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Ann Thorac Surg 2002;74:923-924
© 2002 The Society of Thoracic Surgeons
a Service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou, Paris, France
Accepted for publication April 1, 2002.
* Address reprint requests to Dr Riquet, Service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
e-mail: marc.riquet{at}hop.egp.ap-hop-paris.fr
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Abstract |
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Introduction |
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A 60-year-old man with no significant medical history was referred to our department after a right pneumonectomy performed in another institution in January 1997 for adenocarcinoma of the right lower lobe (T2N0M0). The early postoperative course had been complicated by an empyema associated with a BPF that was initially treated by antibiotics and chest tube drainage. No data were available regarding the cultures and the antibiotic treatment received during this period. However, the infection was not controlled and 5 months later ingested food particles were seen in the drainage from the chest and the empyema evolved toward "empyema necessitans," at the anterior part of the thoracotomy. EPF was confirmed on gastrograffin swallow. The patient was discharged and referred to our department.
On admission the patient was cachectic and dyspneic. Admission chest roentgenogram demonstrated a right-side air fluid level and left lower lobe pneumonia. Fiberoptic bronchoscopy revealed a fistula of 5 mm in diameter located on the right bronchial stump. Esophagoscopy showed an esophageal fistula of 10 mm in diameter approximately 30 cm from the incisors. There was no evidence of lung cancer recurrence. Because of the poor general status of the patient a new chest tube was inserted. Direct analysis of the pleural fluid revealed Mycobacterium tuberculosis. Antituberculosis therapy was instituted and a feeding jejunostomy was performed in order to start nutritional support. After 2 months of pleural drainage the patients nutritional status was satisfactory and M tuberculosis had disappeared. Owing to the persistence of both fistulas and the recurrence of fever a videothoracoscopy was performed and the pleural cavity cleaned.
One month later a right thoracotomy was performed in view of cure. The cavity was widely debrided and the location of the esophageal fistula and bronchial stump were identified. The esophageal fistula was visualized in the midportion of the esophagus. Its edges were freshened and a single row of interrupted sutures was set very close to the fistula. The BPF was also identified and its edges freshened and was closed by interrupted sutures. An extensive thoracoplasty was then performed with ribs 3 to 8 being removed together with the lower two thirds of the scapula. The sites of esophageal fistula and bronchial stump were then covered by a subscapular muscle flap. Postoperatively the patient suffered from respiratory insufficiency and required a tracheostomy. He finally recovered and endoscopic examinations performed a month after surgery demonstrated complete closure of both fistulas.
Nutritional support through the jejunostomy was progressively reduced and oral food intake started. The following month a nasopharyngeal (cavum) carcinoma was diagnosed and treated by cervicofacial radiotherapy and chemotherapy (Cis-platyl). The patient had no evidence of recurrence of either the bronchial or esophageal fistula. However, a swallowing disorder developed as a consequence of radiotherapy to the neck. He died in July 1998 of acute respiratory insufficiency secondary to aspiration pneumonia.
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Although possibly observed on the left side [4, 6] the majority of reported EPF and BPF have occurred after right lung resection and more specifically pneumonectomy. This right-sided predominance is dictated by mediastinal anatomy [2]. On the right side the esophagus is in close relation to the lung hilum and mediastinal pleura. Conversely, on the left the aorta is interposed between the pleural cavity and the esophagus [2]. Finally, burying of the bronchial stump into the mediastinum is more effective on the left side. Devascularization and operative injury are other major factors that may be incriminated when both fistulas occur immediately after surgery [3].
Nevertheless late EPF without recurrent cancer is believed to result from a peribronchial abscess developing in the space between the bronchial stump and the pleural cover, with subsequent progressive erosion of the esophageal wall. This abscess usually results during the immediate postoperative period from BPF and empyema. This hypothesis is supported by data from Evans [3] who reported 8 cases of EPF, 7 of which were preceded by BPF. In our patient EPF was also preceded by BPF. However, the associated tuberculosis, which had long been unknown, was probably an important factor in the occurrence and duration of the complication.
The two goals of treatment in this patient were to eradicate empyema and to close the BPF and EPF without sacrifiying the native esophagus. Severe malnutrition (and pulmonary tuberculosis in the present case) must also be considered. Nevertheless the first step of treatment is to stop oral food intake and to control the empyema by insertion of a chest tube or more often by performing an open window thoracotomy. An open window thoracotomy performed for ongoing infection during the first period of the empyema may have prevented the occurrence and severity of complications but was not performed in the previous institution. The patients initial physical status on arrival was so poor that it was decided that a new chest tube in better position was the only chance for initial control of the situation. With the patient improving and M tuberculosis discovered, treatment was continued and complementary cleaning of pleural cavity was obtained through videothoracoscopy.
Once the infection was under control and the patient’s nutritional status improved, a direct suture closure of both fistulas was possible. However, the suture lines required a cover by a flap of viable tissue in order to reinforce and separate them. The subscapular muscle flap was chosen and used because the pectoralis major, latissimus dorsi, serratus anterior, and trapezius muscles were unusable as a result of extensive prior thoracotomy and numerous chest tube drainages. The subscapular muscle flap was brought through the third costal bed and placed between the two suture lines of the fistulas. This flap proved perfectly suitable and effective. A combined surgical procedure obliterating the pleural space with thoracoplasty was also necessary to reliably cure such fistulas [5]. Nine months after surgery the patient was eating, gaining weight, and was cured. Unfortunately, death was incidental and due to aspiration pneumonia of another origin [8].
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This article has been cited by other articles:
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  T. F. Molnar Current surgical treatment of thoracic empyema in adults Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 422 - 430. [Abstract] [Full Text] [PDF]
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