Thoracoscopic esophageal repair with barbed suture material in a case of Boerhaave's syndrome

Abstract

A 53-year-old man was referred to our hospital with Boerhaave's syndrome. Thirty hours after onset, a left thoracoscopic operation was performed, with carbon dioxide pneumothorax and the patient in right semi-prone position. The thoracic cavity was copiously irrigated with physiological saline and a 4-cm longitudinal rupture was identified on the left side of the lower esophagus. The esophageal injury was repaired in 2 layers by using barbed absorbable suture material. The patient was allowed oral feeds after contrast esophagography confirmed the absence of contrast leak at the sutured site on postoperative day 7, and discharged by day 28. Suturing of the ruptured esophagus under thoracoscopic guidance is considered to be difficult and requires expertise. This case report demonstrates that the use of a barbed suture material simplifies thoracoscopic esophageal repair and also highlights the importance of pneumothorax and patient position in improving access to the esophagus.

Keywords: Spontaneous esophageal rupture; barbed absorbable suture; carbon dioxide; pneumothorax.

Figure 1

Computed tomography of the chest demonstrating pneumomediastinum, left pneumothorax, and left pleural empyema.

Figure 2

The schema of thoracoscopic port placement in the semi-prone position. a, a 12-mm port in the 9th intercostal space along the posterior axillary line (video camera); b, a 12-mm port in the 7^th intercostal space along the middle axillary line (operator’s use); c, a 5-mm port in the 6^th intercostal space along the posterior axillary line (grasping forceps); d, a 5-mm port in the 5^th intercostal space along the middle axillary line (grasping forceps); e, a 12-mm port in the 8^th intercostal space along the middle axillary line (assistant’s use).

Figure 3

Intraoperative thoracoscopic view. (A) The thoracic cavity is copiously irrigated with physiological saline. In the semi-prone position, the irrigant accumulates anteriorly, enabling effective suctioning; (B) the esophagus is exposed and the longitudinal perforation on the left side of the lower esophagus is identified. Arrows indicate both edges of mucosal tear of the esophagus; (C) the esophageal tear is repaired in 2 layers, of mucosa and muscularis. Arrows indicate the suture line of the mucosal layer. Arrowhead indicates the barbed absorbable material; (D) arrows indicate the suture line of the muscular layer.

Figure 4

Barium swallow on the postoperative day 7 confirms the absence of any leak or stenosis at the site of the esophageal repair.