Asian Cardiovasc Thorac Ann 2003;11:344-345
© 2003 Asia Publishing EXchange Ltd
Esophagopleural Fistula Following Spontaneous Rupture of Traction Diverticulum
Vijay Agarwal, MCh,
Sushil Kumar Singh, MCh,
Mohd Salman Siddiqi, MS,
Lalit Mohan Joshi, MS,
Shekhar Tandon, MCh
Department of Thoracic and Cardiovascular Surgery, King George Medical College and Hospital, Lucknow, India
For reprint information contact: Shekhar Tandon, MCh Tel: 91 0522 257480 Ext 241 Fax: 91 0522 457935 email: tanishq26{at}yahoo.com Department of Thoracic and Cardiovascular Surgery, King George Medical College and Hospital, Lucknow 226003, India.
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ABSTRACT
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A rare case of esophagopleural fistula following spontaneous rupture of a traction diverticulum of the esophagus in a 25-year-old man was successfully treated by diverticulectomy.
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INTRODUCTION
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Esophageal diverticula are considered to be rare.1 Acquired diverticula can be classified as pulsion or traction, according to the mechanism of formation.1 Traction diverticula are almost unknown in the western literature.2 Esophagopleural fistula due to a pulsion or traction diverticulum is unusual and occurs mainly after pneumonectomy.3
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CASE REPORT
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A 25-year-old man presented with gradual onset of breathlessness and fever of 1-month duration. Clinical examination showed decreased air entry on the right side. Chest radiography revealed fluid collection in the right pleural cavity with collapse of the right lung and a mediastinal shift. The pleural cavity was aspirated, revealing pus. A chest tube drain was inserted, which relieved the symptoms. Antitubercular medication was started on confirmation of a diagnosis of tuberculosis. However, after 1 week, the patient noticed food particles in the drain. An esophagogram showed a traction diverticulum in the mid esophageal region, with a broad mouth. Dye leaked into the right pleural cavity along the border of the collapsed right lung (Figure 1
), indicating an esophagopleural fistula. Esophagoscopy was performed to exclude distal obstruction; the mouth of the diverticulum showed mild inflammation. A biopsy excluded esophageal malignancy. A right posterolateral thoracotomy was carried out through the bed of the fifth rib, and decortication of the right lung was undertaken. The area around the diverticulum was densely scarred with adhesions. After performing a diverticulectomy, an intercostal pedicled muscle flap was sutured over the esophagus. The patient made an uneventful recovery and was discharged after 2 weeks, on antitubercular medication. He was free of symptoms at the 1-year follow-up.
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Figure 1. Preoperative esophagogram showing a traction diverticulum of the mid esophagus (arrow) and dye leaking into the right pleural cavity along the border of the collapsed right lung. A chest tube was in situ to drain the pleural cavity.
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DISCUSSION
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Of the two acquired diverticula, pulsion diverticula occur as a result of pressure that leads to mucosal herniation at a weak point in the esophagus. They are associated with motility disorders of the esophagus.4,5 A traction diverticulum results from periesophageal adhesions from diseased bronchial lymph nodes, mainly due to tuberculosis, which form a conical broad-based bulge.6 Less than 10% of esophageal diverticula are symptomatic, and complications in the form of esophagopleural fistula are rare.1 Tubercular empyema is not uncommon, but that arising from a ruptured traction diverticulum is a very unusual occurrence. Esophagopleural fistula can result from operative injury, mediastinal cancer, or a chronic infection; the incidence following pneumonectomy is reported to be between 0.50% and 0.65%.7 Massard and colleagues7 reported 8 cases of esophagopleural fistula of which 7 were postpneumonectomy for lung cancer, the other was due to pulmonary tuberculosis and developed 25 years after septic tubercular recurrence.
In our patient, there was no history of chest surgery and the primary presentation was spontaneous rupture of a traction diverticulum into the right pleural cavity, with no underlying malignancy of the lung or esophagus. Spontaneous rupture of an esophageal diverticulum is known to occur, and bronchoesophageal fistula has been described, but we could not find any previous reports of rupture of a traction diverticulum into the pleural cavity.6,8 The surgical options for treating esophageal diverticula are esophagomyotomy with diverticulectomy for pulsion diverticulum, and diverticulectomy or diverticulopexy for traction diverticula.8 We performed the operation after excluding distal obstruction of the esophagus or malignancy, as these factors may lead to failure of the procedure. After diverticulectomy, intercostal pedicled muscle flap reinforcement was carried out to aid healing of the esophageal wound, along with decortication of the right lung. Although traction diverticula are rare in the western world, they are more common in countries where tuberculosis is still prevalent. This case highlights the potential for a traction diverticulum to develop into an esophagopleural fistula.
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REFERENCES
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ABSTRACT
INTRODUCTION
