Presternal gastric bypass for late postpneumonectomy esophagopleural fistula

Abstract

A 71-year-old diabetic patient underwent right pneumonectomy with wide mediastinal lymph node dissection for lung cancer (right upper lobe). Postoperatively he developed pleura empyema that was successfully treated - drainage and Eloesser window, followed by adjuvant radiotherapy. Two months later he developed an esophagopleural fistula. Due to the patient's physical condition primary repair of the esophageal rupture was considered a high-risk operation. Stenting was also considered as inappropriate due to the existing contamination. Bypassing with the use of the stomach as conduit was preferred due to its simplicity compared to the colon. In order to avoid mediastinum after the postradiation alterations and because of the Eloesser window we adopted a presternal subcutaneous position. Twenty-eight months after the by pass procedure the patient is in good health being able to eat and drink, has gained weight and shows no evidence of malignancy. Presternal gastric esophageal bypass has never been reported as a treatment for esophagopleural fistula. This case report indicates its possible successful use in this debilitating setting, although more experience is needed.

A New Surgical Technique for Spontaneous Esophagopleural Fistula after Pneumonectomy: Cervical Esophagogastrostomy via Presternal and Subcutaneous Route, Using a Thoracic Esophageal Mucosal Stripping

“…Late postpneumonectomy EPF (30 years after pneumonectomy) is extremely rare. 1,2 Most are associated with empyema and communicate with the right pleura space because of the anatomy. 1 The etiology of the EPF in our case remains unclear, and empyema, inflammation, and perforation of traction diverticulum could all be possible.…”

“…Treatment of a postpneumonectomy EPF is very challenging, and treatment modalities include tissue adhesives, stenting, obliteration and thoracoplasty, and bypass surgery. [1][2][3][4] At first, we treated the patient less invasively, but these modalities failed. Because of severely calcified pleural thickening and adhesion, we decided on bypass surgery to treat him instead of thoracoplasty.…”

“…The bypass conduit can be placed in the posterior mediastinum, retrosternal, and subcutaneous route. 2,3 We chose the subcutaneous route and stripped mucosa of the intrathoracic esophagus to avoid a transthoracic approach. Because the intrathoracic esophagus remained in situ, we removed the mucosa to prevent mucosal discharge into pleural cavity and to obliterate the lumen of the intrathoracic esophageal muscle tube.…”

“…Postpneumonectomy esophagopleural fistula (EPF) is extremely rare. 1,2 The treatment of postpneumonectomy EPF is very challenging, and various methods have been performed. In the following report, a new surgical technique for postpneumonectomy EPF is described.…”

Successful tubes treatment of esophageal fistula

“…Thoracoplasty, muscle flap repair of the esophagus, surgical stapler, intraluminal stents, tissue adhesive (fibrin glue, etc. ), and endoclips have seen successfully used by doctors (Siddiqui et al, 2007;Fernando and Benfield, 1996;Asaoka et al, 1988;Sethi and Takato, 1978;Adler et al, 2001;Agosti et al, 1978;Hu et al, 2004;Dosios et al, 2005;Marjolein and Peter, 2005;Eng et al, 1994;Solt et al, 1998;Kishi et al, 2005;Chryssostalis et al, 2005;Teitelbaum et al, 2005;Alberti and Alberti-Flor, 2005;Raymer et al, 2003;Okita et al, 2005;Truong et al, 2004;Talbot et al, 2007;Chappell and Heck, 2007;Gutiérrez San Román et al, 2006;Shichinohe et al, 2006;Rieder et al, 2006;Nguyen et al, 2006;Garand et al, 2006;Harries et al, 2004). The morbidity and mortality appear dramatically diminishing.…”