Minimally invasive management of boerhaave´s syndrome

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Minimally invasive management of boerhaave´s syndrome

  1. 1. Ann Thorac Surg CASE REPORT ASHRAFI ET AL 3172007;83:317–9 MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’Soccur ectopically, affecting the neck, middle or poste- sented to the emergency department with vomiting,rior mediastinum, and lung [5, 6]. However, ectopic followed by severe retrosternal and epigastric pain ofthymoma occurring in the pleura is extremely rare and sudden onset. An esophagogram showed evidence ofhas been infrequently documented [7]. free extravasation of contrast from the left posterolateral The differential diagnoses for giant intrathoracic aspect of the distal esophagus just above the level of themass are a pleural tumor (e.g., solitary fibrous tumor, hiatus. A minimally invasive technique was used tomalignant mesothelioma, and sarcomas), a chest wall repair this injury.tumor, or a metastatic mass. MRI findings of the (Ann Thorac Surg 2007;83:317–9)thymoma have the same or slightly increased intensity © 2007 by The Society of Thoracic Surgeonsas that of muscle on T1-weighted images and increasedintensity on T2-weighted images. Inhomogeneous sig-nal intensity on T2-weighted images with a lobulatedborder, fibrous band, and lobulated internal architec- B oerhaave’s syndrome is associated with a significant risk of mortality and morbidity. Prompt surgical management is the treatment of choice. The acceptedture is indicative of an invasive thymoma [8]. Although management involves surgical repair of the perforationthe MRI features of this case resembled those of using a thoracotomy or laparotomy, or both. Reducingorthotopic thymoma, preoperative diagnosis was diffi- the inflammatory response by minimizing the surgicalcult because of the unusual location. trauma may decrease the mortality risk of this potentially In summary, this report documents an extremely rare lethal condition. We report the successful laparoscopicoccurrence of ectopic pleural thymoma presenting as a and thoracoscopic management of a patient with Boer-giant mass in the thoracic cavity. haave’s syndrome. Although open repair and drainage FEATURE ARTICLES are the gold standard, we conclude that laparoscopic andReferences thoracoscopic management of Boerhaave’s syndrome is a feasible alternative.1. Rosai J, Sobin LH. Histological typing of tumors of the thymus, 2nd ed. New York: Springer, 1999.2. Richardson MA, Sie KYC. The neck: embryology and anat- A 42-year-old man with a long-standing history of inter- omy, 3rd ed. Philadelphia: WB Saunders Co, 1996. mittent dysphagia that required a change in the patient’s3. Rosai J, Levine GD. Tumors of the thymus, 2nd ed. Washing- dietary habits presented to the emergency department ton: Armed Forces Institute Pathol, 1976.4. Detterbeck FC, Parsons AM. Thymic tumors. Ann Thorac with a 5-hour history of vomiting, followed by severe Surg 2004;77:1860 –9. retrosternal and epigastric pain of sudden onset. On5. Moran CA, Suster S, Fishback NF, Koss MN. Primary in- initial presentation, his blood pressure was 142/86, pulse trapulmonary thymoma: a clinicopathologic and immunohis- was 100/min, and his respiratory rate was 22/min. The tochemical study of eight cases. Am J Surg Pathol 1995;19: 304 –12. patient was afebrile and mildly distressed.6. Minniti S, Valentini M, Pinali L, Malago R, Lestani M, On chest exam, there was decreased air entry over the Procacci C. Thymic masses of the middle mediastinum: report left hemithorax, with crackles at the left lung base. His of 2 cases and review of the literature. J Thorac Imag 2004;19: abdominal exam revealed a nondistended abdomen and 192–5.7. Moran CA, Travis WD, Rosado-de-Christenson M, Koss MN, epigastric tenderness without generalized peritonitis. Rosai J. Thymomas presenting as pleural tumors: report of The leucocyte count on admission was 12.1 ϫ 109/L. The eight cases. Am J Surg Pathol 1992;16:138 – 44. initial chest radiograph revealed a small left pleural8. Kushihashi T, Fujisawa H, Munechika H. Magnetic resonance effusion. A contrast-enhanced computed tomography imaging of thymic epithelial tumors. Crit Rev Diagn Imag (CT) scan of the chest demonstrated pneumomediasti- 1996;37:191–259. num and a left pleural effusion highly suggestive of esophageal perforation (Fig 1). The result of a CT scan of the abdomen was normal. A Gastrografin (Tyco/Minimally Invasive Management MallinKrodt, St. Louis, MO) swallow demonstrated freeof Boerhaave’s Syndrome extravasation of contrast from the left posterolateralAhmad S. Ashrafi, MD, Omar Awais, DO, aspect of the distal esophagus just above the level of theand Miguel Alvelo-Rivera, MD hiatus (Fig 2). After aggressive volume resuscitation, commencementThe Heart Lung and Esophageal Surgery Institute, Universityof Pittsburgh Medical Center, Pittsburgh, Pennsylvania of broad-spectrum antibiotics, and analgesia, the patient was taken to the operating room. On-table endoscopy revealed a 2-cm to 3-cm perforation just above a nar-We report the case of a 42-year-old man with Boerhaave’s rowed gastroesophageal junction. A laparoscopic explo-syndrome. His medical history was significant only for a ration showed no intraabdominal pathology.long-standing history of dysphagia. The patient pre- We then harvested a generous portion length of theAccepted for publication May 24, 2006. greater omentum and secured it to the edges of the left crus. We also performed a Heller myotomy given theAddress correspondence to Dr Alvelo-Rivera, The Heart, Lung andEsophageal Surgery Institute, University of Pittsburgh Medical Center, patient’s long-standing history of dysphagia. A laparo-200 Lothrop St, C-800, Pittsburgh, PA 15213; e-mail: alveloriveram@ scopic gastrostomy and feeding jejunostomy were per-upmc.edu. formed, and the port sites were closed.© 2007 by The Society of Thoracic Surgeons 0003-4975/07/$32.00Published by Elsevier Inc doi:10.1016/j.athoracsur.2006.05.111
  2. 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. 3. 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 [5]. 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 [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 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.

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