A 71-year-old male with a history of alcoholism and radiation treatment (total dose of 57.6 Gy) for early-stage vocal cord cancer 16 months earlier was referred to us with radiographic detection of a pulmonary nodule in the right lower lobe. Endobronchial biopsy of the pulmonary nodule revealed the diagnosis of squamous cell carcinoma. Positron emission tomography/computed tomography (CT) revealed accumulation in the pulmonary nodule, but no other lesion was suggestive of metastasis. The tumor was diagnosed as a primary lung cancer, clinical stage IA1 (T1aN0M0), or metastatic pulmonary tumor, and video-assisted thoracoscopic right lower lobectomy with lymph node dissection was performed. Level 8 and 9 lymph nodes were not enlarged; therefore, lymph node dissection of these nodal station was not performed (Fig. 1a), while the level 7 lymph nodes were dissected. There was no direct injury of the esophagus, and no apparent esophageal damage was visualized on magnified video endoscopic images (Fig. 1b). The operation was uneventful. The patient was able to resume oral intake from the day after the surgery.
The patient tended to need to make a strong effort to cough, with swallowing and expectoration having become difficult, presumably due to the radiation therapy given to the larynx. Three days after the operation, the patient developed severe sudden pain in the right shoulder with high fever (39.6 °C). Findings of the chest X-ray obtained with a portable apparatus showed a few infiltrative shadows in the right lung field, and blood examination revealed no findings that were not compatible with the postoperative status of the patient. The patient was started on intravenous antibiotic administration. Absence of air leakage through the chest tube was confirmed, and the chest tube was removed 4 days after the operation. However, a plain chest X-ray revealed increased infiltrative opacities in the right lung field, and the patient developed a right pneumothorax 5 days after the operation. A chest tube was re-inserted into the right pleural cavity. Sputum mixed with a small amount of blood and cloudiness of the discharge from the right chest tube was confirmed 7 days after the operation. Chest CT showed a marked increase in the size of the right pleural effusion, with air bubbles visualized within the opacity. Although suture failure at the bronchial stump could not be confirmed by bronchoscopy, empyema due to BPF was suspected at first, and open-window thoracostomy (OWT) of the right chest was performed.
Two days after the OWT, contamination of the dressing by food particles was confirmed. An esophagogram revealed communication between the lower portion of the esophagus and the right thoracic cavity (Fig. 2a). An upper gastrointestinal endoscopic examination also showed a tiny orifice in the lower portion of the esophagus (Fig. 2b). A nasal W-ED tube™ (Nippon Covidiene Inc., Tokyo, Japan) for simultaneous gastric compression and jejunal alimentation was inserted under endoscopic guidance into the jejunum, and oral intake was totally prohibited.
Dressing changes twice daily were continued, until culture of the thoracic drainage fluid no longer grew pathogens. Omentopexy was performed 20 days after the OWT. A small longitudinal tear, about 1.5 cm in length, was identified in the lower portion of the esophagus (Fig. 3a), below the inferior pulmonary vein stump. No pulmonary fistula formation with esophagus or any BPF was identified. Although the edge of the tear was comparatively clear, the omental pedicle flap (OPF) was sutured around the tear without direct suture, because several days had elapsed after the onset of the esophageal rupture (Fig. 3b). Two thoracic drainage tubes were inserted into the thoracic cavity and the wound was finally closed. The postoperative course was uneventful. An esophagogram obtained 7 weeks after the omentopexy showed no leakage of contrast medium through the esophageal wall (Fig. 4a). The patient was discharged 13 weeks after the operation. A chest CT performed 5 months after the operation revealed complete healing of the EPF and resolution of the empyema of the right thoracic cavity (Fig. 4b).