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 . It is a very uncommon entity, with an estimated incidence in the literature of 1 in 6000 patients . 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% , but if left untreated, ap- proaches 100%. Barrett reported the ﬁrst case of success- ful surgical repair in 1947 . 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
Ann Thorac Surg CASE REPORT ASHRAFI ET AL 3192007;83:317–9 MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’Sescalating 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 delayedinjury. reconstruction. The repair was begun with a myotomy to identify the A Medline search of the literature pertaining to thetrue 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 leftrepair 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 managedWe then covered the repair with omentum. Other op- conservatively . The second report describes a laparo-tions for buttressing include pleura, intercostal muscles, scopic primary repair and a 270° posterior fundoplicationpericardial fat pad, or latissimus/serratus/pectoralis in a 72-year-old man. The patient was discharged homemuscle. after 2 weeks of hospitalization with no leak . 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 thoracoscopicas this was a case of nonconventional surgical manage- management of Boerhaave’s syndrome is a feasiblement. It is possible to use alternative methods of drain- FEATURE ARTICLES alternative.age (eg, chest tube) or none at all, but we prefer to drainlocally with Jackson-Pratt drains. Gastric decompression and nutritional support are Referencesimportant aspects of the postoperative management. 1. Derbes VJ, Mitchell RE Jr. Herman Boerhaave Atrocis, necAlthough a nasogastric tube is an alternative, we rou- descripti prius, morbi historia; the ﬁrst translation of classictinely perform laparoscopic jejunostomy and gastros- case report of rupture of the esophagus, with annotations. Bull Med Libr Assoc 1955;43:217–24.tomy tubes for other conditions, and usually it only adds 2. Lillington GA, Bernatz PE. Spontaneous perforation of esoph-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.of keeping the stomach decompressed. Also, in the event Primary esophageal repair for Boerhaave’s syndrome what-of a prolonged course, it provides a more comfortable ever the free interval between perforation and treatment. Eur J Cardiothorac Surg 2004;25:475–9.drainage technique for the patient. Every patient under- 4. Barrett NR. Report of a case of spontaneous perforation of thegoing surgical management of Boerhaave’s syndrome esophagus successfully treated by operation. Br J Surg 1947;runs the risk of leak or delayed healing, or both. There- 35:216.fore, the feeding tube ensures optimal enteral nutrition 5. Scott HJ, Rosin RD. Thoracoscopic repair of a transmuralin the event that the patient is not able to eat in the rupture of the oesophagus (Boerhaave’s syndrome). J R Soc Med 1995;88:414P–5P.postoperative period. 6. Landen S, El Nakadi I. Minimally invasive approach to We recommend conservative treatment to patients Boerhaave’s syndrome: a pilot study of three cases. Surgwho would not tolerate an operation from a medical Endosc 2002;16:1354 –7.