Esophageal Leak
Patient presentation:
C.B. is a 58 yr old male with lung cancer post resection. He had neoadjuvant chemotherapy and radiation therapy and then surgical resection of the esophagus with an esophagogastrectomy and feeding J-tube. He was discharged on a regular diet and went home. He was readmitted to hospital one month later and found to have a right lower lobe pneumonia and effusion. Thoracentesis was performed and a pigtail catheter was placed but later removed. In addition the patient also had chronic diarrhea. He underwent a bronchoscopy for hemoptysis with no active bleed found but cultures positive for Klebsiella and Candida. Subsequently, patient presented with concern for esophageal leak. Patient’s past medical history includes: asthma, COPD, pneumonia, h/o lung cancer, type 2 diabetes, irritable bowel syndrome, anemia, atrial fibrillation
Labs:
BMP: Na+ 138, K+ 3.8, Ca++ 7.0, Mg++ 1.8, Phos 4.2, BUN 19, Creatinine 0.79
CBC: WBC 21.6, RBC 2.88, Hgb 8.9, Hct 27.6, Plt 142
Treatment:
Pt admitted to SICU for aspiration pneumonia and empyema which leaked into his anastomosis; he underwent placement of a right chest tube for treatment of esophageal anastomotic leak s/p esophagectomy with esophagogastrostomy and right empyema. He then had an esophageal stent placed; during placement of the stent, patient had large amounts of purulent secretions from airway accompanied by oxygen desaturation requiring intubation. Due to the findings of purulent drainage and chest tube not having any drainage over 24 hours, the patient was taken back to the OR for debridement and decortication of right lower lobe abscess and placed on IV antibiotics
Diagnosis:
aspiration pneumonia secondary to esophageal leak
Outcome:
Patient required 2 months in ICU. During that time patient underwent multiple bronchoscopies due to purulent drainage in right lower lobe of lung and had several chest tubes placed due to the purulent secretions and formation of abscess cavity in right lower lobe of lung, thus the patient had a right thoracotomy and decortication.
Case created by Cristin Bowman, 2012.