Repeated episodes of thoracic empyema after spontaneous esophageal rupture

Abstract

A 52-year-old man with a cough, high fever, and inappetence was diagnosed with thoracic empyema on computed tomography at a local hospital. He had undergone continuous thoracic drainage for a spontaneous esophageal rupture that occurred 17 years earlier. He developed left thoracic empyema 2, 14 and 17 years following the initial esophageal rupture that improved with conservative therapy each time. The most recent episode of thoracic empyema also resolved with conservative therapy. However, he was referred to our hospital for further examination and more complete surgical treatment for recurrent thoracic empyema. Gastrointestinal endoscopy showed a scar from the previous esophageal rupture in the lower esophagus. We considered that recurrent esophageal rupture may have caused repeated episodes of thoracic empyema based on endoscopic findings and his past history and elected to perform subtotal esophagectomy to provide a complete cure. A left transthoracic esophagectomy with a left lower lung lobectomy and gastric tube reconstruction via a retrosternal route were performed. A latissimus dorsi muscle flap was used to eliminate the dead space after lower lung lobectomy to prevent recurrent thoracic empyema. The bronchial stump was covered with a pedicled intercostal muscle flap to prevent leakage from the stump. Minor leakage from the esophagogastrostomy site developed during the postoperative course but resolved with conservative therapy. The patient was transferred to the previous hospital on the 36th postoperative day. Four years after surgery, he had good oral intake and nutritional status without any evidence of recurrent thoracic empyema.

Keywords: spontaneous esophageal rupture; thoracic empyema.

Fig. 1

Endoscopic findings and esophagography after the fourth episode Fig. 1a: Gastrointestinal endoscopy showing a depression that seemed to be a scar of an esophageal rupture in the left wall of the lower esophagus (white arrow). Fig. 1b: Esophagography showing a bulge of contrast medium at the depression presumed to be a fistula without contrast extravasation from the esophagus (white arrow).

Fig. 2

CT image after the fourth episode Fig. 2a: Contrast-enhanced coronal CT image showing an abscess along the mediastinum in the left lower pleural cavity. Fig. 2b: CT showing a fistula from the abscess (white arrows) that continued through the mediastinum from the thoracic cavity to the esophagus (white arrowheads).

Fig. 3

A change of chest CT image from the third to the fourth episode Fig. 3a: CT performed at the onset of the third episode showing an intrathoracic abscess with niveau formation. Fig. 3b: CT performed four months after the fourth episode showing resolved niveau formation with a small amount of encapsulated liquid in the bottom of the lung. Fig. 3c: CT performed at the onset of the fourth episode showing an intrathoracic abscess with niveau formation.

Fig. 4

Operative findings Fig. 4a: Creation of a latissimus dorsi muscle flap (white arrow). Fig. 4b: Thoracotomy with a pedicled intercostal muscle flap (arrow). Fig. 4c: Removal of the left lower lung lobe that was integrated with the abscess wall and the esophagus. Fig. 4d: Use of a latissimus dorsi muscle flap to eliminate the dead space after lower lung lobectomy with abscess wall resection (white arrow); use of a pedicled intercostal muscle flap to cover the bronchial stump (white arrowhead).

Fig. 5

Histological findings of the resected specimen Histological examination of the resected specimen revealing disruption of the muscularis mucosa in the depression that appeared to be a scar resulting from an esophageal rupture with fibrosis and foreign body deposits (between the black arrows).