Penetrating Iniury of the Chest and Coronary Arteriovenous Fistula *
Preoperative
Dfpa1c K. Mu1cherfee, M.D.;- - VillI/a s. Banka, M.D., F.C.C.P.t; Narong Ke08athit, M.D.;t and
RlchGrd H. Hellant, M.D., F.C.C.P.§
PCG
An u ....... C8Ie of coroD&ry artery fistula, due to a stab woDDd In the chest In a 17-year-old male patient, with a resultant acute inferior myocardJai Infarction is preIented. At lDI1ery, complete transection of the right corOD&ry artery W8S found, wblch formed a ftstuIous comm"eatloD with both tile right atrium and the right ventrlde. The development of a contlDuo. murmur In the period lmmedl8tely lifter the bajury, the "'aee of hemoperlc8nllam, ud multiple canIiac-ehamber bavolvements were UDlque features of the case. The inferior myocardial willi W81 akinetic due to Infarction aDd did not Improve 1000"'" ~~tlon surgery. A brief review of the Uteratare II also presented.
4th Rt. ICS
C
4th Rt.
oronary arteriovenous fistula secondary to penetrating injury to the chest is relatively rare, and comparatively few case reports have been published. I - IO The reason for such rarity may be that penetrating injury to the heart is usually fatal due to assOciated exsanguination, hemopericardium with cardiac tamponade, and various acute intracardiac shunts, as well as laceration of the major coronary arteries. I ,2,e,10,11 We report here a unique case of traumatic coronary arteriove~ous fistula due to a stab injury to the chest which caused a complete transection of the right coronary artery and fonned a fistulous track through the atrioventricular groove into the right atrium and the right ventricle with associated acute inferior wall myocardial infarction.
CASEREroRT A 17-year-old blade male patient was admitted to a Philadelphia hospital in shock after a stab injury to his chest over the right third intercostal space outside the sternal edge. A chest tube was inserted to drain the hemothorax. Two days later, the patient developed a new episode of persistent severe chest pain and shortness of breath. A continuous munnur was heard for the first time over the site of the stab wound at the sternal edge. An electrocardiogram showed an acute inferior and possible posterior wall myocardial infarction. The patient received digitalis and was transferred one week later to Presbyterian-University of Pennsylvania Medical Center, Philadelphia, where physical examination on admission showed a regular and bounding pulse of 84 beats per minute and blood pressure of 140/60 mm "g. Jugular -From the School of Medicine, University of Pennsylvania, and Presbyterian-University of Pennsylvania Medical Center Philadelphia. - - Fe&w; Division of Cardiology. t Assistant Professor of Medicine and Director, Cardiac Catheterization Laboratory. tDepartment of Thoracic and Cardiovascular Surgery. §Associate Professor of Clinical Medicine and Chief, Division of Cardiology. R~rint requem: Dr. Hellant,51 North 39th Street, Philadelphia 19104
CHEST 69: 6, JUNE, 1976 f
PeG 4th Rt. ICS Postoperative
ECG
-Jv- _t t:wt~" '-~' '- '~- -_dii4w:&~-- ',
PCG
PCG
4th Rt.
ICS-.,.·.~""-~",,,,,-,,,,,,,,,,,,,,,,,,,,,,,~,,,,,,,-
" ICS--+:r~1
.....- ...'.....- ...........
a'\J
IA (upper panel). Preoperative phonocardiogram (PCG, frequency range, 120 to 250 Hz and 70 to 150 Hz) with simultaneous recording of electrocardiographic lead 2 and carotid pulse tracing, showing continuous murmur at right fourth intercostal space (ICS) with systolic and diastolic accentuation partially obscuring first and second heart sounds. IB (lower panel). Postoperative phonocardiogram with simultaneous electrocardiographic tracing and carotid pulse tracing ( CT) showing disappearance of murmur. First (SI) and second (S2) heart sounds are now well depicted. P2, Pulmonic second sound, A2' aortic second sound. FICURE
venous pressure was normal. The lungs were clear. A I-in X ~ in healed scar was seen in the third intercostal space at the right sternal edge. The point of maximal impulse was located 9 em from the left sternal edge in the fifth intercostal space. A systolic thrill was palpable at the right sternal border maximally over the scar. The .first and second heart sounds were normal at the apex. A continuous murmur with systolic and diastolic accentuation obscuring. the first and second heart sounds was localized over the scar, with poor radiation. The liver and the spleen were not enlarged, and there was no peripheral edema. Laboratory findings, including cardiac enzyme levels, were within normal limits. An ECG showed acute inferior and possible posterior wall myocardial infarction. An x-ray film of the chest showed normal cardiac size with slight pleural effusion on the right side. A phonocardiogram revealed a continuous munnur obscuring the first and second heart sounds at the right fourth intercostal space (Fig lA). Cardiac catheterization performed one week later revealed no diagnostic oxygen step-up at the right atrial, ventricular, or the pulmonary arterial level. A dye-dilution curve (indocyanine green. injected into pulmonary artery and sampled from aorta) revealed an early recirculation pattern. Meglumine diatrizoate (Renografin-76) injected into the aortic root
PENmATING INJURY OF CHEST 793
FIGURE 2A (left). Preoperative arteriogram (left anterior oblique view) with contrast material injected into aOrtic root, showing dilated right coronary artery fistula opening into right atrium and right ventricle. 2B (right). Postoperative arteriogram (left anterior oblique view) with selective injection of contrast material into right coronary artery, showing entire vessel with portion of saphenous-vein graft interposed between proximal and distal segments.
showed a dilated right coronary artery forming a fistulous track through the atrioventricular groove into the right ventricle and the right atrium (Fig 2A). The calculated pulmonary-ta-systemic How ratio was 1.3: 1. The left ventriculogram exhibited akinesia of the inferior wall. Three weeks later, open-heart surgery was perfonned. The right coronary artery was seen to be completely transeeted above the level of the acute margin, with its proximal portion forming a fistulous track into the atrioventricular groove, communicating separately with the right ventricle and the right atrium. The tricuspid valve and annulus were not involved, and there was no tricuspid insufficiency. The fistula was excised, and a saphenous-vein graft was placed between the proximal and the distal end of the transeeted artery. After surgery the patient recovered uneventfully, and the murmur disappeared. Cardiac catheterization repeated three weeks later revealed no shunt. The right coronary artery was visualized throughout its course {Fig 2B). On a ventriculogram the akinetic segment of the inferior wall was unchaDged. The postoperative phonocardiogram confirmed the disappearance of the continuous murmur (Fig IB). The ECG remained unchanged. DISCUSSION
The present case is unique in several respects. First, the patient survived despite complete transection of the right coronary artery, although he became quite symptomatic with chest pain and congestive heart failure. Secondly, cardiac tamponade did not occur following the injury, and no evidence of hemopericardium was observed at surgery. It was noteworthy that the arteriovenous fistula in this patient developed soon after the injury, as evidenced by the development of a continuous murmur for the first time on the third day after admission. This is in contrast to most of the published reports of coronary arteriovenous fistula, as well as the observation by Anderson et al, 2 and indicates that the fistula can develop in the period immediately after the injury. Furthermore, the fistulous track communicated with
794 MUKHERJEE ET At
both the right ventricle and right atrium in the present patient. This has not been previously docwnented with a stab injury. Nine of the 11 previously reported cases of traumatic coronary arteriovenous fistula were caused by a bullet or other missile injury. The present case and only two other case reports were due to stab wounds. Most reported cases have had a fistulous track between the right c0ronary artery and the right atrium. The need for early diagnosis and therapy in cases of coronary arteriovenous fistula has been emphasized in previous reports in order to prevent complications of bacterial endocarditis, cardiac failure, rupture of an aneurysmally dilated vessel, and myocardial infarction. 2 -11.10 As a diagnostic point, coronary arteriovenous fistula should be a major consideration in patients with penetrating chest injury who develop a continuous murmur over the precordium follOwing the injury. The diastolic accentuation of the continuous murmur, due presumably. to increased coronary blood How during diastole, has· been pointed out as a diagnostic feature indicating fistulous connection with the right ventricle. The phonocardiographic demonstration of systolic accentuation of the murmur has also been noted in cases where the fistulous track communicated with the right atrimn. 12 Interestingly, the present case shows accentuation of both the systolic and diastolic components of the murmur (Fig. lA). ACKNOWLEDGMENT: We wish to thank Miss Jeume Harrison and Mrs. Marcy Moore for their secretarial usiatance.
REFERENCES 1 Bravo AJ, Glancy D1., Epstein- SE. et a1: Traumatic coronary arteriovenous fistula. Am J Cardiol 27 :673-676, 1971 2 Anderson GP. Adicoff A. Motsay GJ. et al: Traumatic right coronary arterial-right atrial fistula. Am J Cardiol
CHEST, 69: 6, JUNE, 1976
35:439-443, 1975 3 Jones RC, Jahnke EJ: Coronary artery-atriovenbicular .&stula and venbicular septal defect due to penetrating wound ·of the heart. Circulation 32:995-1000, 1865_.~.,. _'.' 4 Storey CF, Kuzman WJ: Traumatic coronary artery-right abia1 &stula. Ann Thorac Surg 4:352-359, 1967 5 Tsagaris TJ, Bustamante RA: Coronary arteriovenous &stula and myocardial infarction due to trauma. Am J CardioI18:777-781, 1966 6 Sarot lA, Schechter DC, Weber DJ: Post-traumatic coronary arteriovenous fistulas with surgical cure. Ann Thorac Surg 6:172-177, 1968 7 Aaron BL, Doohen DH: Traumatic coronary artery-right abial &stula caused by a penetrating metal fragment. J Trauma 13:81-84, 1973 8 Cheng TO, Adkins PC: Traumatic aneurysm of left anterior descending coronary artery with fistulous opening into left venbic1e and left venbicular aneurysm after stab wound of chest. Am J Cardiol 31 :384-390, 1973 9 Siepser SL, Kalbnan AJ, Mills N, et a1: Coronary collateral flow after traumatic &stula between right coronary artery and right abium. N Engl J Med 287:754-756, 1972 10 North RL, BIalce HA, Nelson WP: Coronary artery right abia1 &stula secondary to bullet wound of the heart: Report of a case with successful surgical repair. Milit Med 136:267-270, 1971 11 Parmley LF, Marion WC, Mattingly TW: Penetrating wounds of the heart and aorta. Circulation 17:953-973, 1958 12 Gasul BM, Arcilla RA, Fell EH, et al: Congenital coronary arteriovenous fistula. Pediabics 25:531-560, 1960
Esophagopleural Fistula after Pneumonectomy· I. David Richardson, M.D.; Donald Cam."beU, M.D., F.C.C.P.; and I. Kent Trinkle, M.D., F.C.C.P. Rupture of the esophagus Into the space left alter pneumonedomy Is • nre and often fatal compUcation. Esop....ople...... 8ItuIas occurred In three patients following pneumonedomy. After previous methods failed, two patIe.... were _ treated by ...... a one",e procedure wldeh Included (1) suture closure of the 8ItuIa, (2) buttressing the repair with a viable, pedicled, two-rib IatefCOltlll-musele flap, and (3) perfo......... an estenslve thoracoplasty with a continuous drip infusion of neomycin. Such • procedure ofters the muimum opportunity for successful treatment of this catastrophic lesion. of the esophagus into the space left after Rupture pneumonectomy a rare and frequently fatal comis
plication. The three cases presented illustrate the difficultiesin the. management of this catastrophe. One patient died in the immediately postoperative period after a colon bypass procedure. The other two patients have
remained asymptomatic following fistula closure by the procedure advocated by Engleman and co-workers. 1 CASE REPoRTS CASE
1
A 61-year-old man underwent pleuropneumonectomy in
June 1968 for a destroyed right lung with empyema and persistently positive sputum cultures for acid-fast bacteria. During the difficult dissection, a small area of the middle portion of the esophagus was contused without mucosal perforation. The muscular wall was reinforced with sutures. Three weeks after surgery, the patient developed an esophagopleural fistula at the level of the repair. After initial drainage with a tube, a two-layer repair of the 1.5 X 1 em . perforation was performed with a gastrostomy and cervical loop esophagostomy. Within a few days the fistula recurred, and open-ehest drainage was performed. The patient was maintained by feedings through the gastrostomy tube, with the saliva diverted through the cervical esophagostomy. The fistula failed to close. In April 1969, a substernal right colonbypass procedure was performed. The patient died suddenly on the seventh postoperative day from a massive pulmonary embolus. Although oral feedings had not been started, the colon transplant and suture lines were intact. CASE
2
A 51-year-old man was admitted in 1972 with a destroyed right lung. The sputum culture was negative for tuberculosis and fungi, but a variety of pathogenic organisms was cultured. Right pneumonectomy was performed. The esophagus was not adherent and was not injured. Cultures of the resected lung revealed Bacteroides organisms, and appropriate antibiotic therapy was administered. The patient did well until three weeks after surgery, when a small bronchopleural fistula developed, requiring drainage with a tube. Neither transbronchoscopic cauterization nor secondary closure with pleural flaps was successful in obliterating the fistula. Open drainage of the pleural space (Eloesser2 flap) was performed; the patient was subsequently discharged, and the fistula closed. Approximately one year later, after a night of CCindigestion" and cCretching," the patient noted that oral fluids came out of the pleural drainage site. A large midesophageal fistula was demonstrated with a swallow of meglumine diatrizoate (Gastrografin) . Esophagoscopic and fiberoptic bronchoscopic examinations through the Eloesser flap showed a 1.5 em defect. The right pleural space was reopened, and a portion of the dense mediastinal scar was divided to permit a two-layer closure of the esophageal perforation. A pedicled flap of the fourth and fifth intercostal bundles was .sutured over the repaired esophagus. A nine-rib thoracoplasty and feeding jejunostomy were also performed. After surgery the patient did well, except for development of duodenal obstruction apparently due to a superior mesenteric arterial syndrome accentuated by high placement of the jejunostomy tube. Intravenous hyperalimentation was added to provide additional caloric intake. Barium swallow showed an intact esophagus. One year later, the patient was eating and gaining weight. CASE
3
°From the San Al)tonio State Chest Hospital and the Division of Cardiothoracic Surgery, the University of Texas Health Science Center, San A:ntonio. Reprint requests: Dr. Richardson, Department of Surgefll, 7703 Floyd Curl, San Antonio 78284
A 62-year-old woman underwent left pneumonectomy in 1971 for a destroyed lung with hemoptysis due to tuberculosis. After surgery the patient developed a bronchopleural fistula and empyema requiring open thoracostomy (Eloesser flap). The open thoracostomy gradually closed over the next
CHEST, 69: 6, JUNE, 1976
ESOPHAGOPLEURAL FlmU AFTER PNEUMONECTOMY 795
Preoperative
Dfpa1c K. Mu1cherfee, M.D.;- - VillI/a s. Banka, M.D., F.C.C.P.t; Narong Ke08athit, M.D.;t and
RlchGrd H. Hellant, M.D., F.C.C.P.§
PCG
An u ....... C8Ie of coroD&ry artery fistula, due to a stab woDDd In the chest In a 17-year-old male patient, with a resultant acute inferior myocardJai Infarction is preIented. At lDI1ery, complete transection of the right corOD&ry artery W8S found, wblch formed a ftstuIous comm"eatloD with both tile right atrium and the right ventrlde. The development of a contlDuo. murmur In the period lmmedl8tely lifter the bajury, the "'aee of hemoperlc8nllam, ud multiple canIiac-ehamber bavolvements were UDlque features of the case. The inferior myocardial willi W81 akinetic due to Infarction aDd did not Improve 1000"'" ~~tlon surgery. A brief review of the Uteratare II also presented.
4th Rt. ICS
C
4th Rt.
oronary arteriovenous fistula secondary to penetrating injury to the chest is relatively rare, and comparatively few case reports have been published. I - IO The reason for such rarity may be that penetrating injury to the heart is usually fatal due to assOciated exsanguination, hemopericardium with cardiac tamponade, and various acute intracardiac shunts, as well as laceration of the major coronary arteries. I ,2,e,10,11 We report here a unique case of traumatic coronary arteriove~ous fistula due to a stab injury to the chest which caused a complete transection of the right coronary artery and fonned a fistulous track through the atrioventricular groove into the right atrium and the right ventricle with associated acute inferior wall myocardial infarction.
CASEREroRT A 17-year-old blade male patient was admitted to a Philadelphia hospital in shock after a stab injury to his chest over the right third intercostal space outside the sternal edge. A chest tube was inserted to drain the hemothorax. Two days later, the patient developed a new episode of persistent severe chest pain and shortness of breath. A continuous munnur was heard for the first time over the site of the stab wound at the sternal edge. An electrocardiogram showed an acute inferior and possible posterior wall myocardial infarction. The patient received digitalis and was transferred one week later to Presbyterian-University of Pennsylvania Medical Center, Philadelphia, where physical examination on admission showed a regular and bounding pulse of 84 beats per minute and blood pressure of 140/60 mm "g. Jugular -From the School of Medicine, University of Pennsylvania, and Presbyterian-University of Pennsylvania Medical Center Philadelphia. - - Fe&w; Division of Cardiology. t Assistant Professor of Medicine and Director, Cardiac Catheterization Laboratory. tDepartment of Thoracic and Cardiovascular Surgery. §Associate Professor of Clinical Medicine and Chief, Division of Cardiology. R~rint requem: Dr. Hellant,51 North 39th Street, Philadelphia 19104
CHEST 69: 6, JUNE, 1976 f
PeG 4th Rt. ICS Postoperative
ECG
-Jv- _t t:wt~" '-~' '- '~- -_dii4w:&~-- ',
PCG
PCG
4th Rt.
ICS-.,.·.~""-~",,,,,-,,,,,,,,,,,,,,,,,,,,,,,~,,,,,,,-
" ICS--+:r~1
.....- ...'.....- ...........
a'\J
IA (upper panel). Preoperative phonocardiogram (PCG, frequency range, 120 to 250 Hz and 70 to 150 Hz) with simultaneous recording of electrocardiographic lead 2 and carotid pulse tracing, showing continuous murmur at right fourth intercostal space (ICS) with systolic and diastolic accentuation partially obscuring first and second heart sounds. IB (lower panel). Postoperative phonocardiogram with simultaneous electrocardiographic tracing and carotid pulse tracing ( CT) showing disappearance of murmur. First (SI) and second (S2) heart sounds are now well depicted. P2, Pulmonic second sound, A2' aortic second sound. FICURE
venous pressure was normal. The lungs were clear. A I-in X ~ in healed scar was seen in the third intercostal space at the right sternal edge. The point of maximal impulse was located 9 em from the left sternal edge in the fifth intercostal space. A systolic thrill was palpable at the right sternal border maximally over the scar. The .first and second heart sounds were normal at the apex. A continuous murmur with systolic and diastolic accentuation obscuring. the first and second heart sounds was localized over the scar, with poor radiation. The liver and the spleen were not enlarged, and there was no peripheral edema. Laboratory findings, including cardiac enzyme levels, were within normal limits. An ECG showed acute inferior and possible posterior wall myocardial infarction. An x-ray film of the chest showed normal cardiac size with slight pleural effusion on the right side. A phonocardiogram revealed a continuous munnur obscuring the first and second heart sounds at the right fourth intercostal space (Fig lA). Cardiac catheterization performed one week later revealed no diagnostic oxygen step-up at the right atrial, ventricular, or the pulmonary arterial level. A dye-dilution curve (indocyanine green. injected into pulmonary artery and sampled from aorta) revealed an early recirculation pattern. Meglumine diatrizoate (Renografin-76) injected into the aortic root
PENmATING INJURY OF CHEST 793
FIGURE 2A (left). Preoperative arteriogram (left anterior oblique view) with contrast material injected into aOrtic root, showing dilated right coronary artery fistula opening into right atrium and right ventricle. 2B (right). Postoperative arteriogram (left anterior oblique view) with selective injection of contrast material into right coronary artery, showing entire vessel with portion of saphenous-vein graft interposed between proximal and distal segments.
showed a dilated right coronary artery forming a fistulous track through the atrioventricular groove into the right ventricle and the right atrium (Fig 2A). The calculated pulmonary-ta-systemic How ratio was 1.3: 1. The left ventriculogram exhibited akinesia of the inferior wall. Three weeks later, open-heart surgery was perfonned. The right coronary artery was seen to be completely transeeted above the level of the acute margin, with its proximal portion forming a fistulous track into the atrioventricular groove, communicating separately with the right ventricle and the right atrium. The tricuspid valve and annulus were not involved, and there was no tricuspid insufficiency. The fistula was excised, and a saphenous-vein graft was placed between the proximal and the distal end of the transeeted artery. After surgery the patient recovered uneventfully, and the murmur disappeared. Cardiac catheterization repeated three weeks later revealed no shunt. The right coronary artery was visualized throughout its course {Fig 2B). On a ventriculogram the akinetic segment of the inferior wall was unchaDged. The postoperative phonocardiogram confirmed the disappearance of the continuous murmur (Fig IB). The ECG remained unchanged. DISCUSSION
The present case is unique in several respects. First, the patient survived despite complete transection of the right coronary artery, although he became quite symptomatic with chest pain and congestive heart failure. Secondly, cardiac tamponade did not occur following the injury, and no evidence of hemopericardium was observed at surgery. It was noteworthy that the arteriovenous fistula in this patient developed soon after the injury, as evidenced by the development of a continuous murmur for the first time on the third day after admission. This is in contrast to most of the published reports of coronary arteriovenous fistula, as well as the observation by Anderson et al, 2 and indicates that the fistula can develop in the period immediately after the injury. Furthermore, the fistulous track communicated with
794 MUKHERJEE ET At
both the right ventricle and right atrium in the present patient. This has not been previously docwnented with a stab injury. Nine of the 11 previously reported cases of traumatic coronary arteriovenous fistula were caused by a bullet or other missile injury. The present case and only two other case reports were due to stab wounds. Most reported cases have had a fistulous track between the right c0ronary artery and the right atrium. The need for early diagnosis and therapy in cases of coronary arteriovenous fistula has been emphasized in previous reports in order to prevent complications of bacterial endocarditis, cardiac failure, rupture of an aneurysmally dilated vessel, and myocardial infarction. 2 -11.10 As a diagnostic point, coronary arteriovenous fistula should be a major consideration in patients with penetrating chest injury who develop a continuous murmur over the precordium follOwing the injury. The diastolic accentuation of the continuous murmur, due presumably. to increased coronary blood How during diastole, has· been pointed out as a diagnostic feature indicating fistulous connection with the right ventricle. The phonocardiographic demonstration of systolic accentuation of the murmur has also been noted in cases where the fistulous track communicated with the right atrimn. 12 Interestingly, the present case shows accentuation of both the systolic and diastolic components of the murmur (Fig. lA). ACKNOWLEDGMENT: We wish to thank Miss Jeume Harrison and Mrs. Marcy Moore for their secretarial usiatance.
REFERENCES 1 Bravo AJ, Glancy D1., Epstein- SE. et a1: Traumatic coronary arteriovenous fistula. Am J Cardiol 27 :673-676, 1971 2 Anderson GP. Adicoff A. Motsay GJ. et al: Traumatic right coronary arterial-right atrial fistula. Am J Cardiol
CHEST, 69: 6, JUNE, 1976
35:439-443, 1975 3 Jones RC, Jahnke EJ: Coronary artery-atriovenbicular .&stula and venbicular septal defect due to penetrating wound ·of the heart. Circulation 32:995-1000, 1865_.~.,. _'.' 4 Storey CF, Kuzman WJ: Traumatic coronary artery-right abia1 &stula. Ann Thorac Surg 4:352-359, 1967 5 Tsagaris TJ, Bustamante RA: Coronary arteriovenous &stula and myocardial infarction due to trauma. Am J CardioI18:777-781, 1966 6 Sarot lA, Schechter DC, Weber DJ: Post-traumatic coronary arteriovenous fistulas with surgical cure. Ann Thorac Surg 6:172-177, 1968 7 Aaron BL, Doohen DH: Traumatic coronary artery-right abial &stula caused by a penetrating metal fragment. J Trauma 13:81-84, 1973 8 Cheng TO, Adkins PC: Traumatic aneurysm of left anterior descending coronary artery with fistulous opening into left venbic1e and left venbicular aneurysm after stab wound of chest. Am J Cardiol 31 :384-390, 1973 9 Siepser SL, Kalbnan AJ, Mills N, et a1: Coronary collateral flow after traumatic &stula between right coronary artery and right abium. N Engl J Med 287:754-756, 1972 10 North RL, BIalce HA, Nelson WP: Coronary artery right abia1 &stula secondary to bullet wound of the heart: Report of a case with successful surgical repair. Milit Med 136:267-270, 1971 11 Parmley LF, Marion WC, Mattingly TW: Penetrating wounds of the heart and aorta. Circulation 17:953-973, 1958 12 Gasul BM, Arcilla RA, Fell EH, et al: Congenital coronary arteriovenous fistula. Pediabics 25:531-560, 1960
Esophagopleural Fistula after Pneumonectomy· I. David Richardson, M.D.; Donald Cam."beU, M.D., F.C.C.P.; and I. Kent Trinkle, M.D., F.C.C.P. Rupture of the esophagus Into the space left alter pneumonedomy Is • nre and often fatal compUcation. Esop....ople...... 8ItuIas occurred In three patients following pneumonedomy. After previous methods failed, two patIe.... were _ treated by ...... a one",e procedure wldeh Included (1) suture closure of the 8ItuIa, (2) buttressing the repair with a viable, pedicled, two-rib IatefCOltlll-musele flap, and (3) perfo......... an estenslve thoracoplasty with a continuous drip infusion of neomycin. Such • procedure ofters the muimum opportunity for successful treatment of this catastrophic lesion. of the esophagus into the space left after Rupture pneumonectomy a rare and frequently fatal comis
plication. The three cases presented illustrate the difficultiesin the. management of this catastrophe. One patient died in the immediately postoperative period after a colon bypass procedure. The other two patients have
remained asymptomatic following fistula closure by the procedure advocated by Engleman and co-workers. 1 CASE REPoRTS CASE
1
A 61-year-old man underwent pleuropneumonectomy in
June 1968 for a destroyed right lung with empyema and persistently positive sputum cultures for acid-fast bacteria. During the difficult dissection, a small area of the middle portion of the esophagus was contused without mucosal perforation. The muscular wall was reinforced with sutures. Three weeks after surgery, the patient developed an esophagopleural fistula at the level of the repair. After initial drainage with a tube, a two-layer repair of the 1.5 X 1 em . perforation was performed with a gastrostomy and cervical loop esophagostomy. Within a few days the fistula recurred, and open-ehest drainage was performed. The patient was maintained by feedings through the gastrostomy tube, with the saliva diverted through the cervical esophagostomy. The fistula failed to close. In April 1969, a substernal right colonbypass procedure was performed. The patient died suddenly on the seventh postoperative day from a massive pulmonary embolus. Although oral feedings had not been started, the colon transplant and suture lines were intact. CASE
2
A 51-year-old man was admitted in 1972 with a destroyed right lung. The sputum culture was negative for tuberculosis and fungi, but a variety of pathogenic organisms was cultured. Right pneumonectomy was performed. The esophagus was not adherent and was not injured. Cultures of the resected lung revealed Bacteroides organisms, and appropriate antibiotic therapy was administered. The patient did well until three weeks after surgery, when a small bronchopleural fistula developed, requiring drainage with a tube. Neither transbronchoscopic cauterization nor secondary closure with pleural flaps was successful in obliterating the fistula. Open drainage of the pleural space (Eloesser2 flap) was performed; the patient was subsequently discharged, and the fistula closed. Approximately one year later, after a night of CCindigestion" and cCretching," the patient noted that oral fluids came out of the pleural drainage site. A large midesophageal fistula was demonstrated with a swallow of meglumine diatrizoate (Gastrografin) . Esophagoscopic and fiberoptic bronchoscopic examinations through the Eloesser flap showed a 1.5 em defect. The right pleural space was reopened, and a portion of the dense mediastinal scar was divided to permit a two-layer closure of the esophageal perforation. A pedicled flap of the fourth and fifth intercostal bundles was .sutured over the repaired esophagus. A nine-rib thoracoplasty and feeding jejunostomy were also performed. After surgery the patient did well, except for development of duodenal obstruction apparently due to a superior mesenteric arterial syndrome accentuated by high placement of the jejunostomy tube. Intravenous hyperalimentation was added to provide additional caloric intake. Barium swallow showed an intact esophagus. One year later, the patient was eating and gaining weight. CASE
3
°From the San Al)tonio State Chest Hospital and the Division of Cardiothoracic Surgery, the University of Texas Health Science Center, San A:ntonio. Reprint requests: Dr. Richardson, Department of Surgefll, 7703 Floyd Curl, San Antonio 78284
A 62-year-old woman underwent left pneumonectomy in 1971 for a destroyed lung with hemoptysis due to tuberculosis. After surgery the patient developed a bronchopleural fistula and empyema requiring open thoracostomy (Eloesser flap). The open thoracostomy gradually closed over the next
CHEST, 69: 6, JUNE, 1976
ESOPHAGOPLEURAL FlmU AFTER PNEUMONECTOMY 795
