a rigid time-cutoff approach.