Boerhaave’s syndrome is an esophagus rupture which occurs idiopathically and was first reported by Herman Boerhaave in 1724 [4]. It is a serious disease with a mortality rate of 20–40%, and in many cases, a perforation is located on the left side of the lower third of the esophagus [5]. The treatment method varies depending on disease severity; conservative treatment, gastrointestinal endoscopic therapy, and surgical therapy are available. Surgical therapy is generally classified into transthoracic or transhiatal procedures.
Recent reports have demonstrated the usefulness of conservative treatment for esophagus rupture [6, 7]. Its indication has been reported by Cameron et al. and Altorjay et al. with the recommendation that close attention should be paid with regard to sepsis under the following conditions: the lesion is localized, no tumor tissue is found, no perforation is found in the abdominal cavity, and no obstructive esophageal disease is found [8, 9]. However, all of these cases were based on a retrospective study performed on a small sample. In the clinical setting, physicians must make a decision based on individual symptoms. Furthermore, some studies on endoscopic treatment have also been reported. Although they examined a small sample, patients underwent treatment by clipping the perforation under endoscope guidance, and recovery of these patients followed a more benign course [10, 11].
It has also been reported that an esophagus stent provided good results for iatrogenic esophageal perforation and failure of the sutures after simple closure. However, some reports showed more fatal outcome with stentinding than surgical treatment [12, 13]. Spontaneous esophageal rupture has also been reported to have increased mortality if proper intervention is not performed within 24 h of onset [14]. There is a risk of missing the optimal timing for surgery if the conservative treatment is not effective. Non-surgical treatment including endoscopic therapy should be considered carefully in the context of the individual patient symptoms because these methods may miss an opportunity which is best suited for surgery.
As previously described, the usefulness of conservative treatment has also been examined, but surgical treatment is still a basic modality of therapy for this disease [10]. The purpose of surgical treatment includes a lavage drainage and suture closure of the perforation, and in some cases, construction of gastric fistula and intestinal fistula depending on the clinical condition of the patient. To decide on an operative method, it is extremely important to identify the location of the perforation. Conventionally, thoracotomy is mainly performed, and recently, the number of reports on thoracoscopic surgery has increased [1,2,3]. Cho et al. showed that results of thoracoscopic surgery were not inferior to thoracotomy. Nakano et al. reported no difference in surgery results of laparotomy between patients who underwent primary suture with omentopexy via a laparotomy followed by left thoracoscopic mediastinal drainage and patients who underwent left thoracoscopic primary suture and mediastinal drainage [3]. Thoracoscopic surgery is becoming common and effectual therapy for Boerhaave’s syndrome.
However, reports of laparoscopic transhiatal simple closure approach are scarce. Landen et al. used a peritoneoscope in three patients with Boerhaave’s syndrome as a minimally invasive approach [15] with good postoperative course in one patient, one patient dying of sepsis, and one patient developed failure of the sutures. Intrathoracic perforation was suspected in the patient who died and the patient with failure of the sutures by CT scan. Ashrafi et al. used peritoneoscope combined with thoracoscope for patients with intrathoracic perforation, performing a two-layer repair for the perforation. The postoperative course was uneventful, and he was discharged on day 9 after the procedure [16]. Mikami et al. performed a hand-assisted laparoscopy in a patient with perforation localized in the mediastinum, performed simple closure of the perforation, and inserted drains. The patient’s postoperative course was uneventful, and he was discharged on week 3 after the procedure [17]. Kimberley et al. inserted drains into the left pleural cavity in addition to transperitoneal drain insertion, as well as suture closure laparoscopically. The patient was discharged on day 15 after the surgery, and they concluded that the laparoscopic approach should be performed for patients without sepsis [18].
Recently, transperitoneal laparoscopic surgery has been performed frequently in patients with esophagogastric junction cancer, and the opportunity to gain experience in such surgery around the lower esophagus has also increased. It is now thought that surgeons who have learned the techniques of removal or replacement of the esophagus and suture in a narrow space can attempt laparoscopic surgery for Boerhaave’s syndrome. This method can avoid thoracotomy in patients without intrathoracic perforation such that a less invasive treatment can be provided because thoracic cavity drain is not required.
Although the indication for laparoscopic surgery should be considered carefully, it should be considered for patients who meet the following conditions: no sepsis, stable general condition, no intrathoracic perforation is observed, and the location of perforation is identified as the lower esophagus. This procedure should be limited to cases within 24 h of onset. It is believed that this procedure is not positively recommended, considering the risk of complications in cases that do not meet the aforementioned criteria. In our patient, we laparoscopically confirmed no intrathoracic perforation during his surgery.
Laparoscopic transhiatal simple closure is a more reliable procedure than non-surgical treatment because we can observe the site of perforation. And this procedure is less invasive than thoracotomy for Boerhaave’s syndrome compared to conservative treatment after being carefully considered.
