A 65-yr-old man underwent endoscopic pneumatic dilatation for achalasia on April 17, 2012. Two hours after procedure, he complained of epigastric pain and dyspnea. Chest CT scan revealed that focal rupture at the left lateral wall of lower thoracic esophagus just above esophagogastric junction (Fig. 1). He referred for esophageal perforation and operation was performed 25 hr after pneumatic dilatation. The left lateral thoracotomy was done through the seventh intercostal space with partial resection of the eighth rib. The ruptured portion was 2 cm in length at the left lateral wall of lower thoracic esophagus 3 cm above the upper margin of phrenoesophageal membrane. Gastroplasty was performed and intercostal muscle flap was overlapped at the repair site. He had an uneventful recovery and esophagogram with gastrografin on the post-operative 8th day showed that passage disturbance or leakage at the anastomosis site was not detected. He could be discharged on the 16th day after operation. 6 months later, endoscopy revealed that reflux esophagitis of LA classification A was noted and she did not complain any reflux symptoms or dysphagia after operation for nine months.

A 54-yr-old woman referred for esophageal perforation after pneumatic dilatation for achalasia on October 18, 2012, which was detected during procedure (Fig. 2A). Six hours after perforation, operation was performed. The left lateral thoracotomy was done through the seventh intercostal space. The ruptured portion was 5 cm in length at the left lateral wall of lower thoracic esophagus just above the upper margin of phrenoesophageal membrane. Gastroplasty was done and she had an uneventful recovery. Confirming of neither passage disturbance nor leakage of contrast through esophagogram on the postoperative 8th day (Fig. 3), she could be discharged on the 23th day after operation. 4 months later, endoscopy revealed that reflux esophagitis of LA classification A was detected. Although the gastroesophageal junction was opened (Fig. 2B), he did not have any reflux symptoms or dysphagia for 13 months after operation.

Left lateral thoracotomy was performed through the seventh intercostal space with or without partial resection of the 8th rib. The ruptured mediastinal pleura over the esophagus were dissected and the esophagus was mobilized from the mediastinum. The phrenoesophageal membrane was opened, and gastric cardia was mobilized and pulled up into the pleural cavity. The muscular tear in esophagus was extended by incision upward to ensure the full extent of mucosal defect. After trimming of ruptured esophageal mucosa, caudal longitudinal incision of all layers was made as long as the length of perforated esophagus onto the cardia across the lower esophageal sphincter. Transverse single layer interrupted suture with 4-0 black silk were passed through all layers of esophagus and cardia with the knots tied on the outside (Fig. 4A), suggesting the Heineke-Mikulicz pyloroplasty. The remaining portion of cardia wrapped over the anastomosis portion and lower esophagus (Fig. 4B), which was similar to fundoplication of Belsey Mark IV procedure. In case 2, because the length of esophageal rupture was too long, cardiotomy and gastroplasty was undertaken at the distal half. The primary repair was made at the proximal portion and it was covered with intercostal muscle flap. After placing the Levin tube in proper position, the cardia was reduced into the peritoneal cavity and the incised diaphragm was repaired primarily on which the cardia was anchored to be placed properly. A single chest tube, sizes No 32Fr, was introduced and placed near the anastomosis site, and the thoracotomy incision was closed layer by layer.