Successful primary repair in a late presentation of Boerhaave's syndrome. Case report.

We present a case of Boerhaave's syndrome successfully managed by open transabdominal approach 48 h after the acute event. A 55-year-old female presented with hydropneumothorax, chest pain, dyspnea, vomiting and fever. The urgent radiologic (X-ray, CT) and endoscopic study revealed the large defect of left posterolateral wall of esophagus with extrusion of fluid and gastric contents into the mediastinum and left chest. Emergency intercostal drainage insertion was performed and patient was transferred to our hospital. By open transabdominal approach after the wide sagittal diaphragmotomy the primary repair over the nasogastric tube using simple interrupted sutures (Vicryl 3/0) and partial fundoplication to cover the suture line was performed. Chest drainage tubes was then positioned near and parallel to the repaired esophagus and feeding jejunostomy was then performed for enteral nutrition. On the seventh postoperative day, a gastrografin swallow showed a small leak in the repair site without any collection, which was healed after 1,5 month of conservative treatment. We consider, that proactive surgical approach with primary surgical repair is still possible and feasible option despite the late presentation of Boerhaave's syndrome. KEY WORDS: Active drainage, Boerhaave's syndrome, Primary repair.

A comparative study of laparoscopic and open Nissen fundoplication for GERD in Georgia.

AIM: The study compares and analyzes the effectiveness and outcomes of open A. Chernousov modified Nissen fundoplication (CMNF) and laparoscopic total fundoplication in Georgia for gastroesophageal reflux disease (GERD) concerning perioperative course, postoperative complications, symptomatic relief, recurrent disease and the need for reinterventional surgery. MATERIALS AND METHODS: A prospective randomized trial was performed. Twohundred fortythree patients with GERD were randomized, 123 patients underwent open CMNF procedure and 120 patients of laparoscopic total fundoplication. Pre- and postoperative tests included endoscopy, X-Ray, patient questionnaire (GERD - HQRL scale) and clinical assessment. Patients were followed for 10 years. RESULTS: This prospective randomized trial showed good and excellent long-term results after open and laparoscopic total fundoplication for GERD (92,7% vs 88,5% respectively) (p=0,03). After open CMNF procedure there were 3 cases of postoperative ventral hernia, 9 cases of mild dysphagia. There was no recurrence. After laparoscopic approach there were 7 cases of solid and transient dysphagia, 3 cases of hard stenosis of cardiacs caused by wrap. There were 2 cases of recurrence, 3 cases of reflux and 1 case of epigastral trocar hernia. CONCLUSION: In Georgia as well as throughout the world laparoscopic total fundoplication at the present time is the preferred method of choice for the treatment of GERD. It has best cosmetic effect, less pain and wound problems, shorter hospital stay, early return to work. Open CMNF is safe and effective procedure too. It prevents slippage syndrome and is characterized by better control of reflux and less frequency of recurrence and guarantees slightly better long-term functional results. KEY WORDS: Antireflux surgery, GERD, Modified Nissen fundoplication, Prospective randomized trial.