1. Thoracoscopic Primary Esophageal Repair in
Patients With Boerhaave’s Syndrome
Jeong Su Cho, MD, Yeong Dae Kim, MD, Jong Won Kim, MD, Ho Seok I, MD, and
Min Su Kim, MD
Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea
Background. Early diagnosis and appropriate treatment (group A) and eight patients had a thoracotomy (group
GENERAL THORACIC
are important for a good outcome in Boerhaave’s syn- B). The mean interval between perforation and surgery
drome. The results of recent studies suggest that primary was 43.5 hours (group A) and 40.2 hours (group B) (p ‫؍‬
esophageal repair should be performed for perforations, 0.487). The mean operative time was 3.7 hours (group A)
and some authors suggest that there are benefits from and 5.3 hours (group B) (p ‫ .)500.0 ؍‬Postoperative leaks
thoracoscopic surgery in cases that are diagnosed early. were confirmed by esophagography in one patient in
Methods. From December 2004 to May 2010, 15 patients group A and in two patients in group B. There was no
with Boerhaave’s syndrome presented to our department; mortality in group A and one death postoperatively in
the medical records were reviewed retrospectively for group B.
preoperative signs and symptoms, interval between per- Conclusions. The results of this study suggest that
foration and surgery, surgical methods, and outcomes of thoracoscopic esophageal repair may be a good surgical
treatment. The patients were divided into two groups alternative in patients with Boerhaave’s syndrome who
according to the surgical approach (thoracoscopy versus have a relatively stable vital sign or mild inflammation,
thoracotomy) to evaluate the outcomes of thoracoscopic regardless of the time interval between perforation and
surgery in patients with Boerhaave’s syndrome. surgery.
Results. All patients were men, with a mean age of 53.1
years, and all underwent primary esophageal repair. (Ann Thorac Surg 2011;91:1552–5)
Seven patients underwent a thoracoscopic approach © 2011 by The Society of Thoracic Surgeons
B oerhaave’s syndrome is a full-thickness transmural
rupture of the esophagus; it is the most severe
abnormality associated with esophageal perforation and
this problem are in poor general condition, excessive
trauma should be avoided in these patients to minimize
postoperative complications [8]. The outcomes of treat-
has a mortality rate ranging from 20% to 30% [1– 4]. Delay ment in patients with Boerhaave’s syndrome were re-
in the diagnosis of Boerhaave’s syndrome is common viewed in this study to investigate the usefulness of
because of its nonspecific symptoms, which are often thoracoscopic surgery.
misdiagnosed as acute pancreatitis, myocardial infarc-
tion, or peptic ulcer disease. A delay in the diagnosis
occurs in more than 50% of patients and results in high
mortality [5]; especially when treatment is delayed be- Patients and Methods
yond 48 hours. Such delays can lead to fatal mediastinitis From December 2004 to May 2010, 15 patients with
and multisystem organ failure [2]. Therefore, early diag- Boerhaave’s syndrome presented to our department.
nosis and appropriate treatment based on the patient’s This study includes only patients with Boerhaave’s syn-
condition are important for good outcomes. The results
drome; therefore, if the esophageal perforation was
of recent studies recommend primary esophageal repair
caused by instrumentation, foreign bodies, external
for perforations, regardless of the time interval between
trauma, or an underlying disorder such as neuromotor
perforation and surgery [6, 7], and some investigators
disease or esophageal cancer, these cases were excluded.
have suggested that the minimally invasive thoraco-
We have performed thoracoscopic esophageal repair for
scopic technique is particularly well suited for repair of a
Boerhaave’s syndrome since 2004. The medical records
perforated esophagus with wide drainage of the medias-
tinum when diagnosed early. Because most patients with were reviewed retrospectively for preoperative signs and
symptoms, interval between perforation and surgery,
surgical time and methods, and outcomes of treatment
Accepted for publication Jan 26, 2011.
(hospitalization, postoperative leakage, in-hospital mor-
Address correspondence to Dr Kim, Department of Thoracic and Cardio- tality, and postoperative complications). The patients
vascular Surgery, Pusan National University School of Medicine, Gu-
were divided into two groups according to the surgical
deok-ro Seo-gu, Busan, 602-739, Republic of Korea; e-mail:
domini@pnu.edu. This study was supported for two years by Pusan approach (group A, thoracoscopy; group B, thoracotomy).
National University Research Grant. This study was approved by the institutional review
© 2011 by The Society of Thoracic Surgeons 0003-4975/$36.00
Published by Elsevier Inc doi:10.1016/j.athoracsur.2011.01.082

2. Ann Thorac Surg CHO ET AL 1553
2011;91:1552–5 THORACOSCOPIC ESOPHAGEAL REPAIR
Table 1. Preoperative Characteristics of Patients
Group A (mean Ϯ SD) Group B (mean Ϯ SD) p Value
Age (years) 52.0 Ϯ 8.8 54.1 Ϯ 10.6 0.684
Interval (hours) 43.5 Ϯ 23.2 39.3 Ϯ 34.1 0.786
White blood cell count (103/␮L) 10.5 Ϯ 8.8 8.6 Ϯ 5.7 0.620
Hemoglobin (g/dL) 15.1 Ϯ 1.4 14.9 Ϯ 2.0 0.841
Platelet count (103/␮L) 185.6 Ϯ 20.2 196.5 Ϯ 78.8 0.715
C-reactive protein 16.7 Ϯ 16.4 14.0 Ϯ 14.9 0.745
Systolic blood pressure (mm Hg) 111.43 Ϯ 10.7 95.0 Ϯ 16.9 0.046
Heart rate (beats/minute) 81.7 Ϯ 9.76 111.8 Ϯ 21.1 0.004
Spo2 (%) 96.7 Ϯ 1.8 93.6 Ϯ 6.1 0.199
GENERAL THORACIC
Body temperature (°C) 37.1 Ϯ 1.1 37.2 Ϯ 0.9 0.865
Interval ϭ Interval between perforation and surgery; SD ϭ standard deviation; Spo2 ϭ oxygen saturation as measured by pulse oximetry.
board of Pusan National University, Busan, Republic of Group, Norwalk, CT), for retraction of the diaphragm. In
Korea. Informed consent was not required for this retro- group B, conventional thoracotomy was performed, and
spective study. buttress sutures were used in two patients with delayed
diagnoses who had significant necrosis of the esophagus:
Initial Management and Operative Technique a diaphragmatic flap in one patient and an omental flap
Initially, all patients received hydration and broad- in the other patient to secure the primary suture line and
spectrum antibiotics and were treated with chest tube provide a secondary barrier against possible postopera-
drainage for hydropneumothorax. Regardless of the time tive leakage.
interval since perforation, emergency surgery was per-
formed with primary repair. Although we did not have a Postoperative Management
definite indication for thoracoscopic surgery in Boer- All patients received nutrition parenterally. Systemic
haave’s syndrome, when the blood pressure, heart rate, antibiotics were provided until removal of the chest tube.
and Sao2 were stable before operation, we considered The nasogastric tube was left in place until the seventh
some of these patients as candidates for thoracoscopic postoperative day; the patient then underwent an
surgery, which was the preferred surgical approach (Ta- esophagography. An oral diet was resumed gradually
ble 1). once the integrity of the esophagus was ensured. In
In all patients, the inflammatory and necrotic tissue as patients with postoperative leaks noted after esophago-
well, as the purulent material in the pleural cavity around graphy, a second esophagogram was obtained when the
the esophageal perforation site, was removed and the amount of chest tube drainage had decreased and
status of the esophageal perforation was determined. cleared.
Before the repair, the muscular layer was incised to Regular follow-up was performed in the outpatient
ensure that the entire length of the mucosal defect could clinic after discharge over 1 to 2 months. When related
be visualized clearly. Interrupted sutures with absorb- symptoms occurred after the initial follow-up, the pa-
able polyfilament 4-0 thread were provided at the site of tients returned for additional evaluation. The related
mucosal perforation. The repair was tested by injecting symptoms, such as dysphagia or gastroesophageal reflux,
air into a nasogastric tube with occlusion of the distal were assessed by interview during the follow-up period
esophagus while under saline solution. Interrupted su- in the outpatient clinic or by phone calls directly to the
tures were then provided in the muscular layer using patients until June 2010.
nonabsorbable polyfilament 3-0 thread. Other para-
esophageal and mediastinal spaces were explored, the Statistics
pleural spaces and mediastinum were copiously irri- Data are reported as the mean (range) or as proportions.
gated, and two drain catheters were inserted, with one All data were analyzed with SPSS version 12.0 software
catheter placed close to the esophageal suture line along (SPSS, Inc, Chicago, IL). Comparisons of the two groups
the diaphragm for effective drainage. were performed with the Mann-Whitney and ␹2 tests for
In group A, four incisions were made to perform the variables of interest. The postoperative C-reactive
thoracoscopic surgery: the first incision was made in the protein (CRP) curves of the two groups were analyzed by
seventh intercostal space (ICS) of the midaxillary line to the repeated measures of analysis of variance (ANOVA).
insert the thoracoscope; the second incision was made in
the sixth ICS of the anterior axillary line; the third
incision was made in the eighth ICS of the midaxillary
Results
line to insert thoracoscopic instruments, and the fourth All patients were men, with a mean age of 53.1 years
incision was made in the ninth ICS of the postaxillary line (range, 39 to 71 years). All patients underwent primary
to insert Endo Retract II (Auto Suture, Tyco Healthcare esophageal repair; seven patients underwent a thoraco-

3. 1554 CHO ET AL Ann Thorac Surg
THORACOSCOPIC ESOPHAGEAL REPAIR 2011;91:1552–5
scopic approach (group A) and eight patients had a
thoracotomy (group B). Regarding the preoperative char-
acteristics of the two groups, systolic blood pressure and
heart rate were significantly different and the rest were
not significantly different (Table 1). All patients experi-
enced forcible vomiting preceding the onset of symp-
toms. The common signs and symptoms identified in-
cluded chest or epigastric pain, dyspnea, fever,
hematemesis, tachycardia, and hypotension; tachycardia
and hypotension were observed only in group B (Table
2). Chest radiographs were obtained in all patients and
showed mediastinal widening, hydropneumothorax, and
GENERAL THORACIC
subcutaneous emphysema. Chest computed tomography
was carried out in all patients. Endoscopy and esopha-
gography were performed to confirm a definite diagnosis
in ten patients and one patient, respectively.
The mean interval between perforation and surgery
was 43.5 hours (range, 18.0 to 78.0 hours) in group A and
39.3 hours (range, 16.5 to 117.0 hours) in group B (p ϭ Fig 1. Curve of postoperative C-reactive protein (CRP) levels. (Preop ϭ
0.79). Pleural contamination was more severe in group B preoperative day; POD ϭ postoperative day.)
than in group A, but there was no significant difference
between the two groups, except in several patients in
group B. In particular, there was no severe necrosis of the A; and pneumonia with empyema occurred in three
esophagus that could not be repaired and no visceral patients in group B (Table 3). Three patients with post-
pleural thickening that needed wide decortication in operative leaks were treated by conservative manage-
group A. The perforation was located exclusively in the ment. Symptoms of the patient with dysphagia were mild
lower third of the esophagus; however, in one patient it and he did not need any intervention such as a pneu-
was detected from the lower thoracic to the upper part of matic balloon procedure. Postoperative pneumonia with
the abdominal esophagus. The mean operative time was empyema developed in three patients; they had fever,
3.7 hours (range, 2.5 to 4.5 hours) in group A and 5.3 leukocytosis, and pulmonary infiltrates on chest radio-
hours (range, 4.0- to 7.5 hours) in group B (p ϭ 0.005). One graphs and underwent thoracoscopic pleural irrigation,
patient in group B died during hospitalization. Postoper- with purulent discharge from the chest tube. However,
ative ventilator support was needed for one patient in one patient did not recover from pneumonia with empy-
group A for 4 hours and in four patients in group B for ema and progressed to acute respiratory distress syn-
an average of 106.8 hours (range, 11 to 148 hours). The drome (ARDS). The patient died from sepsis and ARDS.
mean hospitalization was 36.9 days (range, 13 to 73 days) There were no other serious complications such as atrial
in group A and 38.5 days (range, 18 to 57 days) in group arrhythmia, or other respiratory complications. The me-
B (p ϭ 0.73). The postoperative CRP levels for groups A dian follow-up duration was 40.9 months (range, 0.9 to
and B are shown in Figure 1. 65.0 months) in group A and 25.6 months (range, 1.0 to
Complications occurred in one patient in group A and 46.8 months) in group B (p ϭ 0.25). No patient com-
in five patients in group B as follows: postoperative leaks plained of dysphagia at the last follow-up appointment.
were confirmed by esophagography in one patient in
group A and in two patients in group B; dysphagia was Comment
present in one patient with postoperative leaks in group
The management of Boerhaave’s syndrome remains a
difficult problem, and early diagnosis is the key to a
successful outcome. Most surgeons suggest that primary
Table 2. Preoperative Signs and Symptoms
repair of a perforated esophagus is the treatment of
Group A Group B choice in patients with Boerhaave’s syndrome when the
(n ϭ 7) (n ϭ 8) p Value condition is recognized early [6 – 8]. Furthermore, be-
Pain (chest, epigastric, or 4 8 0.282 cause the general condition of these patients tends to be
abdominal)
Dyspnea 1 3 0.569
Table 3. Postoperative Complications
Hematemesis 2 2 1.000
Fever (body temperature Ͼ 1 2 1.000 Group A (n ϭ 7) Group B (n ϭ 8)
37.5°C)
Postoperative leaks 1 2
Tachycardia (heart rate Ͼ 0 6 0.007
100 beats/minute) Dysphagia 1 0
Hypotension (systolic blood 0 3 0.200 Postoperative bleeding 0 0
pressure Ͻ 90 mm Hg) Pneumonia with empyema 0 3