This case report describes the minimally invasive management of Boerhaave's syndrome in a 42-year-old man. Laparoscopic and thoracoscopic techniques were used to repair a 2-3 cm perforation in the esophagus just above the gastroesophageal junction. The perforation site was identified and repaired with a double layer of sutures. Harvested omentum was used to cover the repair. Postoperatively, the patient recovered well with no evidence of leak on follow up imaging. The report concludes that minimally invasive techniques can be a feasible alternative to open surgery for repair of Boerhaave's syndrome.
2. 318 CASE REPORT ASHRAFI ET AL Ann Thorac Surg
MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S 2007;83:317–9
Fig 1. Computed tomography image of the chest shows pneumome-
diastinum with air tracking laterally towards the left pleural space
and a left pleural effusion.
FEATURE ARTICLES
A double-lumen endotracheal tube was then inserted,
and the patient was positioned in the right lateral decu-
bitus position for video-assisted thoracoscopic explora-
tion of the left chest. The esophageal perforation site was
identified at a level just above the esophageal hiatus. A
two-layer repair was performed using simple interrupted
sutures. The harvested omentum was then used to cover
the entire length of the repaired esophagus. Intraopera-
tive insufflation of the esophagus did not show a leak, Fig 3. A postoperative barium swallow shows essentially a normal
esophagus.
and we placed two chest tubes and two Jackson-Pratt
drains. Incisions were closed and dressings were applied.
The patient was transferred to the intensive care unit
and had an uneventful course. He was discharged to the
ward the next day. A contrast study on postoperative day
4 showed no leak or obstruction (Fig 3). He was dis-
charged home on postoperative day 9.
Comment
Boerhaave’s syndrome, or spontaneous (postemetic) per-
foration of the esophagus, was first described by Her-
mann Boerhaave in 1724 [1]. It is a very uncommon
entity, with an estimated incidence in the literature of 1 in
6000 patients [2]. The esophagus differs from the rest of
the alimentary tract in that it lacks a serosal layer, which
normally contains collagen and elastic fibers. This makes
it more susceptible to rupture at lower pressures than the
rest of the gastrointestinal tract. Spontaneous esophageal
rupture is well documented as a postemetic phenome-
non. Early recognition and prompt treatment are impor-
tant factors in minimizing the mortality. The mortality
ranges from 20% to 30% [3], but if left untreated, ap-
proaches 100%. Barrett reported the first case of success-
ful surgical repair in 1947 [4].
Fig 2. A Gastrografin swallow shows extravasation of contrast in The minimally invasive technique could be used only if
the left chest. the patient is hemodynamically stable, without signs of
3. Ann Thorac Surg CASE REPORT ASHRAFI ET AL 319
2007;83:317–9 MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S
escalating sepsis, without significant medical risk factors standpoint if the presentation is not acute, the perfora-
that would preclude major surgery, and in patients with tion is well contained with good distal flow of contrast,
no contraindications for laparoscopy or thoracoscopy. and in a patient with no signs of sepsis.
In managing this patient, we began with laparoscopy to Postoperative morbidity includes the non-procedure-
harvest the omentum, performed a gastrostomy, a feed- related postoperative complications, stricture formation,
ing jejunostomy, and an esophagomyotomy. We also leak requiring further surgical management, or diver-
wanted to assess potential intraabdominal extent of the sion/esophagectomy, with or without delayed
injury. reconstruction.
The repair was begun with a myotomy to identify the A Medline search of the literature pertaining to the
true apices of the perforation. We then débrided the minimally invasive management of Boerhaave’s syn-
nonviable tissue and performed an interrupted mucosal drome yielded two reports. The first describes a left
repair by using absorbable suture material and a second thoracoscopic intracorporeal suture repair and drainage.
layer of repair by approximating the esophageal muscle. The patient had developed a leak that was managed
We then covered the repair with omentum. Other op- conservatively [5]. The second report describes a laparo-
tions for buttressing include pleura, intercostal muscles, scopic primary repair and a 270° posterior fundoplication
pericardial fat pad, or latissimus/serratus/pectoralis in a 72-year-old man. The patient was discharged home
muscle. after 2 weeks of hospitalization with no leak [6].
Jackson-Pratt drains were used for management of Although open repair and drainage are the gold stan-
potential postoperative leak to act as a controlled fistula, dard, we conclude that laparoscopic and thoracoscopic
as this was a case of nonconventional surgical manage- management of Boerhaave’s syndrome is a feasible
ment. It is possible to use alternative methods of drain-
FEATURE ARTICLES
alternative.
age (eg, chest tube) or none at all, but we prefer to drain
locally with Jackson-Pratt drains.
Gastric decompression and nutritional support are References
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15 to 20 minutes to the operating time. This allows early agus. Dis Chest 1961;39:177– 84.
institution of enteral feeding as well as a more secure way 3. Jougon J, Mc Bride T, Delcambre F, Minniti A, Velly JF.
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