A 50-yrs-old male has a severe vomiting and retching spell with 'sharp substernal pain. He comes to you 4 h later and has a chest film in which the left descending aorta is outlined by air density. Optimum strategy for care would be:

The presence of air in the mediastinum after an episode of vomiting and retching is virtually pathognomonic of spontaneous rupture of the esophagus (Boerhaave syndrome). The evidence is overwhelming that without prompt surgical exploration of the mediastinum by left thoracotomy, the patient has little chance for a short-term outcome of low morbidity. The aspiration of highly acidic gastric contents into the mediastinum creates havoc in the tissues exposed to it. The surgical procedure must include extensive opening of the mediastinal pleura and removal of any particulate debris that might have been aspirated into the thorax from the stomach. Closure of the esophageal laceration with reinforcement by a pleural flap and secure chest tube drainage of the pleural space are mandatory.