Ann Thorac Surg 2007;84:651-652
© 2007 The Society of Thoracic Surgeons
Case Reports
Fecopneumothorax: A Rare Complication of Esophagectomy
Haridimos Markogiannakis, MD*,
Dimitrios Theodorou, MD, PhD,
Dimitrios Tzertzemelis, MD,
Dimitrios Dardamanis, MD,
Konstantinos G. Toutouzas, MD, PhD,
Panagiotis Misthos, MD, PhD,
Stilianos Katsaragakis, MD, PhD
First Department of Propaedeutic Surgery, Hippokrateion Hospital, Athens Medical School, University of Athens, Athens, Greece
Accepted for publication March 6, 2007.
* Address correspondence to Dr Markogiannakis, Aristeidou 239 St, Athens, Kallithea, 17673, Greece (Email: markogiannakis{at}easy.com).
 |
Abstract
|
|---|
Intrathoracic colon herniation after esophagectomy is rare. Furthermore, fecopneumothorax is an extremely infrequent clinical entity. We believe this is the first report in the literature of a patient with fecopneumothorax due to diverticular perforation of intrathoracically herniated transverse colon 2 months after transthoracic esophagectomy and cervical esophagogastric anastomosis. The relative literature addressing cause, clinical presentation, diagnosis, management, and prevention of this life-threatening complication of esophagectomy is reviewed.
|
Introduction
|
|---|
Intrathoracic colon herniation usually occurs in patients with congenital or acquired diaphragmatic hernias; however, such herniation after esophagectomy is rare. Moreover, fecopneumothorax is an infrequent clinical entity. A case of fecopneumothorax due to diverticular perforation of intrathoracically herniated transverse colon 2 months after transthoracic esophagectomy and cervical esophagogastric anastomosis is presented, which we believe is the first reported in the literature. The relative literature regarding cause, predisposing factors, clinical presentation, diagnosis, management, and prevention of this extremely rare, life-threatening complication of esophagectomy is reviewed.
A 62-year-old man with a history of aortic valve replacement and diverticulosis of the transverse, descending, and sigmoid colon was admitted due to an adenocarcinoma of the lower esophageal third. An en block esophagectomy with two field lymph node dissection and cervical esophagogastric anastomosis was performed. No lymph node or distant metastasis was identified. After an uneventful recovery, the patient was discharged on postoperative day 13. Postoperative chemotherapy was initiated.
Two months after the operation, the patient presented with fever and left chest pain. Clinical examination revealed tachycardia and diminished respiratory sounds in the left hemithorax. Leukocytosis and metabolic acidosis were also identified. Chest roentgenogram showed multiple air-fluid levels in the left pleural cavity (Fig 1). An upper gastrointestinal study with Gastrografin was normal. A chest computed tomographic scan demonstrated pneumothorax and colon herniation into the left hemithorax (Fig 2), whereas the patient’s abdominal computed tomographic scan was normal. Exploratory laparotomy revealed intrathoracic transhiatal herniation of the left segment of the transverse colon. The herniated bowel was reduced into the abdomen; a small colonic segment was found to be ischemic and perforated in the location of a diverticulum. After a left hemicolectomy, transverse-sigmoid anastomosis, and cruroplasty with suturing of the gastric tube to the crura, a left posterolateral thoracotomy was performed that revealed gross fecal contamination in the thorax. Meticulous lavage of the pleural cavity was performed and two chest drains were inserted. Histopathologic evaluation confirmed the presence of colonic diverticula, one of which had sustained perforation. The patient had an uneventful recovery and was discharged on postoperative day 15.
View larger version (117K):
[in this window]
[in a new window]
|
Fig 2. Chest computed tomographic scan demonstrated pneumothorax (white arrow) and herniation of the large bowel (black arrow) into the left hemithorax (black arrowhead: gastric neoesophagus).
|
|
|
Comment
|
|---|
Intrathoracic colon herniation usually occurs in patients with congenital or acquired diaphragmatic hernias such as Bochdalek, Morgagni-Larrey, hiatal, and traumatic hernias. Although most congenital hernias are diagnosed in neonates or children, they are rarely identified in adults. Congenital and acquired hernias are usually asymptomatic and are often found incidentally on chest roentgenogram. However, when symptomatic, hernias containing colon can present with symptoms of obstruction or strangulation. Strangulation may lead to necrosis and perforation, which in turn can result in fecopneumothorax such as in the presented case. The presence of diverticula in the herniated transverse colon in our patient may have predisposed perforation.
However, intrathoracic colon herniation after esophagectomy is rare. It has been described in only 17 reports, including a total of 32 patients [1–3]. It is of note, though, that none of these patients sustained colonic perforation and fecopneumothorax. Patients may be asymptomatic or present with variable symptoms. This complication can occur in the early or late postoperative period, in both transhiatal and transthoracic esophagectomies performed either by open or laparoscopic and thoracoscopic technique, and it is considered to be attributable to excessive hiatal manipulation and extension during esophagectomy [1–3]. In an analysis of predisposing factors, post-esophagectomy hernia formation was associated with extended hiatal enlargement due to excessive incision and partial resection of the crura [1].
Among 20 reported adult patients who had a Bochdalek hernia with intrathoracic colon herniation, perforation occurred in 6. Two of these patients presented with pneumothorax, whereas 4 sustained fecopneumothorax. Colon perforation was spontaneous in all cases apart from one that was caused by chest tube placement [4]. Although there have been approximately 160 reported cases of intrathoracic colon herniation attributable to traumatic diaphragmatic hernias, only 12 suffered from fecopneumothorax [5]. In addition, no fecopneumothorax has been described among 52 adult patients with intrathoracic colon herniation due to a Morgagni-Larrey hernia. Moreover, 49 cases of intrathoracic transhiatal colonic herniation in patients with hiatal hernias have been reported; however, perforation or fecopneumothorax has not been reported in any case.
Intrathoracic colon herniation and particularly, fecopneumothorax are very infrequent but life-threatening complications of esophagectomy. They present a diagnostic challenge and delayed management can lead to increased morbidity and mortality. Therefore, a high index of suspicion is necessary while careful evaluation of the findings from clinical examination, chest and abdominal roentgenograms and computed tomographic scans, along with gastrointestinal tract contrast studies are essential for early and prompt diagnosis leading to appropriate management. Surgical treatment should be immediately performed as soon as the diagnosis is established. To prevent this complication of esophagectomy, extended hiatal enlargement should be avoided, and in cases in which such enlargement is necessary, narrowing of the diaphragmatic opening with suturing of the hiatal crura to the gastric tube is advocated.
|
References
|
|---|
- van Sandick JW, Knegjens JL, van Lanschot JJ, Obertop H. Diaphragmatic herniation following oesophagectomy Br J Surg 1999;86:109-112.[Medline]
- Cordero Jr JA, Moores DW. Thoracic herniation of the transverse colon after transhiatal esophagectomy J Thorac Cardiovasc Surg 2000;120:416.[Free Full Text]
- Heitmiller RF, Gillinov AM, Jones B. Transhiatal herniation of colon after esophagectomy and gastric pull-up Ann Thorac Surg 1997;63:554-556.[Abstract/Free Full Text]
- Chai Y, Zhang G, Shen G. Adult Bochdalek hernia complicated with a perforated colon J Thorac Cardiovasc Surg 2005;130:1729-1730.[Free Full Text]
- Seelig MH, Klingler PJ, Schönleben K. Tension fecopneumothorax due to colonic perforation in a diaphragmatic hernia Chest 1999;115:288-291.[Medline]
Top
Abstract
Introduction
