CASE 14195 Published on 27.11.2016

A rare complication of esophagectomy

Section

Chest imaging

Case Type

Clinical Cases

Authors

Logeswaran Selvarajah, Derek G Power

Mercy University Hospital Cork, Ireland; Email:logesselva@gmail.com
Patient

45 years, female

Categories
Area of Interest Lung, Thorax ; Imaging Technique CT, Ultrasound
Clinical History
Our 45-year-old patient had a history of minimally invasive esophagectomy for localized cancer after neoadjuvant chemoradiation. Three years later, she presented with a one-week history of shortness of breath and cough. A retrospective review of case notes revealed multiple recent visits with abdominal pain and dyspeptic symptoms.
Imaging Findings
Chest x-ray revealed an apparent left pleural effusion (Panel A) and a thoracocentesis was planned. However, pre-procedural lung ultrasound showed absence of an effusion. A CT Thorax then confirmed herniation of small bowel and colon into the hemithorax suggesting a diaphragmatic hernia (Panel C & D).
Discussion
Early esophageal carcinoma is increasingly detected with active and robust endoscopic surveillance for Barrett's esophagus. Curative management for localized esophageal carcinoma is surgical resection via open or minimally invasive procedures[1]. Minimally invasive surgery remains the preferred technique due to fewer post operative complications. However, the incidence of post procedural diaphragmatic hernia, a rare complication, is observed to be higher in the minimally invasive group compared to open surgery [2]. Diaphragmatic hernias are characterized by herniation of abdominal contents namely small bowel and colon into the thoracic cavity through a diaphragmatic defect. Clinical symptoms range from being asymptomatic to dyspeptic symptoms or florid respiratory failure [3].

Chest radiography could effectively clinch the diagnosis, however, diagnostic dilemmas do occur as with our case. Her previous history of esophageal cancer coupled with a chest X-ray suggesting a pleural effusion led to a presumed diagnosis of malignant effusion secondary to recurrence of primary neoplastic disease. Though a sensible oncological differential, a diagnosis of diaphragmatic hernia should always be suspected in any patients with previous esophagectomy. The commonest time frame for occurrence of this post operative complication is 2 years, relatively similar to our case [3]. A pre-procedural (thoracocentesis) lung ultrasound provided valuable diagnostic information in showing only trace pleural effusion. This necessitated a CT Thorax to further investigate the initial findings on the presenting chest X-ray which confirmed the diagnosis demonstrating multiple bowel loops in the hemithorax displacing the left lung. Our patient underwent a laparoscopic diaphragmatic hernia repair and made an unremarkable recovery.

The utilization of radiography and ultrasound in making an accurate diagnosis and computed tomography in both confirming and planning for surgery yielded an optimal outcome for our patient. Our case highlights the importance of combined multimodal imaging and clinical suspicion in addressing diagnostically challenging scenarios.
Differential Diagnosis List
Acquired diaphragmatic hernia secondary to previous minimally invasive esophagectomy.
Recurrence of primary disease with malignant effusion (initial)
Diaphragmatic rupture
Final Diagnosis
Acquired diaphragmatic hernia secondary to previous minimally invasive esophagectomy.
Case information
URL: https://www.eurorad.org/case/14195
DOI: 10.1594/EURORAD/CASE.14195
ISSN: 1563-4086
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