Hospital: Hospital Universitario Ramón y Cajal.
Aut@r o Autores: F. González Tello, J. Montilla López-Gay, C. Campos Ferrer, N. Almeida Arostegui, M. Vicente Redondo, B. Lumbreras Fernández.
A 57-year-old male, on his fourteenth post-surgery day after total esophagectomy with gastric plasty, shows clinical deterioration, with significant dyspnea, elevation of acute phase reactants in blood and amylase in pleural fluid (where St. Anginosus is grown), requiring intubation and vasoactive drugs in the last hours. A chest CT is requested that describes the following findings: immediately cranial to the diaphragmatic crura, in the anterior aspect of the gastric plasty, there is a continuity defect of about 4 mm. Adjacent to this one, extraluminal air is visualized that continues with the left pleural cavity, where there is hydropneumothorax. In agreement with these findings, extravasation of the oral contrast in pleural cavity is identified. Findings compatible with entero (gastric) - pleural fistula probably related to dehiscence of the anastomosis.
Entero-pleural fistula is a rare complication that can develop after esophagectomy surgery due to suture dehiscence, which is associated with high mortality. The availability of diagnostic methods is essential, such as endoscopy, gastric transit with fluoroscopy or a CT with oral contrast. The last one is a useful method, allowing the demonstration of contrast leakage, or even the presence of air / collections mediastinal/pleural. Some studies suggest a diagnostic performance superior to conventional fluoroscopic transit.
Sophisticated surgical procedures for esophagectomy cause significant intrathoracic anatomical changes and may confuse image interpretation. The radiologist must understand these changes and be familiar with them to ensure accurate assessment and identify possible complications. Entero-pleural fistula due to dehiscence of the anastomosis is one of these complications and a CT with oral contrast is one of the best methods for its detection.
-Strauss C, Mal F, Perniceri T, Bouzar N, Lenoir S, Gayet B, Palau R. Computed tomography versus water-soluble contrast swallow in the detection of intrathoracic anastomotic leak complicating esophagogastrectomy (Ivor Lewis). A prospective study in 97 pat