Delayed rupture of a primary esophageal repair for Boerhaave's syndrome.

Abstract

We read with interest the article by Jacques Jougon et al. [1], advising primary esophageal repair for Boerhaave’s syndrome independent of the time interval between the perforation and surgical treatment. Recently we had the experience of Boerhaave’s syndrome in a 42-year-old male patient, referred to us from another hospital, with delayed diagnosis of the esophageal rupture (about 48 h). The patient had, at presentation, bilateral empyema, mediastinitis and multiple mediastinal abccess formation on both sides, cervical subcutaneous emphysema and his hemodynamic state was of hypodynamic septic shock (under noradrenaline support). He underwent, immediately after arrival, bilateral posterolateral thoracotomy for drainage of the empyema, mediastinal drainage and debridement and closure of the perforation (2 cm long) on the left side. We decided to primarily close the esophagus in two layers (mucosal–submucosal and muscular) with interrupted Vicryl (3.0) sutures. We covered the repair using a Grillo (pleural) flap [2]. We also performed drainage of the cervix and pretracheal space via a collar cervical incision. The operation was integrated by gastrostomy plus feeding jejeunostomy via a median laparotomy incision. The patient experienced a heavy postoperative period, where both thoracotomies were superficially suppurated and drained. The patient gradually recovered from the septic condition within 13 days, been extubated the 14th postoperative day. He had two normal chest CT scans with contrast medium (gastrograpfin) during his postoperative ICU stay (7th and 17th postoperative days). At the 21st postoperative day, he became septic again and a new chest CT scan with gastrografin showed esophageal leak at the level of the primary repair of the initial tear (chest tubes on the left side were removed on the 17th postoperative day). Drainage of the empyema and bipolar esophageal diversion, followed by esophagectomy and stomach replacement of the esophagus 1 month later gave the solution. Our decision to perform primary repair of the esophagus was based on the viability of the esophageal tear layers seen at the left thoracotomy, and on the age of the patient, despite the suggestion of many experienced surgeons to avoid primary repair in delayed diagnosed esophageal ruptures, with extended pleural and mediastinal contamination [3,4]. The good results reported by Jougon et al. in their series of 25 patients with primary esophageal repair, based only on the characteristics of the esophageal tear [1] and the classic described in the literature management based on the time interval between the rupture and surgery [3–5] is a question under debate, on how to manage surgically, the esophageal tear in Boerhaave’s syndrome. We add the information that a primary esophageal repair, performed in the contaminated mediastianl environment of a spontaneous esophageal rupture, which is treated surgically after 48 h in an hemodynamically unstable patient, has also the danger of the delayed rupture of the repair.