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Minimally Invasive Management of Boerhaave’s Syndrome
317
Ann Thorac Surg 2007;83:317–9
CASE REPORT ASHRAFI ET AL MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S
occur ectopically, affecting the neck, middle or posterior mediastinum, and lung [5, 6]. However, ectopic thymoma occurring in the pleura is extremely rare and has been infrequently documented [7]. The differential diagnoses for giant intrathoracic mass are a pleural tumor (e.g., solitary fibrous tumor, malignant mesothelioma, and sarcomas), a chest wall tumor, or a metastatic mass. MRI findings of the thymoma have the same or slightly increased intensity as that of muscle on T1-weighted images and increased intensity on T2-weighted images. Inhomogeneous signal intensity on T2-weighted images with a lobulated border, fibrous band, and lobulated internal architecture is indicative of an invasive thymoma [8]. Although the MRI features of this case resembled those of orthotopic thymoma, preoperative diagnosis was difficult because of the unusual location. In summary, this report documents an extremely rare occurrence of ectopic pleural thymoma presenting as a giant mass in the thoracic cavity.
sented to the emergency department with vomiting, followed by severe retrosternal and epigastric pain of sudden onset. An esophagogram showed evidence of free extravasation of contrast from the left posterolateral aspect of the distal esophagus just above the level of the hiatus. A minimally invasive technique was used to repair this injury. (Ann Thorac Surg 2007;83:317–9) © 2007 by The Society of Thoracic Surgeons
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 anatomy, 3rd ed. Philadelphia: WB Saunders Co, 1996. 3. Rosai J, Levine GD. Tumors of the thymus, 2nd ed. Washington: Armed Forces Institute Pathol, 1976. 4. Detterbeck FC, Parsons AM. Thymic tumors. Ann Thorac Surg 2004;77:1860 –9. 5. Moran CA, Suster S, Fishback NF, Koss MN. Primary intrapulmonary thymoma: a clinicopathologic and immunohistochemical study of eight cases. Am J Surg Pathol 1995;19: 304 –12. 6. Minniti S, Valentini M, Pinali L, Malago R, Lestani M, Procacci C. Thymic masses of the middle mediastinum: report of 2 cases and review of the literature. J Thorac Imag 2004;19: 192–5. 7. Moran CA, Travis WD, Rosado-de-Christenson M, Koss MN, Rosai J. Thymomas presenting as pleural tumors: report of eight cases. Am J Surg Pathol 1992;16:138 – 44. 8. Kushihashi T, Fujisawa H, Munechika H. Magnetic resonance imaging of thymic epithelial tumors. Crit Rev Diagn Imag 1996;37:191–259.
Minimally Invasive Management of Boerhaave’s Syndrome Ahmad S. Ashrafi, MD, Omar Awais, DO, and Miguel Alvelo-Rivera, MD The Heart Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
We report the case of a 42-year-old man with Boerhaave’s syndrome. His medical history was significant only for a long-standing history of dysphagia. The patient preAccepted for publication May 24, 2006. Address correspondence to Dr Alvelo-Rivera, The Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, 200 Lothrop St, C-800, Pittsburgh, PA 15213; e-mail: alveloriveram@ upmc.edu.
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
oerhaave’s syndrome is associated with a significant risk of mortality and morbidity. Prompt surgical management is the treatment of choice. The accepted management involves surgical repair of the perforation using a thoracotomy or laparotomy, or both. Reducing the inflammatory response by minimizing the surgical trauma may decrease the mortality risk of this potentially lethal condition. We report the successful laparoscopic and thoracoscopic management of a patient with Boerhaave’s syndrome. Although open repair and drainage are the gold standard, we conclude that laparoscopic and thoracoscopic management of Boerhaave’s syndrome is a feasible alternative. A 42-year-old man with a long-standing history of intermittent dysphagia that required a change in the patient’s dietary habits presented to the emergency department with a 5-hour history of vomiting, followed by severe retrosternal and epigastric pain of sudden onset. On initial presentation, his blood pressure was 142/86, pulse was 100/min, and his respiratory rate was 22/min. The patient was afebrile and mildly distressed. On chest exam, there was decreased air entry over the left hemithorax, with crackles at the left lung base. His abdominal exam revealed a nondistended abdomen and epigastric tenderness without generalized peritonitis. The leucocyte count on admission was 12.1 ⫻ 109/L. The initial chest radiograph revealed a small left pleural effusion. A contrast-enhanced computed tomography (CT) scan of the chest demonstrated pneumomediastinum 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/ MallinKrodt, St. Louis, MO) swallow demonstrated free extravasation of contrast from the left posterolateral aspect of the distal esophagus just above the level of the hiatus (Fig 2). After aggressive volume resuscitation, commencement 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 narrowed gastroesophageal junction. A laparoscopic exploration showed no intraabdominal pathology. We then harvested a generous portion length of the greater omentum and secured it to the edges of the left crus. We also performed a Heller myotomy given the patient’s long-standing history of dysphagia. A laparoscopic gastrostomy and feeding jejunostomy were performed, and the port sites were closed. 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.05.111
FEATURE ARTICLES
References
B
318
CASE REPORT ASHRAFI ET AL MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S
Ann Thorac Surg 2007;83:317–9
Fig 1. Computed tomography image of the chest shows pneumomediastinum 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 decubitus position for video-assisted thoracoscopic exploration 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. Intraoperative 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 discharged home on postoperative day 9.
Comment
Fig 2. A Gastrografin swallow shows extravasation of contrast in the left chest.
Boerhaave’s syndrome, or spontaneous (postemetic) perforation of the esophagus, was first described by Hermann 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 phenomenon. Early recognition and prompt treatment are important factors in minimizing the mortality. The mortality ranges from 20% to 30% [3], but if left untreated, approaches 100%. Barrett reported the first case of successful surgical repair in 1947 [4]. The minimally invasive technique could be used only if the patient is hemodynamically stable, without signs of
CASE REPORT ASHRAFI ET AL MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S
escalating sepsis, without significant medical risk factors that would preclude major surgery, and in patients with no contraindications for laparoscopy or thoracoscopy. In managing this patient, we began with laparoscopy to harvest the omentum, performed a gastrostomy, a feeding jejunostomy, and an esophagomyotomy. We also wanted to assess potential intraabdominal extent of the injury. The repair was begun with a myotomy to identify the true apices of the perforation. We then débrided the nonviable tissue and performed an interrupted mucosal repair by using absorbable suture material and a second layer of repair by approximating the esophageal muscle. We then covered the repair with omentum. Other options for buttressing include pleura, intercostal muscles, pericardial fat pad, or latissimus/serratus/pectoralis muscle. Jackson-Pratt drains were used for management of potential postoperative leak to act as a controlled fistula, as this was a case of nonconventional surgical management. It is possible to use alternative methods of drainage (eg, chest tube) or none at all, but we prefer to drain locally with Jackson-Pratt drains. Gastric decompression and nutritional support are important aspects of the postoperative management. Although a nasogastric tube is an alternative, we routinely perform laparoscopic jejunostomy and gastrostomy tubes for other conditions, and usually it only adds 15 to 20 minutes to the operating time. This allows early institution of enteral feeding as well as a more secure way of keeping the stomach decompressed. Also, in the event of a prolonged course, it provides a more comfortable drainage technique for the patient. Every patient undergoing surgical management of Boerhaave’s syndrome runs the risk of leak or delayed healing, or both. Therefore, the feeding tube ensures optimal enteral nutrition in the event that the patient is not able to eat in the postoperative period. We recommend conservative treatment to patients who would not tolerate an operation from a medical
standpoint if the presentation is not acute, the perforation is well contained with good distal flow of contrast, and in a patient with no signs of sepsis. Postoperative morbidity includes the non-procedurerelated postoperative complications, stricture formation, leak requiring further surgical management, or diversion/esophagectomy, with or without delayed reconstruction. A Medline search of the literature pertaining to the minimally invasive management of Boerhaave’s syndrome yielded two reports. The first describes a left thoracoscopic intracorporeal suture repair and drainage. The patient had developed a leak that was managed conservatively [5]. The second report describes a laparoscopic primary repair and a 270° posterior fundoplication in a 72-year-old man. The patient was discharged home after 2 weeks of hospitalization with no leak [6]. Although open repair and drainage are the gold standard, we conclude that laparoscopic and thoracoscopic management of Boerhaave’s syndrome is a feasible alternative.
References 1. Derbes VJ, Mitchell RE Jr. Herman Boerhaave Atrocis, nec descripti prius, morbi historia; the first translation of classic case report of rupture of the esophagus, with annotations. Bull Med Libr Assoc 1955;43:217–24. 2. Lillington GA, Bernatz PE. Spontaneous perforation of esophagus. Dis Chest 1961;39:177– 84. 3. Jougon J, Mc Bride T, Delcambre F, Minniti A, Velly JF. Primary esophageal repair for Boerhaave’s syndrome whatever the free interval between perforation and treatment. Eur J Cardiothorac Surg 2004;25:475–9. 4. Barrett NR. Report of a case of spontaneous perforation of the esophagus successfully treated by operation. Br J Surg 1947; 35:216. 5. Scott HJ, Rosin RD. Thoracoscopic repair of a transmural rupture of the oesophagus (Boerhaave’s syndrome). J R Soc Med 1995;88:414P–5P. 6. Landen S, El Nakadi I. Minimally invasive approach to Boerhaave’s syndrome: a pilot study of three cases. Surg Endosc 2002;16:1354 –7.
FEATURE ARTICLES
319
Ann Thorac Surg 2007;83:317–9
Ann Thorac Surg 2007;83:317–9
CASE REPORT ASHRAFI ET AL MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S
occur ectopically, affecting the neck, middle or posterior mediastinum, and lung [5, 6]. However, ectopic thymoma occurring in the pleura is extremely rare and has been infrequently documented [7]. The differential diagnoses for giant intrathoracic mass are a pleural tumor (e.g., solitary fibrous tumor, malignant mesothelioma, and sarcomas), a chest wall tumor, or a metastatic mass. MRI findings of the thymoma have the same or slightly increased intensity as that of muscle on T1-weighted images and increased intensity on T2-weighted images. Inhomogeneous signal intensity on T2-weighted images with a lobulated border, fibrous band, and lobulated internal architecture is indicative of an invasive thymoma [8]. Although the MRI features of this case resembled those of orthotopic thymoma, preoperative diagnosis was difficult because of the unusual location. In summary, this report documents an extremely rare occurrence of ectopic pleural thymoma presenting as a giant mass in the thoracic cavity.
sented to the emergency department with vomiting, followed by severe retrosternal and epigastric pain of sudden onset. An esophagogram showed evidence of free extravasation of contrast from the left posterolateral aspect of the distal esophagus just above the level of the hiatus. A minimally invasive technique was used to repair this injury. (Ann Thorac Surg 2007;83:317–9) © 2007 by The Society of Thoracic Surgeons
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 anatomy, 3rd ed. Philadelphia: WB Saunders Co, 1996. 3. Rosai J, Levine GD. Tumors of the thymus, 2nd ed. Washington: Armed Forces Institute Pathol, 1976. 4. Detterbeck FC, Parsons AM. Thymic tumors. Ann Thorac Surg 2004;77:1860 –9. 5. Moran CA, Suster S, Fishback NF, Koss MN. Primary intrapulmonary thymoma: a clinicopathologic and immunohistochemical study of eight cases. Am J Surg Pathol 1995;19: 304 –12. 6. Minniti S, Valentini M, Pinali L, Malago R, Lestani M, Procacci C. Thymic masses of the middle mediastinum: report of 2 cases and review of the literature. J Thorac Imag 2004;19: 192–5. 7. Moran CA, Travis WD, Rosado-de-Christenson M, Koss MN, Rosai J. Thymomas presenting as pleural tumors: report of eight cases. Am J Surg Pathol 1992;16:138 – 44. 8. Kushihashi T, Fujisawa H, Munechika H. Magnetic resonance imaging of thymic epithelial tumors. Crit Rev Diagn Imag 1996;37:191–259.
Minimally Invasive Management of Boerhaave’s Syndrome Ahmad S. Ashrafi, MD, Omar Awais, DO, and Miguel Alvelo-Rivera, MD The Heart Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
We report the case of a 42-year-old man with Boerhaave’s syndrome. His medical history was significant only for a long-standing history of dysphagia. The patient preAccepted for publication May 24, 2006. Address correspondence to Dr Alvelo-Rivera, The Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, 200 Lothrop St, C-800, Pittsburgh, PA 15213; e-mail: alveloriveram@ upmc.edu.
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
oerhaave’s syndrome is associated with a significant risk of mortality and morbidity. Prompt surgical management is the treatment of choice. The accepted management involves surgical repair of the perforation using a thoracotomy or laparotomy, or both. Reducing the inflammatory response by minimizing the surgical trauma may decrease the mortality risk of this potentially lethal condition. We report the successful laparoscopic and thoracoscopic management of a patient with Boerhaave’s syndrome. Although open repair and drainage are the gold standard, we conclude that laparoscopic and thoracoscopic management of Boerhaave’s syndrome is a feasible alternative. A 42-year-old man with a long-standing history of intermittent dysphagia that required a change in the patient’s dietary habits presented to the emergency department with a 5-hour history of vomiting, followed by severe retrosternal and epigastric pain of sudden onset. On initial presentation, his blood pressure was 142/86, pulse was 100/min, and his respiratory rate was 22/min. The patient was afebrile and mildly distressed. On chest exam, there was decreased air entry over the left hemithorax, with crackles at the left lung base. His abdominal exam revealed a nondistended abdomen and epigastric tenderness without generalized peritonitis. The leucocyte count on admission was 12.1 ⫻ 109/L. The initial chest radiograph revealed a small left pleural effusion. A contrast-enhanced computed tomography (CT) scan of the chest demonstrated pneumomediastinum 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/ MallinKrodt, St. Louis, MO) swallow demonstrated free extravasation of contrast from the left posterolateral aspect of the distal esophagus just above the level of the hiatus (Fig 2). After aggressive volume resuscitation, commencement 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 narrowed gastroesophageal junction. A laparoscopic exploration showed no intraabdominal pathology. We then harvested a generous portion length of the greater omentum and secured it to the edges of the left crus. We also performed a Heller myotomy given the patient’s long-standing history of dysphagia. A laparoscopic gastrostomy and feeding jejunostomy were performed, and the port sites were closed. 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.05.111
FEATURE ARTICLES
References
B
318
CASE REPORT ASHRAFI ET AL MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S
Ann Thorac Surg 2007;83:317–9
Fig 1. Computed tomography image of the chest shows pneumomediastinum 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 decubitus position for video-assisted thoracoscopic exploration 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. Intraoperative 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 discharged home on postoperative day 9.
Comment
Fig 2. A Gastrografin swallow shows extravasation of contrast in the left chest.
Boerhaave’s syndrome, or spontaneous (postemetic) perforation of the esophagus, was first described by Hermann 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 phenomenon. Early recognition and prompt treatment are important factors in minimizing the mortality. The mortality ranges from 20% to 30% [3], but if left untreated, approaches 100%. Barrett reported the first case of successful surgical repair in 1947 [4]. The minimally invasive technique could be used only if the patient is hemodynamically stable, without signs of
CASE REPORT ASHRAFI ET AL MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S
escalating sepsis, without significant medical risk factors that would preclude major surgery, and in patients with no contraindications for laparoscopy or thoracoscopy. In managing this patient, we began with laparoscopy to harvest the omentum, performed a gastrostomy, a feeding jejunostomy, and an esophagomyotomy. We also wanted to assess potential intraabdominal extent of the injury. The repair was begun with a myotomy to identify the true apices of the perforation. We then débrided the nonviable tissue and performed an interrupted mucosal repair by using absorbable suture material and a second layer of repair by approximating the esophageal muscle. We then covered the repair with omentum. Other options for buttressing include pleura, intercostal muscles, pericardial fat pad, or latissimus/serratus/pectoralis muscle. Jackson-Pratt drains were used for management of potential postoperative leak to act as a controlled fistula, as this was a case of nonconventional surgical management. It is possible to use alternative methods of drainage (eg, chest tube) or none at all, but we prefer to drain locally with Jackson-Pratt drains. Gastric decompression and nutritional support are important aspects of the postoperative management. Although a nasogastric tube is an alternative, we routinely perform laparoscopic jejunostomy and gastrostomy tubes for other conditions, and usually it only adds 15 to 20 minutes to the operating time. This allows early institution of enteral feeding as well as a more secure way of keeping the stomach decompressed. Also, in the event of a prolonged course, it provides a more comfortable drainage technique for the patient. Every patient undergoing surgical management of Boerhaave’s syndrome runs the risk of leak or delayed healing, or both. Therefore, the feeding tube ensures optimal enteral nutrition in the event that the patient is not able to eat in the postoperative period. We recommend conservative treatment to patients who would not tolerate an operation from a medical
standpoint if the presentation is not acute, the perforation is well contained with good distal flow of contrast, and in a patient with no signs of sepsis. Postoperative morbidity includes the non-procedurerelated postoperative complications, stricture formation, leak requiring further surgical management, or diversion/esophagectomy, with or without delayed reconstruction. A Medline search of the literature pertaining to the minimally invasive management of Boerhaave’s syndrome yielded two reports. The first describes a left thoracoscopic intracorporeal suture repair and drainage. The patient had developed a leak that was managed conservatively [5]. The second report describes a laparoscopic primary repair and a 270° posterior fundoplication in a 72-year-old man. The patient was discharged home after 2 weeks of hospitalization with no leak [6]. Although open repair and drainage are the gold standard, we conclude that laparoscopic and thoracoscopic management of Boerhaave’s syndrome is a feasible alternative.
References 1. Derbes VJ, Mitchell RE Jr. Herman Boerhaave Atrocis, nec descripti prius, morbi historia; the first translation of classic case report of rupture of the esophagus, with annotations. Bull Med Libr Assoc 1955;43:217–24. 2. Lillington GA, Bernatz PE. Spontaneous perforation of esophagus. Dis Chest 1961;39:177– 84. 3. Jougon J, Mc Bride T, Delcambre F, Minniti A, Velly JF. Primary esophageal repair for Boerhaave’s syndrome whatever the free interval between perforation and treatment. Eur J Cardiothorac Surg 2004;25:475–9. 4. Barrett NR. Report of a case of spontaneous perforation of the esophagus successfully treated by operation. Br J Surg 1947; 35:216. 5. Scott HJ, Rosin RD. Thoracoscopic repair of a transmural rupture of the oesophagus (Boerhaave’s syndrome). J R Soc Med 1995;88:414P–5P. 6. Landen S, El Nakadi I. Minimally invasive approach to Boerhaave’s syndrome: a pilot study of three cases. Surg Endosc 2002;16:1354 –7.
FEATURE ARTICLES
319
Ann Thorac Surg 2007;83:317–9