A 54-year-old man presents to the emergency department 6 hours after forceful retching and vomiting during a heavy meal. He reports sudden onset of severe retrosternal and epigastric pain radiating to the left shoulder, dyspnea, and neck swelling. On examination, a crunching sound synchronous with the heartbeat is heard on cardiac auscultation (Hamman sign). Chest X-ray shows left pleural effusion and pneumomediastinum. CT with water-soluble oral contrast reveals extravasation from the left posterolateral distal esophagus 3–5 cm above the gastroesophageal junction. The condition marked **B** in the diagram is suspected. Which of the following is the MOST APPROPRIATE immediate management for this hemodynamically stable patient presenting within 24 hours of symptom onset?

Why left thoracotomy with primary repair is correct

The condition marked B is Boerhaave syndrome — spontaneous transmural esophageal rupture. The clinical presentation (Mackler triad: vomiting + lower chest pain + subcutaneous emphysema), imaging findings (pneumomediastinum, left pleural effusion, contrast extravasation from the left posterolateral distal esophagus), and timing (within 24 hours) all indicate a contained, acute rupture in a hemodynamically stable patient. According to Sabiston Textbook of Surgery and Bailey & Love, the gold standard for rupture diagnosed within 24 hours in stable patients is primary surgical repair via left thoracotomy, with longitudinal esophageal closure reinforced by a pleural or intercostal muscle flap and wide mediastinal drainage to prevent mediastinitis and sepsis. Time is the strongest predictor of outcome — diagnosis and repair within 12 hours carries mortality <10%, making urgent surgical intervention the priority.

Why each distractor is wrong

Sabiston Textbook of Surgery 21e; Bailey & Love 28e