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Figure 1. Chest x-ray film showing right pleural effusion.

Figure 2. Esophagram demonstrating extravasation of contrast at right lower esophagus (arrows).

As a life-threatening problem, esophageal perforation should be diagnosed and treated rapidly to provide a good outcome for the patient and prevent serious adverse sequelae. In 1724, Hermann Boerhaave described the syndrome after observing, on postmortem examination, a transmural rupture of the distal esophagus in Admiral Baron John de Wassenaeur of the Holland Navy.^1- 2 Although gastroesophageal reflux is often associated with the syndrome, other entities, including neurological diseases, hypertension, alcoholism, peptic ulcer disease, esophageal stricture, esophagitis, or neoplasm, are contributory factors. Presenting symptoms are often vomiting, nausea, and sharp chest pain. Patients are frequently dyspneic and, in an effort to minimize discomfort, sit upright and forward. Pertinent physical findings include basilar rales, wheezing, and crepitus along the chest wall.

The chest x-ray film findings may show the "V" sign of Naclerio, which indicates chemical pneumonitis of the paramedial aspect of the left lower lobe of the lung.^3- 4 Additional findings include atelectasis, effusion, and some mediastinal air. The diagnosis, however, is usually confirmed with an esophagram demonstrating extravasation of the contrast, but esophagoscopy may also be helpful. A full-thickness tear at the left postolateral area in the lower third of the esophagus is usually found. Occasionally, as in this patient, a right-sided perforation is detected.^5- 6 If a tube thoracostomy is placed within a few hours of the perforation, clear fluid with some food particles is noted in the effluent. In those cases in which the diagnosis is delayed, the effluent is rusty brown in color and has a high amylase level.^3- 4

Surgical management remains the mainstay of therapy for esophageal rupture with debridement of the perforation, primary repair in 2 layers, and drainage of the pleural cavity. Because the perforation is usually on the left side, a thoracic approach is often used. In this patient, a transabdominal approach was used successfully, and his postoperative course was unremarkable. Before the perforation is repaired, the wound should be carefully examined to identify the mucosa, which is often lacerated beyond the extent of the muscular perforation. A buttress or patch over the repair is recommended such as a gastric fundal patch or a pericardial or pleural patch. Recently, some authors have recommended the application of an absorbable mesh with fibrin glue as a form of buttress.⁷