Refractory Empyema Caused by an Intraoperative Rib Fracture Sustained During Esophagectomy: Report of a Case

Abstract

A 57-year-old woman underwent esophagectomy with three-field lymphadenectomy for lower esophageal cancer, followed by gastric roll reconstruction through the posterior mediastinum. A laparotomy and right thoracotomy with partial resection of the right fifth rib were performed. A purulent discharge requiring drainage developed postoperatively and continued for 3 months despite anastomotic integrity and the absence of a bronchopleural fistula. An empyema developed 3 months after drain removal, and a thoracostomy tube was reinserted. A displaced fragment of the right fifth rib was identified within the abscess cavity. Drainage and irrigation were not curative, and removal of the bone fragment was performed 18 months after the initial procedure. The patient has been symptom-free during 1 year of follow-up. We believe that the rib fragment functioned as a foreign body, which complicated treatment of the patient's postoperative infection.

Fractures and other chest wall abnormalities after thoracotomy for esophageal cancer: A retrospective cohort study

“…However, rib or transverse process fractures during esophagectomy are rarely documented. 19 Other chest wall abnormalities, including heterotopic ossifications, are also likely linked to traumatic rib spreading, although also rarely described. 20 In contrast, pneumonia occurs frequently following esophagectomy, presumed to result from thoracic pain impairing deep respiration, hindering mobilization, and inhibiting adequate coughing.…”

“…Transverse process fractures are likely caused by the momentum of rib spreading on the costotransverse articulations. However, rib or transverse process fractures during esophagectomy are rarely documented 19 . Other chest wall abnormalities, including heterotopic ossifications, are also likely linked to traumatic rib spreading, although also rarely described 20 …”

Dislocation of the gastric conduit reconstructed via the posterior mediastinal route is a significant risk factor for anastomotic disorder after McKeown esophagectomy

“…11,12 However, PM reconstruction carries a risk of severe morbidities such as mediastinal abscess, empyema, and tracheobronchial fistula. [13][14][15][16] Therefore, it is important to identify the risk factors for anastomotic disorder of the gastric conduit reconstructed through the PM route.…”