A rare case of a chest wall abscess caused by a migrating oesophageal stent. An iatrogenic gastrocutaneous fistula

Ravindran Karthigan,Nathan Chan,Husein Kaderbhai,Antonio Leyte Golpe,Dimitrios Pissas,Sameer Zar,Matthew Townsend,Christopher Hadjittofi,Kashif Burney,Branavan Rudran,Yasmin Tabbakh

doi:10.1259/bjrcr.20160138

Ravindran Karthigan, Nathan Chan + Show 9 more

Open Access

https://doi.org/10.1259/bjrcr.20160138

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Abstract

We report the case of a 65-year-old male, who presented with septicaemia and a chest wall mass on a background of oesophageal carcinoma. This chest wall mass measured 10 cm by 10 cm, was fluctuant, and was situated on the anterior chest wall. Owing to local erythema and surgical emphysema, necrotising fasciitis was suspected and thus intravenous antibiotic and fluid therapy were instituted. Following a chest radiograph, which confirmed the presence of subcutaneous gas, the patient underwent thoraco-abdomino-pelvic CT, which demonstrated oesophageal stent migration through the gastric fundus to the chest wall, between the 10th and 11th left ribs. Through this migration tract, the chest wall was contaminated with gastric contents, accounting for the mass and sepsis. The patient underwent endoscopic stent removal, and incision and drainage to create a gastrocutaneous fistula. Additionally, a nasojejunal tube and intravenous line were sited for jejunal and total parenteral nutrition, respectively, in order to promote healing of the fistula.

Highlights

Given the above, necrotising fasciitis was suspected and intravenous antibiotic and fluid therapy were instituted
The patient was admitted under the care of the General Surgery team, and underwent a chest radiograph, which confirmed the presence of gas in the left anterior chest wall (Figure 1)
Trachea-oesophageal and aortooesophageal fistulation is well described in the literature, gastrocutaneous fistulas are rare, accounting for only 0.5–3.9% of patients who undergo gastric surgery.[2]

Summary

Introduction

Given the above, necrotising fasciitis was suspected and intravenous antibiotic and fluid therapy were instituted. Physical examination revealed an 10 Â 10 cm erythematous, fluctuant, warm mass over the left anterior chest wall with associated surgical emphysema. TREATMENT Following a multidisciplinary team discussion, the stent was removed endoscopically (Figure 4), and chest wall mass was incised and drained under general anaesthesia, with corrugated drain insertion and stoma bag application (Figure 5), creating a controlled gastrocutaneous fistula.

Results

Conclusion