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Late Esophagopleural Fistula after Pneumonectomy for Bronchial Carcinoma
1 Watson JH, Bartholomae WM: Cardiac injury to nonpenetrating chest trauma. Ann Intern Moo. 52:811-880, 1960 2 Delara A, Morando P, Pampaloni M: Electrocardiographic findings in 98 consecutive nonpenetrating chest injuries. Dis Chest 52:50-56,1967 3 Pannley LF, Manion WC, Mattingly 1W: Nonpenetrating traumatic injury of the heart. Circulation 18:371-396, 1958 4 Noon GP, Boulafendis D, Beall AJ jr: Rupture of the heart secondary to blunt trauma. J Trauma 11: 122-128, 1971 5 Harthorne ]W, Kantrowitz PA, Dinsmore RE, et all Traumatic myocardial infarction. Ann Intern Med 66:341344,1967 6 Levy H: Traumatic coronary thrombosis with myocardial infarction. Arch Intern Med 84:261-276, 1949 7 Lehmus HJ, Sundquist AB, Giddings LW: Coronary thrombosis with myocardial infarction secondary to nonpenetrating injury of the chest wall. Am Heart J 47 :47()" 473, 1954 8 Rea WJ, Sugg WL, Wilson LC, et all Coronary artery laceration. Ann Thor Surg 7 :518-528, 1969 9 O'Sullivan MJ, Spagna PM, Bellinger SB, et al: Rupture of the right atrium due to blunt trauma. J Trauma 12:208214,1972 10 Pepine CJ, Beasley DW, Schang SJ, et all Angiographic diagnosis of coronary artery lacerations. J Thorac Cardiovasc Surg 63:183-184,1972 FICCRE 1. X-ray film before operation showing esophageal
Late Esophagopleural Fistula after Pneumonectomy for Bronchial Carcinoma M. Efthimiodis, M.D.; D. XanthaJds, M.D.; N. Primikf/rlos, M.D.; G. Papadakis, M.D.; and C. ]. Aligizakis, M.D.
We report ODe case of esopb8gopleural fistula occarrbIg after right pneumonectomy. Pathogenesis and .......emeat of this complication lire brlely dIsc:usIecL Dralnage of the empyema ad direct closure of the fistula, with coverage by a pedicle lap of tbe intel'COltal muscle lire the best methods of treatment.
T
he appearance of an esophagopleural 6stual after pneumonectomy is a rare complication. In an extensive review of the literature.>" 35 cases were reported. Most of these cases developed following pneumonectomy for tuberculosis or suppurative pulmonary disease. Only six cases were found in which fistulae developed as early or late complication8 , 8 , 8 after pneumonectomy for carcinoma of the lung. Because of tbe rarity of this complication we are reporting one case. CASEREroRT
This 65-year-old man underwent right pneumonectomy for bronchial carcinoma on Dec 10, 1968. The pathology report showed undiHerentiated carcinoma, requiring exten-
Reprint requests: Dr. Efthimiodis, Alopekis St. 50-52, Athens,
Greece
CHEST, 65: 5, MAY, 1974
leak.
sive resection of infiltrated glands. The patient made an uneventful recovery and on the 21st day after operation he was sent home. Because of the type of carcinoma and the glandular involvement, the prognosis was poor. Six months later the patient was readmitted with a high temperature and chest pain. A diagnosis of empyema neeessitatis was made. Drainage was accomplished through a basal tube. There was no bronchial fistula. After the drainage of the empyema, the condition of the patient improved and thoracoplasty for closure of the empyema cavity was suggested, but the patient refused. He was again discharged and was quite well until June. 1971. By that time he noticed that food was leaking through the drainage tube. The patient was readmitted to the clinic in a very poor general condition. Radiologically, a diagnosis of esophagopleural fistula in the middle of the esophagus was made (Fig 1). Our first impression was that the fistula was due to neoplastic infiltration of the esophagus, although the radiologic findings of esophageal distention were not indicative of metastasis. Esophagoscopy at a depth of 30 an revealed a small fistula in the right lateral wall of the esophagus without neoplastic infiltration. Biopsy findings were negative. Bronchoscopy showed no recurrence in the bronchial stump. The patient was fed lying on his left side, averting the necessity for gastrostomy, and after six weeks his general condition improved. The empyema cavity shrank, but the esophageal lealc persisted. In August, 1971, a thoraeotomy was carried out through the same incision. A small empyema cavity was found, which was drained. A bole of 2 em in length was found at the lateral wall of the esophagus near the bronchial stump. Microscopically, there was no neoplastic disease. After mobilizing the esophagus, the edges of the fistula were excised and the opening was closed in two layers. The suture was reinforced and covered with a flap of
LATE ESOPHAGOPlEURAL FISTULA 578
the cause of an esophagopleural fistula. T• t •s Takaro et
al! report eight cases of esophagopleural fistula after
intrathoracic procedures. In these cases the fistula occurred between eight months and six years following infection of the pleural cavity. The diagnosis of the esophagopleural fistula may present some difficulties when this complication arises in the early period after operation, when it might easily be confused with a bronchopleural fistula. In a late complication simple empyema or a bronchial fistula is suspected. An esophagogram will reveal the presence of a fistula in most cases. Bronchoscopy is necessary to exclude recurrence in the bronchial stump; esophagoscopy COnDnnS the diagnosis and rules out neoplastic infiltration of the esophagus. Conservative measures (gastrostomy) applied in the past have proved ineffective. 1 Attempts to reconstruct the esophagus with segments of colon or esophagogastrectomy also failed. Direct closure of the fistula is the method of choice." The suture line should be covered with a flap of muscle or, better, with a pedicle of intercostal muscle, periosteum and pleura," H the empyema cavity is already small, as it was in our case, concomitant thoracoplasty is not necessary, but it is absolutely essential in a big empyema cavity. We believe that the main factor of successful closure of the esophagopleural fistula is the covering of the suture line and elimination of infection of the empyema cavity with good drainage and instillation of antibiotics.
..
of:'
~
_ .. .. _ . _ "' _
fu:FERENCES
•
FIGURE 2. Postoperation x-ray 6lm showing no leak. intercostal muscle and periosteum. The small empyema cavity was drained. A biopsy examination of fistula specimen was negative for neoplastic tissue. The patient made an uneventful recovery and was discharged on the 21st day. Since then he bas remained well. DISCUSSION
Infection and injury of the esophagus due to operation are probably the most significant causes of esophagopleural fistula after pneumonectomy. Infection of the pleural cavity, rupture of a periesophageal abscess, direct inflammatory involvement of esophageal wall or erosion of the esophagus from a suppurative node after formation of a traction diverticula are responsible for late esophagopleural fistula. T • t • 6 •s Early fistulae are mostly due to injuries of the esophagus at operation, particularly after extensive glandular dissection. It is well known that tuberculous empyema may be
580 EFTHIMIADIS ET At
1 Takaro T, Walkup HE, Okano T: Esophagopleural fistula
2 3 4
5 6 7 8
as a complication of thoracic surgery. J Thome Cardiovasc Surg 40:179,1960 Dumont A, De Graef J: La fistule oesophago-pleurale, complication tardive de la pneumonectomie. Lyon Cbir 57 :481, 1961 Eriksen KR: Oesopbagopleural fistula diagnosed by microscopic examination of pleural fluid. Acta Chir Scand 128: 771,1964 Rollemberg Dos Santos MI, Netto SM, Marcal 0: Fistula esophagopleural traumatica pospneumonectomia: Analise de um caso tratado par esofagogastroplastica retrosternal. Rev Paul Moo 65:263, 1964 Benjamin I, Olsen AM, Ellis FH Jr: Esophagopleural fistula: A rare postpneumonectomy complication. Ann Tborac Surg 7: 139, 1969 Engelman RM, Spencer FC, Berg P: Postpneumonectomy esophageal fistula. J Thome Cardiovasc Surg 59:871, uno Aligizakis C}, Belesiotis Ie, Gouzoulis P, et al: Esophagopleural fistula due to rupture of T.B. empyema. Greek Surg 5:683,1959 Cleland WP: Personal communication. un1
CHEST, 65: 5, MAY, 1974
Late Esophagopleural Fistula after Pneumonectomy for Bronchial Carcinoma M. Efthimiodis, M.D.; D. XanthaJds, M.D.; N. Primikf/rlos, M.D.; G. Papadakis, M.D.; and C. ]. Aligizakis, M.D.
We report ODe case of esopb8gopleural fistula occarrbIg after right pneumonectomy. Pathogenesis and .......emeat of this complication lire brlely dIsc:usIecL Dralnage of the empyema ad direct closure of the fistula, with coverage by a pedicle lap of tbe intel'COltal muscle lire the best methods of treatment.
T
he appearance of an esophagopleural 6stual after pneumonectomy is a rare complication. In an extensive review of the literature.>" 35 cases were reported. Most of these cases developed following pneumonectomy for tuberculosis or suppurative pulmonary disease. Only six cases were found in which fistulae developed as early or late complication8 , 8 , 8 after pneumonectomy for carcinoma of the lung. Because of tbe rarity of this complication we are reporting one case. CASEREroRT
This 65-year-old man underwent right pneumonectomy for bronchial carcinoma on Dec 10, 1968. The pathology report showed undiHerentiated carcinoma, requiring exten-
Reprint requests: Dr. Efthimiodis, Alopekis St. 50-52, Athens,
Greece
CHEST, 65: 5, MAY, 1974
leak.
sive resection of infiltrated glands. The patient made an uneventful recovery and on the 21st day after operation he was sent home. Because of the type of carcinoma and the glandular involvement, the prognosis was poor. Six months later the patient was readmitted with a high temperature and chest pain. A diagnosis of empyema neeessitatis was made. Drainage was accomplished through a basal tube. There was no bronchial fistula. After the drainage of the empyema, the condition of the patient improved and thoracoplasty for closure of the empyema cavity was suggested, but the patient refused. He was again discharged and was quite well until June. 1971. By that time he noticed that food was leaking through the drainage tube. The patient was readmitted to the clinic in a very poor general condition. Radiologically, a diagnosis of esophagopleural fistula in the middle of the esophagus was made (Fig 1). Our first impression was that the fistula was due to neoplastic infiltration of the esophagus, although the radiologic findings of esophageal distention were not indicative of metastasis. Esophagoscopy at a depth of 30 an revealed a small fistula in the right lateral wall of the esophagus without neoplastic infiltration. Biopsy findings were negative. Bronchoscopy showed no recurrence in the bronchial stump. The patient was fed lying on his left side, averting the necessity for gastrostomy, and after six weeks his general condition improved. The empyema cavity shrank, but the esophageal lealc persisted. In August, 1971, a thoraeotomy was carried out through the same incision. A small empyema cavity was found, which was drained. A bole of 2 em in length was found at the lateral wall of the esophagus near the bronchial stump. Microscopically, there was no neoplastic disease. After mobilizing the esophagus, the edges of the fistula were excised and the opening was closed in two layers. The suture was reinforced and covered with a flap of
LATE ESOPHAGOPlEURAL FISTULA 578
the cause of an esophagopleural fistula. T• t •s Takaro et
al! report eight cases of esophagopleural fistula after
intrathoracic procedures. In these cases the fistula occurred between eight months and six years following infection of the pleural cavity. The diagnosis of the esophagopleural fistula may present some difficulties when this complication arises in the early period after operation, when it might easily be confused with a bronchopleural fistula. In a late complication simple empyema or a bronchial fistula is suspected. An esophagogram will reveal the presence of a fistula in most cases. Bronchoscopy is necessary to exclude recurrence in the bronchial stump; esophagoscopy COnDnnS the diagnosis and rules out neoplastic infiltration of the esophagus. Conservative measures (gastrostomy) applied in the past have proved ineffective. 1 Attempts to reconstruct the esophagus with segments of colon or esophagogastrectomy also failed. Direct closure of the fistula is the method of choice." The suture line should be covered with a flap of muscle or, better, with a pedicle of intercostal muscle, periosteum and pleura," H the empyema cavity is already small, as it was in our case, concomitant thoracoplasty is not necessary, but it is absolutely essential in a big empyema cavity. We believe that the main factor of successful closure of the esophagopleural fistula is the covering of the suture line and elimination of infection of the empyema cavity with good drainage and instillation of antibiotics.
..
of:'
~
_ .. .. _ . _ "' _
fu:FERENCES
•
FIGURE 2. Postoperation x-ray 6lm showing no leak. intercostal muscle and periosteum. The small empyema cavity was drained. A biopsy examination of fistula specimen was negative for neoplastic tissue. The patient made an uneventful recovery and was discharged on the 21st day. Since then he bas remained well. DISCUSSION
Infection and injury of the esophagus due to operation are probably the most significant causes of esophagopleural fistula after pneumonectomy. Infection of the pleural cavity, rupture of a periesophageal abscess, direct inflammatory involvement of esophageal wall or erosion of the esophagus from a suppurative node after formation of a traction diverticula are responsible for late esophagopleural fistula. T • t • 6 •s Early fistulae are mostly due to injuries of the esophagus at operation, particularly after extensive glandular dissection. It is well known that tuberculous empyema may be
580 EFTHIMIADIS ET At
1 Takaro T, Walkup HE, Okano T: Esophagopleural fistula
2 3 4
5 6 7 8
as a complication of thoracic surgery. J Thome Cardiovasc Surg 40:179,1960 Dumont A, De Graef J: La fistule oesophago-pleurale, complication tardive de la pneumonectomie. Lyon Cbir 57 :481, 1961 Eriksen KR: Oesopbagopleural fistula diagnosed by microscopic examination of pleural fluid. Acta Chir Scand 128: 771,1964 Rollemberg Dos Santos MI, Netto SM, Marcal 0: Fistula esophagopleural traumatica pospneumonectomia: Analise de um caso tratado par esofagogastroplastica retrosternal. Rev Paul Moo 65:263, 1964 Benjamin I, Olsen AM, Ellis FH Jr: Esophagopleural fistula: A rare postpneumonectomy complication. Ann Tborac Surg 7: 139, 1969 Engelman RM, Spencer FC, Berg P: Postpneumonectomy esophageal fistula. J Thome Cardiovasc Surg 59:871, uno Aligizakis C}, Belesiotis Ie, Gouzoulis P, et al: Esophagopleural fistula due to rupture of T.B. empyema. Greek Surg 5:683,1959 Cleland WP: Personal communication. un1
CHEST, 65: 5, MAY, 1974