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Background Boerhaave’s syndrome has a high mortality rate (14–40%). Surgical treatment varies from a minimal approach consisting of adequate debridement with drainage of the mediastinum and pleural cavity to esophageal resection. This study compared the results between a previously preferred open minimal approach and a video-assisted thoracoscopic surgery (VATS) procedure currently considered the method of choice. Methods In this study, 12 consecutive patients treated with a historical nonresectional drainage approach (1985–2001) were compared with 12 consecutive patients treated prospectively after the introduction of VATS during the period 2002–2009. Baseline characteristics were equally distributed between the two groups. Results In the prospective group, 2 of the 12 patients had the VATS procedure converted to an open thoracotomy, and 2 additional patients were treated by open surgery. In the prospective group, 8 patients experienced postoperative complications compared with all 12 patients in the historical control group. Four patients (17%), two in each group, underwent reoperation. Six patients, three in each group, were readmitted to the hospital. The overall in-hospital mortality was 8% (1 patient in each group), which compares favorably with other reports (7–27%) based on drainage alone. Conclusions Adequate surgical debridement with drainage of the mediastinum and pleural cavity resulted in a low mortality rate. The results for VATS in this relatively small series were comparable with those for an open thoracotomy.

A 46-year-old man presented to the emergency department having had 2 large, nonbloody vomits and abdominal pain over the preceding 3 hours. He had no history of gastresophageal reflux disease or other relevant medical conditions. He had a 20-year history of drinking 10-15 cans of beer a week. On examination, his abdomen was rigid and tender in the left upper quadrant. Laboratory results showed elevated leukocytes at 13.8 (normal 4.5-11.5) × 109/L with 77.8% neutrophils and high sensitivity C-reactive protein of < 0.02 (normal < 0.80) mg/dL. A chest radiograph showed pneumomediastinum, and a subsequent computed tomography scan of the patient's chest also showed pneumomediastinum and left hydropneumothorax. We diagnosed Boerhaave syndrome, perforation of the esophagus.

Boerhaave’s syndrome is a rare and life-threatening form of spontaneous esophageal perforation, typically triggered by forceful vomiting and often misdiagnosed due to nonspecific clinical features. Although Mackler’s triad (vomiting, chest pain, and subcutaneous emphysema) is classically associated with the condition, it is infrequently observed in full. We present the case of a 32-year-old man with a history of ulcerative colitis (UC) who presented to the emergency department with acute chest pain and repeated vomiting following dinner. He reported a sensation of food impaction and sought care 2 hours after symptom onset. Examination revealed subcutaneous emphysema and abdominal tenderness. Imaging with oral contrast-enhanced computed tomography revealed pneumomediastinum, pneumoperitoneum, and a distal esophageal perforation, confirming Boerhaave’s syndrome. He underwent robotic-assisted laparoscopic repair with anterior fundoplication, endoscopic stenting, and drainage. His postoperative course included thoracentesis, IV antibiotics, and a gradual reintroduction of diet. A mild UC flare was managed with mesalamine. He was discharged in stable condition on postoperative day 9 and had full radiologic recovery at 3 months. This case stands out for its complete presentation of Mackler’s triad, a rare occurrence that facilitated early diagnosis. The patient’s young age and concurrent UC added clinical complexity. Prompt imaging and early minimally invasive surgical management, combined with coordinated multidisciplinary care, were key to a favorable outcome. This case underscores the importance of considering Boerhaave’s syndrome in atypical presentations and acting swiftly when classical signs do appear.

BackgroundSpontaneous esophageal perforation (Boerhaave’s syndrome) is a highly morbid condition traditionally associated with poor outcomes. The Pittsburgh perforation severity score (PSS) accurately predicts risk of morbidity, length of stay (LOS) and mortality. Operative management is indicated among patients with medium (3–5) or high (> 5) PSS; however, the role of minimally invasive surgery remains uncertain.MethodsConsecutive patients presenting with Boerhaave’s syndrome with intermediate or high PSS managed via a thoracoscopic and laparoscopic approach from 2012 to 2018 were reviewed. Demographics, clinical presentation, management, and outcomes were analyzed.ResultsTen patients (80% male) with a mean age of 61.3 years (range 37–81) were included. Two patients had intermediate and eight had high PSS (7.9 ± 2.8, range 4–12). The mean time from onset of symptoms to diagnosis was 27 ± 12 h and APACHE II score was 13.6 ± 4.9. Thoracoscopic debridement and primary repair was performed in eight cases, with two perforations repaired primarily over a T-tube. Laparoscopic feeding jejunostomy was performed in all patients. Critical care LOS was 8.7 ± 6.8 days (range 3–26), while inpatient LOS was 23.1 ± 12.5 days (range 14–46). Mean comprehensive complications index was 42.1 ± 26.2, with grade IIIa and IV morbidity in 60% and 10%, respectively. One patient developed dehiscence at the primary repair, which was managed non-operatively. In-hospital and 90-day mortality was 10%.ConclusionMinimally invasive surgical management of spontaneous esophageal perforation with medium to high perforation severity scores is feasible and safe, with outcomes which compare favorably to the published literature.

Castleman´s disease (CD) is a rare lymphoproliferative disorder often presenting as a hypervascular mass. This case highlights the unique challenges of surgically managing a posterior mediastinal CD mass adherent to vital structures. A 58-year-old woman was incidentally diagnosed with an asymptomatic posterior mediastinal mass during routine imaging for COVID-19. Computed tomography angiography revealed a 34 x 26 mm hypervascular mass closely associated with the esophagus, pulmonary artery, and bronchus. Initial surgical resection via VATS was converted to a posterolateral thoracotomy due to significant bleeding and adhesions. Histopathological examination confirmed hyaline vascular Castleman´s disease. The patient experienced an uneventful recovery and demonstrated a one-year remission. This case underscores the importance of advanced imaging and intraoperative flexibility in managing rare mediastinal masses. It also highlights the excellent prognosis achievable with complete resection, even in anatomically challenging cases.

Tissue-engineered extracellular matrix populated with autologous pluripotent cells can result in de-novo organogenesis, but the technique is complex, not widely available, and has not yet been used to repair large oesophageal defects in human beings. We aimed to use readily available stents and extracellular matrix to regenerate the oesophagus in vivo in a human being to re-establish swallowing function. In a patient aged 24 years, we endoscopically placed a readily available, fully covered, self-expanding, metal stent (diameter 18 mm, length 120 mm) to bridge a 5 cm full-thickness oesophageal segment destroyed by a mediastinal abscess and leading to direct communication between the hypopharynx and the mediastinum. A commercially available extracellular matrix was used to cover the stent and was sprayed with autologous platelet-rich plasma adhesive gel. The sternocleidomastoid muscle was placed over the matrix. After 4 weeks, stent removal was needed due to stent migration, and was replaced with three stents telescopically aligned to improve anchoring. The stents were removed after 3·5 years and the oesophagus was assessed by endoscopy, biopsy, endoscopic ultrasonography, and high-resolution impedance manometry. After stent removal we saw full-thickness regeneration of the oesophagus with stratified squamous epithelium, a normal five-layer wall, and peristaltic motility with bolus transit. 4 years after stent removal, the patient was eating a normal diet and maintaining a steady weight. Maintenance of the structural morphology of the oesophagus with off-the-shelf non-biological scaffold and stimulation of regeneration with commercially available extracellular matrix led to de-novo structural and functional regeneration of the oesophagus. None.

Mediastinal abscess, mostly resulting from esophageal perforation or cardiothoracic surgery, is a serious condition carrying high morbidity and mortality. Antibiotic therapy alone normally did not achieve a satisfactory outcome, due to poor circulation of abscess that hampers drug delivery. Surgical intervention for debridement and drainage is recommended, but it poses a high risk in patients with poor health status and could lead to various complications. Recent studies proposed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as an effective alternative to surgery; however, repeated TBNA procedures are usually needed for complete clearance of the lesion, thus causing increased patient suffering and medical expenses. Here, we present the first case of successful application of EBUS-guided transbronchial incision and drainage, which provides a novel, safe, and effective treatment for patient with mediastinal abscess unwilling or unsuitable to undergo surgical intervention.

Boerhaave syndrome is a rare clinical entity associated with high rates of morbidity and mortality. Early recognition of the symptoms, and identification of the site and extension of the injury are key in improving the prognosis. This study presents data on the mortality, morbidity and length of hospital stay in patients diagnosed with Boerhaave syndrome. The data were retrieved from a prospectively collected database in a single surgical unit between 2012 and 2022. The study makes a comparison with the surgical outcomes of the previous decade. Some 33 patients were diagnosed with Boerhaave syndrome and were treated surgically between 2012 and 2022 in a specialist upper gastrointestinal surgical unit. All patients underwent standard surgical repair (in-theatre diagnostic endoscopy, T-tube placement through thoracotomy and feeding jejunostomy through laparotomy). The mean size of the defects in the oesophageal lumen was 3.3cm. Delayed presentation was noted for 13 patients (39%); 8 patients (24%) died in hospital, and 19 patients (58%) developed postoperative complications. Mortality was similar to the rate recorded for the 20 patients from the previous decade (24% vs 20%, respectively). The mean length of hospital stay was 41 days, and was comparable to the 35.7 days reported between 1997 and 2011. Early and aggressive management of spontaneous oesophageal rupture ameliorates the postoperative recovery and prognosis. The surgical results of our unit were found comparable to the previous decade in the population of patients who were treated surgically.

Anterior mediastinal procedures are increasingly being performed using robot-assisted thoracic surgery (RATS) or video-assisted thoracoscopic surgery (VATS). While both approaches have shown superior outcomes compared to open surgery, their comparative benefits are not as distinct. The aim of this retrospective study was to bridge this knowledge gap using a multicenter dataset. Patients who underwent elective minimally invasive surgery for anterior mediastinal disease between 2015 and 2022 were deemed eligible. The study participants were grouped based on whether a robot was used or not, and perioperative outcomes were compared. To mitigate selection bias, inverse probability of treatment weighting (ITPW) was applied using the propensity score. The final analysis included 312 patients (RATS = 120; VATS = 192). Following the application of IPTW, RATS was found to be associated with a longer operating time (215.3 versus 139.31 min, P < 0.001), fewer days with a chest tube (1.96 versus 2.61 days, P = 0.047), and a shorter hospital stay (3.03 versus 3.91 days, P = 0.041) compared to VATS. Subgroup analyses indicated that the benefit of RATS in reducing the length of hospital stay was particularly pronounced in patients with tumors larger than 6 cm (mean difference [MD] =  – 2.28 days, P = 0.033), those diagnosed with myasthenia gravis (MD =  – 3.84 days, P = 0.002), and those who underwent a trans-subxiphoid surgical approach (MD =  – 0.81 days, P = 0.04). Both VATS and RATS are safe and effective approaches for treating anterior mediastinal disease. However, RATS holds distinct advantages over VATS including shorter hospital stays and reduced chest tube drainage periods.

Background Surgical treatment is usually required for Boerhaave’s syndrome (post-emetic esophageal perforation), and the technique should be chosen based on the local infection status and patient’s general condition. This study was performed to examine the current status of surgical treatment of Boerhaave’s syndrome in Japan. Methods Ninety-five patients with Boerhaave’s syndrome who underwent surgical treatment from January 2010 to December 2015, obtained from a national survey were retrospectively analyzed. The details of each surgical treatment and the type of treatment performed according to the patients’ characteristics were examined. Results Primary closure was performed in 75 (78.9%) patients, T-tube insertion in 15 (15.8%), and esophagectomy in 5 (5.3%). The length of the postoperative stay was significantly shorter in patients who underwent primary closure ( p  = 0.0011). Esophagectomy tended to be performed more often in patients with a long perforation and was performed significantly more often in patients with a high C-reactive protein concentration ( p  = 0.0118). The postoperative hospital stay was significantly longer in patients with leakage of the primary closure site ( p  < 0.0001). As a result, leakage of the primary closure site was significantly correlated with a long duration from symptom onset to patient presentation ( p  = 0.042), diagnostic imaging of the intrathoracic perforation ( p  = 0.013), and abscess formation in the mediastinal cavity ( p  = 0.006). Conclusions Selection of an appropriate surgical procedure may contribute to reduced mortality rates in patients with esophageal rupture. With regard to primary closure, it is necessary to understand that leaks are likely to occur in patients with a long duration from symptom onset to presentation or with severe intrathoracic/mediastinal inflammation, and to select an appropriate surgical procedure in consideration of the degree of invasiveness and QOL.