Repair of distal esophageal perforation (Boerhaave’s syndrome) by left thoracoscopy with the patient in prone position
Epublication WebSurg.com, Mar 2013;13(03). URL: http://websurg.com/doi/vd01en3816
Background: Boerhaave’s syndrome is an emergency disease related to a high risk of mortality and morbidity. Surgical treatment is usually performed by thoracotomy or thoracoscopy with the patient in lateral position. The authors report a patient with a distal esophageal perforation treated by left thoracoscopy in prone position. Clinical case: A 44-year-old man was admitted to our emergency room following a 14-hour episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated with a pneumomediastinum. The patient underwent a left thoracoscopy in a prone position, after induction of general anesthesia using a Carlens-type double lumen tube. Three trocars of 5mm, 10mm, and 5mm, were placed in the 5th, 7th, and 10th intercostal spaces respectively. Exploration of the chest cavity revealed the presence of free liquid and fibrin, with no evidence of esophageal perforation. However, the esophageal perforation was demonstrated after dissection of the mediastinal pleura, and appeared to be 2cm in length. A nasogastric tube was advanced into the stomach under visual control, and an additional trocarless grasper was placed in the 10th intercostal space to improve exposure. The esophagus perforation was closed using 2/0 silk interrupted sutures, with a reinforcement patch using the inferior pulmonary ligament. The cavity was cleansed and the 5mm trocar was replaced with a chest tube in the 10th intercostal space, with its tip close to the suture. Results: Operative time was 90 minutes, and no significant operative bleeding was noted. The patient was admitted to hospital in the Intensive Care Unit and extubated after 24 hours. A chest tube was placed in the right chest after 10 days for a pleural effusion, and a pericardial drain was placed after 16 days for pericardial tamponade. A gastrograffin swallow test on postoperative day 10 revealed a residual sinus at the site of the perforation. Another gastrograffin swallow test on postoperative day 20 was negative for leakage. The patient was discharged after 32 days. Conclusions: Esophageal perforation can be treated by thoracoscopy with the patient placed in a prone position as access is facilitated by the effect of gravity on the cardiopulmonary organs. The success of the primary suture depends on the timing between the incident and the treatment; however, morbidity remains high.