Ann Thorac Surg 2002;74:1711-1712
© 2002 The Society of Thoracic Surgeons
Case report
A large mediastinal tumor with spontaneous regression 30 years after esophageal bypass surgery
Steffen Frese, MDa,
Robert M. Stein, MDa,
Jan-Rasmus Kuster, MDa,
Ralph A. Schmid, MDa*
a Division of General Thoracic Surgery, University Hospital Berne, Berne, Switzerland
Accepted for publication July 11, 2002.
* Address reprint requests to Dr Schmid, Division of General Thoracic Surgery, University Hospital Berne, CH, 3010 Berne, Switzerland.
e-mail: ralph.schmid{at}insel.ch
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Abstract
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We describe the case of an 80-year-old man admitted to the hospital for the first time with chest pain and progressive respiratory difficulty. Radiographic findings of the chest showed a large, cystic mediastinal mass from the jugulum to the diaphragm. The patient’s history revealed bypass operation for a benign esophageal stricture 30 years ago. During the hospital stay, clinical symptoms resolved within 48 hours without specific treatment. Seven days after admission a chest roentgenogram showed almost complete regression of the tumor, which was supposed to be a mucocele of the colon bypassing the esophagus.
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Introduction
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Symptomatic mucocele after surgical bypass of the espohagus is a rare complication. All cases in the literature described a mucocele arising from the excluded esophagus. We report here a patient who developed a large mucocele of the colonic bypass 30 years after bypass operation for esophageal stricture. Remarkably, according to the patient’s statement he has been without complaint for the past 30 years.
An 80-year old man presented to the emergency department with first-time chest pain and progressive dyspnea accompanied by a pronounced stridor that worsened in the supine position.
The patient’s history included an operation 30 years ago, with colonic bypass for stricture of the proximal esophagus. The stricture of unknown origin had caused dysphagia. Review of the surgical report showed that the right colon together with 8 cm of the terminal ileum had been mobilized and transposed to the retrosternal space through the minor omentum. Anastomosis of the aboral end was set to the gastric fundus using two-layer sutures. There was no exact description on how the proximal anastomosis of the ileum to the esophagus 3 cm above the jugulum was performed, and there was no mention of any exclusion of the esophagus during this operation.
Radiographic findings on presentation showed a large, cystic mediastinal tumor from the jugulum to the diaphragm. The tumor compressed the trachea and the upper venous trunk. Pleural effusion was seen on both sides (Fig 1A, 2).
After swallowing soluble contrast agent there was a normal esophageal passage. To our surprise, endoscopy of the upper gastrointestinal tract, which was performed at day 3 after admission, showed normal anatomy and mucosa of the esophagus with a slight stricture of the proximal part, mild esophagitis, and superficial gastric and duodenal ulcers. The actual anastomosis of a colonic bypass could not be detected in the esophagus or in the stomach. Although a scar in the gastric posterior aspect was seen, it could not be surpassed by a guidewire.
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Fig 1. (A) Posteroanterior chest radiograph on the day of admission. (B) Posteroanterior chest radiograph on day 7 after admission.
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Fig 2. Computed tomographic scans of the chest on the day of admission show a large mediastinal tumor that is partially subdivided into sections and that compresses the trachea.
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With no specific treatment, the acute symptoms such as dyspnea, stridor, and chest pain resolved gradually within 48 hours. The gastric and duodenal ulcerations were treated with antacids, and the patient received a single dose of antifungals for the Candida esophagitis. Along with the diminished clinical symptoms computed tomographic scan 3 days after admission showed a much reduced mass behind the sternum (Fig 3).
Chest roentgenogram after 7 days showed almost complete regression of the mediastinal tumor (Fig 1B), and the patient was discharged from hospital the same day without any symptoms.
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Fig 3. Computed tomographic scan of the chest on day 3 after admission shows comprehensive reduction of the mediastinal mass.
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Comment
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We assume this cystic, mediastinal tumor to be a mucocele of a colonic bypass 30 years after operation for esophageal stricture.
Esophageal bypass is commonly performed in patients with malignant or benign strictures of the esophagus. The purpose of the procedure is to restore the ability to swallow. As a result of this operation, the bypassed esophagus is excluded sometimes from the gastrointestinal system either only at the proximal end or at both ends [1]. A possible complication of this technique is the formation of a mucocele. This phenomenon was studied in a dog model, which suggested that the mucocele of the excluded esophagus remains small and has no clinical relevance [2]. A clinical study with 38 patients after surgical exclusion of the esophagus demonstrated mucoceles in 20 of them, 19 of which were small and asymptomatic [1]. Clinical reports about formation of symptomatic mucoceles are rare. Symptoms include chest pain [3, 4] abdominal pain and vomiting [5], respiratory distress [4], and fever and sepsis [6]. Moreover, there is no clear concept for the therapy of this infrequent complication. Kamath and colleagues [4] recommended surgical resection as soon as the patient becomes symptomatic. Other reports suggest drainage [6] or conservative treatment which can result in spontaneous regression [3].
Different from all reports of symptomatic mucocele, the patient reported here had no excluded esophagus, which was validated by endoscopy. There was, rather, a mucocele of the colonic bypass, indicating that the bypass had never worked properly and that the patient’s symptoms 30 years ago had subsided spontaneously.
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References
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- Mannell A., Epstein B. Exclusion of the oesophagus: is this a dangerous manoeuvre?. Br J Surg 1984;71(6):442-445.[Medline]
- Deaton W.R., Bradshaw H.H. The fate of an isolated segment of the esophagus. J Thorac Surg 1952;23:570-574.
- Van Gelderen W.F. Mucocele of the surgically isolated esophagus. Abdom Imaging 1993;18(1):13-14.[Medline]
- Kamath M.V., Ellison R.G., Rubin J.W., Moore H.V., Pai G.P. Esophageal mucocele: a complication of blind loop esophagus. Ann Thorac Surg 1987;43(3):263-269.[Abstract]
- Erasmus J.J., McAdams H.P., Goodman P.C. Diagnosis please. Case 5: esophageal mucocele after surgical bypass of the esophagus. Radiology 1998;209(3):757-760.[Free Full Text]
- Olsen C.O., Hopkins R.A., Postlethwait R.W. Management of an infected mucocele occurring in a bypassed excluded esophageal segment. Ann Thorac Surg 1985;40(1):73-75.[Abstract]
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Abstract
Introduction
