Minimally Invasive Rescue of Boerhaave Syndrome

A 59-years-old male visited some other hospital with severe chest pain and dyspnoea following bouts of vomiting. He was diagnosed as having MI initially and was evaluated by a cardiologist who found him to be having left pleural effusion, but no signs of cardiac ischemia were found. A chest tube was inserted, and the patient had symptomatic relief, but toxaemia persisted, and the chest tube output was very high. The chest tube also contained a whitish fluid with high triglyceride levels, hence a diagnosis of chylothorax with the collapse of the left lung was made, and he was referred to a CTVS surgeon at Max Super Speciality Hospital, Mohali. 

On presentation, the patient had an output of 3 litres per day from the chest tube. A CECT chest was done, revealing a leakage of contrast through the oesophagus into the pleural cavity. An Upper GI Endoscopy was done that showed a tear at the lower end of the oesophagus with communication with the pleural cavity. A feeding tube was inserted into the jejunum, and feed was started. Chest tube output decreased subsequently. The patient was being prepared for decortication and ligation of the thoracic duct.

GI surgery consult was taken for lower oesophagal perforation. On going through the whole history and physical examination, it was found that the patient had Boerhaave Syndrome, i.e., perforation of the oesophagus at the lower end following bouts of vomiting. High output in the chest tube was due to the oesophagus pleural fistula and contained an oral liquid that the patient was taking in addition to exudative pleural fluid due to pyothorax. Since the patient continued to take fluids orally after insertion of the chest tube, it was a leakage of oral diet into the pleural cavity that resulted in high triglyceride levels in pleural fluid. When tube feeding was given into the jejunum, and oral diet was stopped, the chest tube output decreased.

After evaluation, the patient was prepared for minimally oesophagal repair/Oesophagectomy and decortication. A laparoscopic assessment of the lower end of the oesophagus was made, and communication with the pleural cavity was taken down after mobilising the lower end of the oesophagus. The tear at the lower end of the oesophagus was closed with interrupted sutures, and Fundoplication was done to buttress the suture line. The cardiothoracic team led by Dr Deepak Puri did video-assisted decortication of the left lung.

The patient was restricted from eating and drinking for six days and was fed through a nasojejunal tube before the surgery. An oral dye study was done after six days that did not reveal any leak from the repair site, and then the patient was started on an oral diet. He tolerated the oral diet well and was discharged after around one and half months of stay in the hospital. Chest drains were removed subsequently on follow-up after the left lung had fully expanded.