Minimally invasive repair of oesophageal perforation: a case report

A 42-year-old, previously well, male presented acutely following sudden-onset vomiting associated with severe epigastric pain radiating to his back. He was febrile but hemodynamically stable, with raised inflammatory markers and an elevated lactate. A computed tomography (CT) scan confirmed a distal thoracic oesophageal rupture with a large left hydropneumothorax.

View Figure 1–5.

Initial management at Nelson Hospital included resuscitation; intubation and broad-spectrum intravenous antibiotics, piperacillin/tazobactam; and antifungal therapy, fluconazole. A 32Fr left chest drain was inserted, immediately draining 1,000mL of food-contaminated brown fluid. He was transferred to Christchurch Hospital with intensive care unit–support via fixed-wing air transfer and proceeded to operative management the same day. He underwent laparoscopy, gastroscopy and video-assisted thoracoscopy. Time from presentation to transfer and then surgery was approximately 10 hours.

Method

Gastroscopy was performed first to identify the defect and distance from hiatus. This step is critical, as the length of the mucosal defect may extend beyond what is visible externally due to mucosal splitting beneath the adventitia.

Laparoscopy was then performed using a standard hiatus set up. The phrenoesophageal ligament was divided to access the mediastinum, allowing mobilisation and improved visualisation of the lower thoracic oesophagus. The defect was identified in the distal thoracic oesophagus with clear exposure of the entire mucosal edges. Primary repair was performed using a two-layer technique, with the mucosa closed first, followed by muscular layer with 2-0 absorbable V-Loc^TM sutures.

Extensive intrathoracic contamination was encountered. Thorough wash-out and suction were performed laparoscopically as well as thoracoscopically, removing significant food debris. Thoracoscopic access was achieved using the existing chest drain site and two additional ports, facilitating effective clearance of contamination between the thoracic and abdominal fields.

Gastroscopy was repeated to perform a leak test and deploy an oesophageal stent to buttress the repair. The stent was secured laparoscopically using Vicryl Rapide^TM sutures proximally. An omental patch was then used to cover the defect with V-Loc^TM. A feeding jejunostomy was then placed laparoscopically. As contamination was confined to the chest, only chest drains were placed.

Post-operatively, the patient was managed in the intensive care unit for observation. His recovery was uncomplicated. Chest drains were removed, and he was discharged on post-operative day 10 on a fluid diet. Four weeks later, he returned electively for stent removal under general anaesthesia with gastroscopy. The stent was easily removed, with dissolution of the Vicryl Rapide^TM suture. He progressed to a normal diet within 48 hours, and the feeding jejunostomy was removed at 6 weeks.

Discussion

Boerhaave syndrome is a spontaneous full-thickness oesophageal rupture resulting from forceful vomiting against a closed upper oesophageal sphincter. Although rare, it carries significant morbidity and mortality if not promptly recognised and treated due to rapid progression to mediastinitis, sepsis and multi-organ failure.¹

Traditional management has favoured thoracotomy and laparotomy, particularly in unstable patients with gross contamination.¹ However, evidence from oesophageal cancer surgery demonstrates that minimally invasive techniques are associated with reduced post-operative complications, faster recovery and reduced morbidity compared with open surgery.² These principles can be extrapolated to Boerhaave syndrome in selected patients, particularly those diagnosed early and treated within 24 hours who remain physiologically stable.

This case demonstrates the feasibility and safety of a minimally invasive approach in managing spontaneous oesophageal perforation. Successful management relied on early diagnosis, rapid resuscitation and timely transfer to a tertiary centre with access to specialist upper gastroenterology services. This reflects the importance of collaborative multidisciplinary care and effective regional-tertiary referral pathways.

A 2019 literature review identified only 48 reported cases managed using minimally invasive techniques, all described in case reports.¹ Primary suture repair was the most common intervention (60%), with an overall mortality of 8.3%. Another systematic review including case reports and cohort studies reported success rates of up to 98% for thoracoscopic approaches, although the evidence remains limited and heterogeneous.³ Reported mortality for Boerhaave syndrome overall ranges from 10 to 50%.^4,5

Given the rarity of this condition, high-quality comparative studies are limited. Nevertheless, this case adds to the growing body of evidence suggesting that minimally invasive repair, combined with effective contamination control and multidisciplinary management, can be a safe and effective option in carefully selected patients.