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Esophageal perforations: one is bad, two is worse
  1. Dustin Price,
  2. David Skarupa
  1. Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
  1. Correspondence to DrDustinPrice, Surgery, University of Florida College of Medicine, Jacksonville, FL 32610, USA; drprice10{at}gmail.com

Footnotes

  • Contributors DP and DS are the sole contributors of this submission.

  • Funding The authors have not declared a specific grant for this research from anyfunding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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Choice B

The esophageal stent was removed and a right VATS was performed. A 24-French T-tube was placed in the inferior mid-EP and externalized. The pleural space was irrigated and widely drained (figure 2). A re-exploration of his abdomen was performed and an 18-French Stamm gastrojejunostomy tube was placed. We attempted to mobilize his gastroesophageal junction for proximal gastric exclusion; however, adhesions from his recent exploratory laparotomy precluded adequate mobilization. The following day, a left thoracotomy was performed and a 24-French T-tube was placed in the lower thoracic EP just proximal to the gastroesophageal junction. The T-tube was secured to the diaphragm, externalized through the left chest, and the pleural space was irrigated and widely drained (figure 3). Intraoperative cultures of the pleural fluid grew Candida albicans, C. glabrata, and Serratia liquefaciens, which were treated with broad-spectrum intravenous antibiotic and antifungal therapy. A complicated postoperative course ensued, including reintubation, fluctuating vasopressor requirements, and development of a subsegmental pulmonary embolism requiring anticoagulation therapy. He developed an acute right hemothorax requiring packed red blood cell transfusion on hospital day 32. Additionally, he became more fatigued and frustrated with his oscillating clinical course and requested no further resuscitative efforts. He died on hospital day 35 after initiating comfort care measures.

Figure 2

Intraoperative photograph demonstrating the T-tube within the right mid-thoracic esophageal perforation (white arrow). The left-sided perforation was of similar size, quality and configuration.

Figure 3

Postoperative chest X-ray demonstrating the right T-tube (red) and left T-tube (blue), and widely drained bilateral pleura spaces.

Our case demonstrates an atypical and uncommon presentation of two distal EP/fistulas of uncertain etiology and chronicity. The patient presented with significant weight loss (>20lbs, BMI 17 kg/m2) with evidence of malnutrition and recent EGD with several biopsies. Pathology from these biopsies did not reveal an explanation for the development of the EP/fistulas and it is unclear if the biopsy procedures themselves contributed to the esophageal injuries. Treatment algorithms for EP classically vary depending on chronicity with management of acute perforations favoring primary repair and chronic perforations managed through wide drainage of the pleural cavity. Treatment often includes a multimodal and multidisciplinary approach including surgeons, advanced endoscopists and intensivists. Esophageal stenting has become more widely utilized and is often an initial modality in the modern era for both acute and chronic perforations, providing a minimally invasive means of management with the intent of improved morbidity compared to surgical management. However, as demonstrated by our case, there is still a role for surgical management of EP, whether for salvage of failed stent therapy or as initial management. Despite the array of treatment options, morbidity and mortality from EP remains high and these patients often require prolonged organ support in an intensive care setting. An EP can present a significant clinical challenge, and an even larger challenge when more than one perforation exists.

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Footnotes

  • Contributors DP and DS are the sole contributors of this submission.

  • Funding The authors have not declared a specific grant for this research from anyfunding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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