A previously healthy 20-year-old man is admitted to a hospital with acute onset of left-sided chest pain. The electrocardiographic findings are normal but chest x-ray shows a 40% left pneumothorax. Treatment consists of which of the following procedures?

Spontaneous pneumothorax usually results from the rupture of subpleural blebs in young men (age 20-40), which is often signaled by a sudden onset of chest and shoulder pain. Pneumothorax of more than 25% requires placement of a chest tube; thoracotomy with bleb excision and pleural abrasion is generally recommended if spontaneous pneumothorax is recurrent. Small pneumothoraxes in patients with minimal symptoms usually resolve and therefore can be observed. A spontaneous perforation of the esophagus (Boerhaave syndrome) can result in hydropneumothorax as well as the more usual pneumomediastinum but would not present with an isolated 40% pneumothorax. Barium swallow is an appropriate diagnostic test for evaluation of a suspected leaking esophagus.