Repair of Distal Esophageal Perforation (Boerhaave’s Syndrome) By Left Thoracoscopy with the Patient in Prone Position

Giovanni Dapri, MD, FACS, FASMBS, HonFPALES, Sergio Carandina, MD, Luisa Brambilla, RN, Leonard Gerard, MD, Etienne Stevens, MD, Alain Roman, MD, Jacques Himpens, MD, Guy-Bernard Cadière, MD, PhD

Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium

Background: Boerhaave’s syndrome is an emergency disease related to 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.

Video: A 44-year old male was admitted to emergency room after 14 hours of an episode of vomiting and hematemesis. Preoperative work-up evidenced a perforation of the distal esophagus on the left side, associated to a pneumomediastinum. The patient underwent left thoracoscopy in prone position, after induction of general anesthesia using Carlens double lumen tube. Three trocars of 5-mm, 10-mm, 5-mm, were placed in the 5th, 7th and 10th intercostal spaces respectively. The exploration of the chest cavity showed presence of free liquid and fibrin, without evident esophageal perforation. The latter was however demonstrated after dissection of the mediastinal pleura, and appeared to be 2 cm in length. A nasogastric tube was advanced into the stomach under view, and a supplementary trocar-less grasper was placed in the 10th 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 cleaned and a chest tube replaced the 5-mm trocar 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 hospitalized 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 pericardic drain was placed after 16 days for pericardic tamponade. The gastrograffin swallow at 10 days showed a residual sinus at the site of the perforation, and a repeat gastrograffin swallow at 20 days was negative for leak. The patient was allowed to be discharged after 32 days.

Conclusions: Esophageal perforation can be treated in prone position thoracoscopy because the access is advantageous by the effect of gravity on the cardio-pulmonary organs. Success of primary suture depends on the timing between the incidence and the treatment; however the morbidity remains high.

Session: Video Channel Day 1

Program Number: V042

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