Sepsis in the Postpneumonectomy Space: Pathogenesis, Recognition, and Management

Empyema may occur in the pleural space after pulmonary resection. Subsequent bacterial contamination results in infection and development of frank empyema. Pneumonectomy-surgical removal of the entire lung-is the treatment of choice for centrally located bronchogenic carcinoma, diffuse malignant mesothelioma, and chronic inflammatory lung diseases with destroyed lung from pulmonary tuberculosis, fungal infections, and bronchiectasis. In the uncomplicated case, on the pneumonectomy side, the diaphragm becomes elevated as the air-fluid level decreases with chest wall deformation and gradual disappearance of hydrothorax. The pneumonectomy space is at potential risk for getting infected from bacterial contamination and developing empyema.

A rare cause of esophagopleural fistula due to intensity-modulated proton therapy: a case report and review of literature

Esophagopleural fistula (EPF), initially described in 1960, is an abnormal communication between the esophagus and the pleural cavity which can occur due to congenital malformation or acquired due to malignancy or iatrogenic treatment. The most common presenting symptoms are of a respiratory infection, such as fever, chest tenderness, cough and imaging findings consistent with pleural fluid consolidation. In this report, we present a 59-year-old man who exhibited shortness of breath, productive cough, and significant weight loss for 2 weeks. His medical history was significant for smoking-related lung disease and pulmonary squamous cell carcinoma (SCC). His SCC (T4N0) was diagnosed 6 years prior to this presentation and was treated with chemoradiotherapy. The cancer recurred a year ago and he was treated with intensity-modulated proton therapy (IMPT) and consolidation chemotherapy. During admission, he was found to have an EPF by CT scan after initially failing antibiotic treatment for suspected complicated pneumonia and pleural effusion. Multiple attempts of esophagopleural fistula closure were made using endoscopic self-expandable metallic stents and placement of an esophageal vacuum-assisted closure device. However, these measures ultimately failed and, therefore, he required an iliocostalis muscle flap (Clagett window) procedure for closure. Esophageal pulmonary fistulae should be suspected whenever patients have undergone thoracic IMPT and may present with acute pulmonary complications, particularly pneumonia refractory to antibiotic treatment. This case reviews the current literature, potential complications, and treatment options for esophagopleural fistulas.

Caustic ingestion: CT findings of esophageal injuries and thoracic complications

Ingestion of caustic substances, whether accidental or for the purpose of suicide, can cause severe lesions of the lips, oral cavity, pharynx, upper gastrointestinal system, and upper airways. In particular, caustic agents could be responsible for severe esophageal injuries resulting in short- and long-term complications. Because of these important clinical implications, timely diagnosis and appropriate management are crucial. In the evaluation of esophageal injuries, thoraco-abdominal computed tomography (CT) is preferable to endoscopy as it avoids the risk of esophageal perforation and allows the evaluation of esophageal injuries as well as of the surrounding tissue. In this review, we report CT findings of esophageal injuries and possible related thoracic complications caused by caustic ingestion.

Successful treatment of esophagopleural fistula following pulmonary resection for primary lung cancer: a case report

BACKGROUND

We report a rare case of esophagopleural fistula (EPF) developing during the postoperative period after pulmonary resection for primary lung cancer.

CASE PRESENTATION

A 71-year-old male who underwent video-assisted thoracoscopic right lower lobectomy with lymph node dissection for primary lung cancer developed severe stabbing pain in his right shoulder and high fever 3 days after the operation. The fever persisted, the cough became more productive, and a plain chest X-ray showed slight a few infiltrative opacities in the right lung field. Intravenous antibiotic therapy was initiated. The patient developed a right pneumothorax 5 days after the operation, and contaminated discharge from the right chest tube was noted. A chest computed tomography showed right-sided empyema, while bronchoscopic examination revealed no evidence of a bronchopleural fistula. Open-window thoracostomy (OWT) was performed. Finally, 2 days after the OWT, the patient was diagnosed as having an EPF, because the right chest cavity was found to be contaminated with food materials. Ample purification of the right chest cavity was achieved by repeated dressing changes, and the EPF was finally closed by omentopexy. The post-surgical course was uneventful. Five weeks after the omentopexy, an esophagogram revealed no leakage of the contrast medium from the esophageal wall. The patient was discharged 13 weeks after the omentopexy.

CONCLUSION

While EPF following pulmonary resection is a rare complication, it can lead to critical situations and the diagnosis is difficult. Prompt OWT and omentopexy were found to be effective treatment procedures for EPF following lung surgery.

Endoscopic Treatment of Esophago-Pleural Fistula Following Total Gastrectomy: A Case Report

This paper is designed to report the endoscopic treatment for a rare esophagopleural fistula after total gastrectomy. Esophagopleural fistula is a rare complication following total gastrectomy. Nonoperative treatment using endoscopic injection of tissue glue is a less invasive and effective option. The history, treatment, and options for managing an esophagopleural fistula following gastrectomy are discussed. A 53-year-old female patient underwent total gastrectomy for advanced gastric cancer. An anastomotic leak with esophagopleural fistula formation developed at the esophagojejunostomy site. The fistula was successfully managed by endoscopic injection with n-butyl-2-cyanoacrylate into the fistula, chest tube drainage, systemic antibiotics, and total parenteral nutrition. This case report suggests that combing effective drainage and the use of n-butyl-2-cyanoacrylate of nonoperative treatment options for esophagopleural fistula.

Treatment of Traumatic Esophagopleural Fistula Using the Over-the-Scope-Clip System

Esophagopleural fistula (EPF) is a rare condition that is usually accompanied by severe infection and life-threatening morbidity. Here, we report the successful treatment of an EPF by closing an esophageal orifice using the over-the-scope-clip (OTSC) system without postprocedural complications. A 41-year-old man had serious thoracic and abdominal trauma due to a traffic accident. Computed tomography revealed findings suggestive of esophageal rupture due to Boerhaave syndrome. An emergent explorative operation was performed for primary repair with the insertion of a vacuum-assisted closure device. A postoperative upper gastrointestinal series revealed an EPF tract connecting the left pleural space and distal esophagus. We performed an endoscopic procedure using the "traumatic-type"OTSC to seal the EPF, and the esophageal orifice was completely healed 2 weeks postoperatively. The OTSC system might represent a safe and feasible modality for the treatment of EPF.

A case of spontaneous esophagopleural fistula successfully treated by endoscopic stent insertion

The most common cause of esophagorespiratory fistulas (ERFs) is associated with malignancy. The use of self-expandable metal stents is effective for the treatment of malignant ERFs, but benign ERF is rare, which is why its optimal treatment is not defined yet. There have been few reports describing benign esophagopleural fistula and its treatments in South Korea. Here, we report a rare case of spontaneous esophagopleural fistula, which was successfully treated by endoscopic placement of a membrane covered metal stent.

Interventional management of esophagorespiratory fistula

An esophagorespiratory fistula (ERF) is an often fatal consequence of esophageal or bronchogenic carcinomas. The preferred treatment is placement of esophageal and/or airway stents. Stent placement must be performed as quickly as possible since patients with ERFs are at a high risk for aspiration pneumonia. In this review, choice of stents and stenting area, fistula reopening and its management, and the long-term outcome in the interventional management of malignant ERFs are considered. Lastly, a review of esophagopulmonary fistulas will also be provided.