occur ectopically, affecting the neck, middle or poste-rior mediastinum, and lung [5, 6]. However, ectopicthymoma occurring in the pleura is extremely rare andhas been infrequently documented [7].

The differential diagnoses for giant intrathoracicmass are a pleural tumor (e.g., solitary fibrous tumor,malignant mesothelioma, and sarcomas), a chest walltumor, or a metastatic mass. MRI findings of thethymoma have the same or slightly increased intensityas that of muscle on T1-weighted images and increasedintensity on T2-weighted images. Inhomogeneous sig-nal intensity on T2-weighted images with a lobulatedborder, fibrous band, and lobulated internal architec-ture is indicative of an invasive thymoma [8]. Althoughthe MRI features of this case resembled those oforthotopic thymoma, preoperative diagnosis was diffi-cult because of the unusual location.

In summary, this report documents an extremely rareoccurrence of ectopic pleural thymoma presenting as agiant mass in the thoracic cavity.

References

1. Rosai J, Sobin LH. Histological typing of tumors of thethymus, 2nd ed. New York: Springer, 1999.

2. Richardson MA, Sie KYC. The neck: embryology and anat-omy, 3rd ed. Philadelphia: WB Saunders Co, 1996.

3. Rosai J, Levine GD. Tumors of the thymus, 2nd ed. Washing-ton: Armed Forces Institute Pathol, 1976.

4. Detterbeck FC, Parsons AM. Thymic tumors. Ann ThoracSurg 2004;77:1860–9.

5. Moran CA, Suster S, Fishback NF, Koss MN. Primary in-trapulmonary thymoma: a clinicopathologic and immunohis-tochemical study of eight cases. Am J Surg Pathol 1995;19:304–12.

6. Minniti S, Valentini M, Pinali L, Malago R, Lestani M,Procacci C. Thymic masses of the middle mediastinum: reportof 2 cases and review of the literature. J Thorac Imag 2004;19:192–5.

7. Moran CA, Travis WD, Rosado-de-Christenson M, Koss MN,Rosai J. Thymomas presenting as pleural tumors: report ofeight cases. Am J Surg Pathol 1992;16:138–44.

8. Kushihashi T, Fujisawa H, Munechika H. Magnetic resonanceimaging of thymic epithelial tumors. Crit Rev Diagn Imag1996;37:191–259.

Minimally Invasive Managementof Boerhaave’s SyndromeAhmad S. Ashrafi, MD, Omar Awais, DO,and Miguel Alvelo-Rivera, MD

The Heart Lung and Esophageal Surgery Institute, Universityof Pittsburgh Medical Center, Pittsburgh, Pennsylvania

We report the case of a 42-year-old man with Boerhaave’ssyndrome. His medical history was significant only for along-standing history of dysphagia. The patient pre-

sented to the emergency department with vomiting,followed by severe retrosternal and epigastric pain ofsudden onset. An esophagogram showed evidence offree extravasation of contrast from the left posterolateralaspect of the distal esophagus just above the level of thehiatus. A minimally invasive technique was used torepair this injury.

(Ann Thorac Surg 2007;83:317–9)© 2007 by The Society of Thoracic Surgeons

Boerhaave’s syndrome is associated with a significantrisk of mortality and morbidity. Prompt surgical

management is the treatment of choice. The acceptedmanagement involves surgical repair of the perforationusing a thoracotomy or laparotomy, or both. Reducingthe inflammatory response by minimizing the surgicaltrauma may decrease the mortality risk of this potentiallylethal condition. We report the successful laparoscopicand thoracoscopic management of a patient with Boer-haave’s syndrome. Although open repair and drainageare the gold standard, we conclude that laparoscopic andthoracoscopic management of Boerhaave’s syndrome is afeasible alternative.

A 42-year-old man with a long-standing history of inter-mittent dysphagia that required a change in the patient’sdietary habits presented to the emergency departmentwith a 5-hour history of vomiting, followed by severeretrosternal and epigastric pain of sudden onset. Oninitial presentation, his blood pressure was 142/86, pulsewas 100/min, and his respiratory rate was 22/min. Thepatient was afebrile and mildly distressed.

On chest exam, there was decreased air entry over theleft hemithorax, with crackles at the left lung base. Hisabdominal exam revealed a nondistended abdomen andepigastric tenderness without generalized peritonitis.The leucocyte count on admission was 12.1 � 109/L. Theinitial chest radiograph revealed a small left pleuraleffusion. A contrast-enhanced computed tomography(CT) scan of the chest demonstrated pneumomediasti-num and a left pleural effusion highly suggestive ofesophageal perforation (Fig 1). The result of a CT scan ofthe abdomen was normal. A Gastrografin (Tyco/MallinKrodt, St. Louis, MO) swallow demonstrated freeextravasation of contrast from the left posterolateralaspect of the distal esophagus just above the level of thehiatus (Fig 2).

After aggressive volume resuscitation, commencementof broad-spectrum antibiotics, and analgesia, the patientwas taken to the operating room. On-table endoscopyrevealed a 2-cm to 3-cm perforation just above a nar-rowed gastroesophageal junction. A laparoscopic explo-ration showed no intraabdominal pathology.

We then harvested a generous portion length of thegreater omentum and secured it to the edges of the leftcrus. We also performed a Heller myotomy given thepatient’s long-standing history of dysphagia. A laparo-scopic gastrostomy and feeding jejunostomy were per-formed, and the port sites were closed.

Accepted for publication May 24, 2006.

Address correspondence to Dr Alvelo-Rivera, The Heart, Lung andEsophageal Surgery Institute, University of Pittsburgh Medical Center,200 Lothrop St, C-800, Pittsburgh, PA 15213; e-mail: alveloriveram@upmc.edu.

317Ann Thorac Surg CASE REPORT ASHRAFI ET AL2007;83:317–9 MINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S

© 2007 by The Society of Thoracic Surgeons 0003-4975/07/$32.00Published by Elsevier Inc doi:10.1016/j.athoracsur.2006.05.111

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A double-lumen endotracheal tube was then inserted,and the patient was positioned in the right lateral decu-bitus position for video-assisted thoracoscopic explora-tion of the left chest. The esophageal perforation site wasidentified at a level just above the esophageal hiatus. Atwo-layer repair was performed using simple interruptedsutures. The harvested omentum was then used to coverthe entire length of the repaired esophagus. Intraopera-tive insufflation of the esophagus did not show a leak,

and we placed two chest tubes and two Jackson-Prattdrains. Incisions were closed and dressings were applied.

The patient was transferred to the intensive care unitand had an uneventful course. He was discharged to theward the next day. A contrast study on postoperative day4 showed no leak or obstruction (Fig 3). He was dis-charged home on postoperative day 9.

Comment

Boerhaave’s syndrome, or spontaneous (postemetic) per-foration of the esophagus, was first described by Her-mann Boerhaave in 1724 [1]. It is a very uncommonentity, with an estimated incidence in the literature of 1 in6000 patients [2]. The esophagus differs from the rest ofthe alimentary tract in that it lacks a serosal layer, whichnormally contains collagen and elastic fibers. This makesit more susceptible to rupture at lower pressures than therest of the gastrointestinal tract. Spontaneous esophagealrupture is well documented as a postemetic phenome-non. Early recognition and prompt treatment are impor-tant factors in minimizing the mortality. The mortalityranges from 20% to 30% [3], but if left untreated, ap-proaches 100%. Barrett reported the first case of success-ful surgical repair in 1947 [4].

The minimally invasive technique could be used only ifthe patient is hemodynamically stable, without signs of

Fig 1. Computed tomography image of the chest shows pneumome-diastinum with air tracking laterally towards the left pleural spaceand a left pleural effusion.

Fig 2. A Gastrografin swallow shows extravasation of contrast inthe left chest.

Fig 3. A postoperative barium swallow shows essentially a normalesophagus.

318 CASE REPORT ASHRAFI ET AL Ann Thorac SurgMINIMALLY INVASIVE MANAGEMENT OF BOERHAAVE’S 2007;83:317–9

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escalating sepsis, without significant medical risk factorsthat would preclude major surgery, and in patients withno contraindications for laparoscopy or thoracoscopy.

In managing this patient, we began with laparoscopy toharvest the omentum, performed a gastrostomy, a feed-ing jejunostomy, and an esophagomyotomy. We alsowanted to assess potential intraabdominal extent of theinjury.

The repair was begun with a myotomy to identify thetrue apices of the perforation. We then débrided thenonviable tissue and performed an interrupted mucosalrepair by using absorbable suture material and a secondlayer of repair by approximating the esophageal muscle.We then covered the repair with omentum. Other op-tions for buttressing include pleura, intercostal muscles,pericardial fat pad, or latissimus/serratus/pectoralismuscle.

Jackson-Pratt drains were used for management ofpotential postoperative leak to act as a controlled fistula,as this was a case of nonconventional surgical manage-ment. It is possible to use alternative methods of drain-age (eg, chest tube) or none at all, but we prefer to drainlocally with Jackson-Pratt drains.

Gastric decompression and nutritional support areimportant aspects of the postoperative management.Although a nasogastric tube is an alternative, we rou-tinely perform laparoscopic jejunostomy and gastros-tomy tubes for other conditions, and usually it only adds15 to 20 minutes to the operating time. This allows earlyinstitution of enteral feeding as well as a more secure wayof keeping the stomach decompressed. Also, in the eventof a prolonged course, it provides a more comfortabledrainage technique for the patient. Every patient under-going surgical management of Boerhaave’s syndromeruns the risk of leak or delayed healing, or both. There-fore, the feeding tube ensures optimal enteral nutritionin the event that the patient is not able to eat in thepostoperative period.

We recommend conservative treatment to patientswho would not tolerate an operation from a medical

standpoint if the presentation is not acute, the perfora-tion is well contained with good distal flow of contrast,and in a patient with no signs of sepsis.

Postoperative morbidity includes the non-procedure-related postoperative complications, stricture formation,leak requiring further surgical management, or diver-sion/esophagectomy, with or without delayedreconstruction.

A Medline search of the literature pertaining to theminimally invasive management of Boerhaave’s syn-drome yielded two reports. The first describes a leftthoracoscopic intracorporeal suture repair and drainage.The patient had developed a leak that was managedconservatively [5]. The second report describes a laparo-scopic primary repair and a 270° posterior fundoplicationin a 72-year-old man. The patient was discharged homeafter 2 weeks of hospitalization with no leak [6].

Although open repair and drainage are the gold stan-dard, we conclude that laparoscopic and thoracoscopicmanagement of Boerhaave’s syndrome is a feasiblealternative.

References

1. Derbes VJ, Mitchell RE Jr. Herman Boerhaave Atrocis, necdescripti prius, morbi historia; the first translation of classiccase report of rupture of the esophagus, with annotations.Bull Med Libr Assoc 1955;43:217–24.

2. Lillington GA, Bernatz PE. Spontaneous perforation of esoph-agus. Dis Chest 1961;39:177–84.

3. Jougon J, Mc Bride T, Delcambre F, Minniti A, Velly JF.Primary esophageal repair for Boerhaave’s syndrome what-ever the free interval between perforation and treatment. EurJ Cardiothorac Surg 2004;25:475–9.

4. Barrett NR. Report of a case of spontaneous perforation of theesophagus successfully treated by operation. Br J Surg 1947;35:216.

5. Scott HJ, Rosin RD. Thoracoscopic repair of a transmuralrupture of the oesophagus (Boerhaave’s syndrome). J R SocMed 1995;88:414P–5P.

6. Landen S, El Nakadi I. Minimally invasive approach toBoerhaave’s syndrome: a pilot study of three cases. SurgEndosc 2002;16:1354–7.

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