A case of acute dyspnoea after subtotal Ivor Lewis oesophagectomy

A 72-year-old male patient underwent subtotal Ivor Lewis oesophagectomy with gastric conduit for oesophageal tumour (T2/N0/M0) of the middle third of the oesophagus. Two weeks after surgery the patient presented with sudden dyspnoea and fever, associated with gasping and absence of vesicular breath sounds in the right hemithorax.

The immediate postoperative course was unremarkable. The routine fluoroscopic examination performed in standing position on the 6th day after surgery, before refeeding, did not show any leak (Fig. 1). After the onset of dyspnoea and fever, mechanic ventilation, septic protocol, and chest X-ray were immediately performed. Chest X-ray showed diffuse hypolucency of the right hemithorax (Fig. 2). The endoscopic examination failed to demonstrate any leak and CT was performed on the same day. CT examination included unenhanced and intravenous contrast-enhanced scans (Figs 3,4). A scan with iodinated oral contrast medium (diatrizoate meglumine diluted 1/3, Fig. 5) was acquired later, due to initial technical difficulties in positioning the NG tube. The CT findings allowed to reach the diagnosis of hydro-pneumothorax due to an anastomotic leak and oesophago-pleural fistula. The patient was immediately transferred to surgery where he underwent gastric conduit resection and cervical oesophagostomy.

Background: Oesophagectomy is used to treat several oesophageal diseases, mostly oesophageal cancer. The most common surgical techniques are transthoracic oesophagectomies, such as the Ivor Lewis and McKeown techniques, and transhiatal oesophagectomy.  These techniques include different choices of replacing conduit (i.e. stomach, colon). [1] The possible post-surgical complications are leakage, stricture, delayed emptying or dumping syndrome. [1] In particular, leaks have been reported to occur in 10-44% and mostly within the first 10 days after surgery. [1] They are caused by poor tissue apposition or infarcted tissue. [1]

Clinical perspective: A post-oesophagectomy leak may be asymptomatic if small, otherwise it may lead to respiratory problems and unstable haemodynamics. [1] Clinical presentations may vary according to the defect's size, the way the leak is contained or drained, and the degree of the associated sepsis. [2]  Patients with oesophageal anastomotic leak have a 3 times higher death risk than patients without this complication. [2]  

Imaging perspective: Fluoroscopic imaging with either water-soluble contrast alone or followed by barium sulphate is routinely performed to rule out an anastomotic leak in the post-operative period, before the time of refeeding. [1] A leak is demonstrated by the presence of extraluminal contrast. Both fluoroscopic imaging and CT scanning with oral contrast have high specificity (98%) in detecting anastomotic leaks. However, the high negative predictive value (97%) and the trend toward greater sensitivity of CT suggest its role in ruling out anastomotic leak. [3]^, Moreover, CT is often the favoured examination since it also allows the elimination of other causes of sepsis (such as pulmonary complications). [2] On CT, a leak is demonstrated by the presence of extraluminal contrast, mediastinal fluid, and gas collections [1,3] although small volumes of fluid and gas can be normal findings in the early postoperative period. It should be noted, however, that there is a general lack of consensus with great discrepancies existing ­­­in imaging diagnosis, management, and survival.

Therapeutic options: In case of sepsis, patients should be immediately transferred to intensive care for resuscitation and antimicrobial therapy. Surgical or radiological drainage is needed, and, in the case of underlying necrosis, immediate re-intervention is required with gastric conduit resection and oesophagostomy. [2]

Written informed patient consent for publication has been obtained.