AB006. 74. Thoracoscopic debridement and primary repair of spontaneous oesophageal perforation (Boerhaave’s syndrome)

Abstract: The TIME and MIRO trials now provide Level 1 evidence supporting minimally invasive approaches for oesophageal cancer, with oncologic equivalence and reduced pulmonary complications versus open surgery. However, whether a minimally invasive approach also provides benefit in the context of oesophageal emergencies is unclear. Herein we demonstrate a case of Boerhaave’s syndrome managed with thoracoscopic debridement and primary repair. A 67-year-old male presented with a 12-hour history of chest pain and dyspnoea following an episode of vigorous vomiting related to alcohol. Computed tomography and water-soluble contrast swallow confirmed a perforation of the distal oesophagus into the right pleural space. The Pittsburgh severity score was 5 (severe) and APACHE II was 25 (55% predicted mortality). After initial resuscitation, thoracoscopy demonstrated a 2 cm defect in the distal oesophagus with significant mediastinal and pleural contamination. Following copious washout and debridement, primary repair of the oesophageal defect was performed with full-thickness inverting 3/0 vicryl interrupted sutures. A posterior mediastinal Jackson-Pratt drain, wide bore chest drains, and a laparoscopic feeding jejunostomy were then placed. Comprehensive complications index was 26.2 with a 10-day critical care length-of-stay (LOS), a 16-day inpatient LOS, and a dysphagia score of 0 at 8 months follow-up. Thoracoscopic washout and primary repair of intrathoracic perforation of the oesophagus is technically feasible, and facilitates direct source control while minimizing surgical trauma, and hence may be associated with reduced postoperative morbidity.

Keywords: Thoracoscopy; minimally invasive surgery; Boerhaave’s syndrome; oesophageal perforation