Mediastinal Fluid Collections Research Articles

Tulip-bundle technique for suture dehiscence in a Boerhaave syndrome.

A 55-year-old-woman was admitted to the emergency department with hematemesis and abdominal pain. Her physical examination was unremarkable. Laboratory results without anemia. The upper gastrointestinal endoscopy revealed a deep large tear between 36 and 39 cm with transmural perforation. A diagnosis of Boerhaave syndrome was made. Thoraco-abdominal CT-scan revealed a laceration in the left posterolateral side of the esophagus, measuring 6.5 cm proximal to the esophagogastric junction (GEJ), associated with a pneumomediastinum, pneumoperitoneum and a mediastinal air fluid collection anteriorly to the GEJ. The patient was submitted to laparoscopic surgery with closure of the perforation, Graham patch confection. Nine days after, the esophago-gastric transit showed luminal contrast leakage to the posterior mediastinum. An endoscopic evaluation showed a 2 cm suture dehiscence. We applied a hemostatic clip in the distal end of the tear to bring the edges closer, but it was impossible to put additional ones. It was decided to perform a tulip-bundle technique with a single-channel endoscope in a sequential two-step maneuver and another two clips were placed in the borders of the tear with an endoloop applied over the clips with success. One month later, an endoscopic revaluation was performed, revealing the clips involved by the endoloop and no signs of leakage. After that, she started oral diet without any complications.

Aortic Perigraft Seroma Following Total Arch Replacement

Perigraft seromas (PGS) are a rare but important complication following aortic surgery. This study presents experience of a proximal aortic PGS in a young male following a fourth redo cardiac surgery, and reviewed the published literature on the management of proximal aortic PGS. A case report and review of all published cases of proximal aortic PGS. A 25-year-old male with Marfan syndrome underwent a fourth redo cardiac surgery for completion of a total arch replacement via a clamshell thoracotomy. A mediastinal fluid collection around the distal aspect of the aortic graft was first noted 6 months postoperatively on a computed tomogram angiogram. Extensive investigations including a diagnostic aspirate were performed to determine the aetiology of the collection. Although initially asymptomatic, the patient became symptomatic 6 years postoperatively, with the collection measuring 115mm x 93mm x 110 mm. He underwent an exploratory left anterior mediastinotomy, where the diagnosis of a PGS was confirmed. Reports of PGS complicating proximal aortic grafts are exceedingly rare, with four other cases described in the literature. It is believed that this is the largest reported proximal aortic PGS, and the only case where intervention was performed via a mediastinotomy. Proximal aortic perigraft collections can represent a diagnostic challenge. Stable collections in asymptomatic patients with normal inflammatory markers may be suitable for conservative management with close surveillance. This study presents a guideline for the investigation and management of asymptomatic perigraft collections.

血胸を伴う出血性ショックを来した左胃動脈瘤破裂の1例(A ruptured aneurysm of left gastric artery that progressed to right hemothorax: a case report)

症例は50歳代女性，心窩部痛と呼吸苦で発症し，近医にて胸水を指摘されて前医を受診した。前医では，単純CT検査で血性胸腹水，食道壁肥厚，膵周囲の脂肪織濃度の上昇を認め，2日間加療したが改善を認めないため精査目的に当院へ紹介された。来院時，四肢末梢に湿潤を認め，脈拍110/分，血圧80/50mmHg（ドパミン9μg/kg/min）であった。造影CT検査で右血性胸水と食道裂孔ヘルニア，胸部中部以下の食道から胃噴門部小弯側にかけての血腫を認めたが，食道や肺野など胸部には出血源を認めなかった。腹腔内には血性腹水とともに，胸部中部食道周囲から胃小彎側に連続する血腫を認め，内部に直径1.5cmの左胃動脈瘤を認めた。左胃動脈瘤破裂による出血が，食道裂孔を介して縦隔へ進展し，胸腔内に穿破して血胸に至ったものと推測した。血胸に対して単回の胸腔穿刺，左胃動脈瘤破裂に対して血管造影による塞栓術を施行した。翌日から経口摂取を開始し，血胸が再燃することもなく経過は良好で，第22病日に自宅退院した。腹部内臓動脈瘤破裂による出血が食道裂孔を介して胸腔内に穿破し，血胸を契機に診断された稀な症例を経験したので報告する。 A 59–year–old woman visited her local hospital with dyspnea and epigastric pain. A chest X–ray showed a right pleural effusion. The patient consulted a second hospital where she was treated for two days, but due to her unstable vital signs, she was transferred to our hospital. A contrast–enhanced CT scan revealed a right hemothorax and esophageal hiatal hernia. While there was no source of bleeding in the thoracic cavity, there was an intra–abdominal hemorrhage from a ruptured aneurysm of the left gastric artery. The suspected cause of the hemothorax was bleeding from a ruptured aneurysm that entered the thoracic cavity through the esophageal hiatus. We performed a transcatheter arterial embolization for the ruptured aneurysm. After treatment, the patient recovered without significant incidents and was discharged on the 22nd day of hospitalization. We speculated that the hemorrhage from the rupture of the gastric aneurysm extended through the esophageal hiatus into the mediastinum and perforated into the thoracic cavity, resulting in a hemothorax. Since such conditions are rare, we will report this case with a review of the literature. 腹部内臓動脈瘤は破裂すれば出血性ショックにより致死的状況に至ることもある重篤な疾患である。本邦の腹部内臓動脈瘤破裂として報告されている症例の多くは腹腔内出血による出血性ショックを呈している 1, 2。しかし，今回我々は左胃動脈瘤破裂による出血が食道裂孔ヘルニアを介して縦隔，胸腔内へ進展し，出血性ショックを来した症例を経験したので，文献的考察を加えて報告する。 本論文は，個人情報保護法に基づいて匿名化がなされており，本人から論文報告に関する同意を得ている。また，本論文は倫理委員会の承諾を要する事項として該当しない。 症 例：50歳代の女性 主 訴：心窩部痛 現病歴：搬送6日前に突然の心窩部痛，呼吸困難感が出現し，食事摂取ができなくなった。搬送2日前に近医を受診したところ，胸水を指摘され前医を紹介された。前医受診時より血圧が低下しており，単純CT検査で血性胸腹水，食道壁肥厚，膵周囲の脂肪織濃度の上昇を認め急性膵炎などが疑われた。2日間の入院加療後も改善に乏しく，循環動態の維持にカテコラミン投与を要する状態となったため，当院救命救急センターへ搬送された。 既往歴：特記事項なし 生活歴：ビール１本/日，喫煙なし 来院時現症：意識清明。軽度の呼吸困難感の訴えを認めるが呼吸促拍はなく，呼吸数22/分，酸素飽和度97%（3L/min），顔面蒼白，四肢末梢に冷感湿潤を認め，脈拍110/分，血圧80/50mmHg（ドパミン 9µg/kg/min）。左背部痛の訴えがあるものの圧痛は認めなかった。 血液検査：RBC 213×104 /μL，Hb 6.7g/dL（前医受診時 Hb 9.8g/dL）と著明な貧血を認めた。血小板数や凝固検査には異常を認めなかった。 画像検査：胸腹部造影CT検査；胸部CTでは右血胸，滑脱型食道裂孔ヘルニアを認め，周囲に縦隔血腫，左少量胸水を認めた。腹部CTでは直径1.5cmの左胃動脈瘤を認め（Fig. 1a），周囲の血腫は胸部中部食道周囲から胃小弯側へ連続していた（Fig. 1b）。左肝動脈は左胃動脈から分岐しており，肝左葉外側区に微小動脈瘤を認めた。食道や肺野には出血源を認めなかった。 An enhanced CT scan of the abdomen revealed a pseudoaneurysm of the left gastric artery. Computed tomography (CT) of the chest showed a right massive hemothorax，a slipped esophageal hiatal hernia, and a mediastinal fluid collection (black arrow). 搬入後経過：乳酸リンゲル液の急速輸液を行うとともに輸血を開始した。搬入後より呼吸困難感が増悪し，仰臥位の維持が困難となったため，右血胸に対し慎重に胸腔穿刺を施行したところ，約830mLの血性排液を認めた。穿刺後，呼吸困難感の改善を認め，輸血投与後よりバイタルサインの安定を得た。左胃動脈瘤からの出血が食道裂孔ヘルニアを介して血胸に進展したものと推測し，動脈瘤に対して緊急interventional radiology（IVR）による止血術を行う方針とした。 腹部血管造影：腹腔動脈からの造影では，直径1.5cmの左胃動脈瘤を認め（Fig. 2a），瘤よりも近位より分岐する左胃動脈分枝，瘤末梢から分岐する左肝動脈を金属コイルでisolationし，瘤内をNBCA（n–butyl–2–cyanoacrylate）により塞栓した（Fig. 2b）。 Celiac artery angiography showed a pseudoaneurysm of the left gastric artery and left hepatic artery. Transcatheter arterial embolization (TAE) was done successfully. Arterial flow for the aneurysm was shut out. 入院後経過：後日判明したmyeloperoxidase–anti–neutrophil cytoplasmic antibodies（MPO–ANCA）や，proteinase–3–anti–neutrophil cytoplasmic antibodies （PR3–ANCA）などの血管炎マーカーはいずれも陰性であり，微小動脈瘤形成の所見から，臨床的に節性動脈中膜壊死（segmental arterial mediolysis: SAM）と診断した。濃厚赤血球4単位の輸血投与と緊急IVR後は循環動態の安定が得られた。呼吸器症状も改善し第2病日から経口摂取を開始した。胸水の再貯留は認めず，その後も血胸が再燃することはなかった。IVR後大きな合併症なく経過は良好で，第22病日に独歩で退院した。その後発症から1年までの時点では，新たな動脈瘤の形成もなく経過している。 腹部内臓動脈瘤は比較的稀な疾患であり，その発生頻度は0.01～2%とされている。Stanleyらの腹部内臓動脈瘤1,118例の集計によると，脾動脈が最も多く656例（58.7%），次いで肝動脈が227例（20.2%），上腸間膜動脈瘤89例（7.9%）と続くのに対し，胃動脈瘤は53例（4.7%）であると報告されている 3。 腹部内臓動脈瘤の成因としては，動脈硬化，神経線維種症I型やEhlers–Danlos症候群などの先天性疾患，腹部外傷，ベーチェット病や高安病，多発血管炎などの膠原病，正中弓状靭帯圧迫症候群，慢性膵炎などの炎症性疾患などがあるが，近年画像診断の進歩に伴って，SAMが注目されている 4。SAMは1976年にSlavinらにより提唱された疾患概念 5で，腹部内臓動脈の中膜が分節性に融解し動脈瘤を呈する病態である。稲田らの報告によると，SAMと診断された患者の35.7%に多発動脈瘤を認めており，一般的には異所性，異時性に動脈瘤を形成することが多いとされている 6。 SAMの確定診断は切除標本からの病理学的診断によってなされていたが，近年，画像診断の進歩や開腹手術と比較して低侵襲であるIVRが動脈瘤治療の第一選択となってきており，病理学的確診が得られる機会が少なくなってきた。内山ら 7は腹部内臓動脈瘤の中で，①中高年の患者，②炎症性変化や動脈硬化性病変などの基礎疾患がない患者，③突然の腹腔内出血で発症，④血管造影で血管の数珠状の不正な拡張と狭小化を認める，の4項目をSAMの特徴とし，これに合致するものをSAMと診断する臨床的診断基準を提唱している。本症例においては，中年女性であること，非動脈硬化性，非炎症性であること，血管造影検査で左胃動脈だけでなく左肝動脈外側区領域にも動脈瘤を形成し，特徴的な数珠状変化も認めていたことから臨床的にSAMと診断した。 また，胃動脈瘤の中では左胃動脈瘤破裂が最も多く報告されている。医学中央雑誌による検索では，左胃動脈瘤破裂の本邦報告例は25例であり，いずれも腹腔内出血あるいは消化管出血によるショック症状で搬送されていた。海外においては，腹部内臓動脈瘤破裂に伴い胸水貯留を呈した症例についての報告 8, 9, 10が散見される。一般に，腹部内臓動脈瘤破裂は血性腹水の貯留を認めるが，本症例の場合は血胸を呈していた。横隔膜を隔てた液体成分の移動に関して，腹腔内圧の上昇に伴い，横隔膜小孔を通じて胸腔内へ液体成分が漏出した症例報告がみられる。本症例では，滑脱型食道裂孔ヘルニアが存在し，腹腔内における血腫が食道裂孔を介して腹腔から縦隔へ連続していた。食道裂孔は伸縮性を持つ約3cmの筋性管で，左右の横隔膜脚内側縁により境界される。食道裂孔を形成する筋束は右脚の内側部から送られ，これが食道を包むようにめぐっており，下部食道～胃噴門部は横隔食道膜という靭帯に固定されている。食道裂孔ヘルニアとは，加齢によりこの横隔食道膜が弛緩することにより胃の一部が胸腔側に逸脱した状態である。食道は漿膜を持たず，周囲は疎な結合組織と脂肪組織に覆われているため，食道胃接合部手術における剥離は容易である。また，右胸腔とは薄い食道臓器鞘で接していることから，剥離操作時には右胸腔開放に注意を要する。腹部内臓動脈瘤破裂症例で，合併する食道裂孔ヘルニアを通じて胸腔穿破，胸水貯留を来した報告は少数にみられ 11, 12，食道裂孔ヘルニア内の胃穿孔から縦隔気腫や膿瘍を形成した報告例 13もある。また，慢性膵炎における仮性膵嚢胞で，嚢胞が後腹膜を頭側へ進展することで食道裂孔を貫き，胸腔へ穿破，内瘻を形成したことで膵性胸水貯留を来した症例も報告されている 14。食道裂孔部が弛緩した状態では，食道周囲の結合組織が疎であることによる血腫の下縦隔への進展，そこに接する胸膜穿破が起こりうると考える。本症例は，画像診断では血胸の原因となる病変を肺，胸膜，食道に認めず，単回の胸腔穿刺ドレナージとIVRによる止血術で血胸の再燃を認めなかった。左胃動脈瘤破裂による出血が，腹腔内の圧が上昇したことで，最も抵抗の少ない食道裂孔ヘルニア部から疎な結合組織を通じて縦隔へ進展し，壁側胸膜を穿破して血胸に至ったものと推測した。 右血胸を伴い出血性ショックを呈した左胃動脈瘤破裂の症例を経験した。腹腔内を出血源とする血液が，食道裂孔ヘルニアを介して主に胸腔内へと進展した可能性が考えられた。 共著者全員が利益相反はない。

741 ACUTE PURULENT MYOPERICARDITIS SECONDARY TO ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION CYTOLOGY

Abstract Introduction Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic method to sample peritracheal and peribronchial le- sions under real-time ultrasound guidance. The most important use of TBNA is the diagnosis and staging of lung cancer and the evaluation of sarcoidosis. Although TBNA is considered generally safe, serious or even fatal complication may develop after the procedure. Here we present a case report of acute purulent myopericarditis complicated by cardiac tamponade occurred after EBUS-TBNA procedure. Case Report A 62-year-old man with preexisting hypertension and previous myocardial infarction and coronary angioplasty was admitted to our hospital for persistent, oppressive and worsening chest pain, which started a few days before admission. Of note, the patient underwent EBUS-TBNA 10 days before admission because he was found to have a tumor in the upper lobe of the left lung and enlargement of multiple mediastinal, right hilar, subcarinal and para-aortic lymph nodes. Two days after the procedure, one week before admission, he was treated with amoxicillin clavulanate and levofloxacin because of fever onset. At the ER, his vital signs showed a blood pressure of 80/60 mmHg and a heart rate of 115 bpm; O2 saturation on room-temperature air was 97%. The ECG at presentation showed concave ST segment elevation in anterolateral and inferior leads. The echocardiography revealed moderate circumferential pericardial effusion without clear tamponade signs. Emergency coronary angiography showed patent coronary arteries. The next morning, the patient developed persistent hypotension (BP 75/50 mmHg). A transthoracic echo showed moderate to large circumferential pericardial effusion with tamponade physiology. He therefore underwent subxiphoid pericardiotomy with drainage of 400 ml of frank pus. Cultures from pericardial fluid were negative for common germs. Cytology was negative for malignancy and acid-fast bacilli. Histological examination of the pericardial tissue was diagnostic for acute fibrinous-purulent pericarditis. The patient was started on broad spectrum antibiotics (piperacillin/tazobactam and ciprofloxacin) with subsequent decrease of inflammation markers and clinical improvement. Control contrast enhanced chest CT scan revealed persistency of a mediastinal pluri-concamerate fluid collection. After a collective discussion with cardiac surgeons, infectious disease specialists and oncologists, given the progressive clinical and instrumental improvement, we decided to discharge the patient with long term oral antibiotics plus colchicine and ibuprofen for pericarditis. Infectious disease and oncological follow up was planned before discharge. Conclusion Complications following TBNA are relatively low, typically around 1.2%-1.4%. To date, only few cases of purulent pericarditis secondary to EBUS-TBNA have been reported in literature. Our case report adds to the existing scant literature regarding cardiac infective bronchoscopic complications and emphasizes concern of weather antibiotic prophylaxis may be needed before respiratory tract invasive procedures. Further research is necessary to better understand the existence of risk factors that could increase the probability to develop such rare but potentially lethal complications.

A RARE CASE OF BRONCHOLITHIASIS PRESENTING WITH CHRONIC COUGH AND MEDIASTINAL ABSCESS

TYPE: Case Report TOPIC: Disorders of the Mediastinum INTRODUCTION: Broncholithiasis is a rare condition characterized by the erosion of calcified material into the tracheobronchial tree. We present a case of broncholithiasis complicated by mediastinal abscess. CASE PRESENTATION: A 58-year-old male presented with chronic cough and lithoptysis. Chest PET-CT demonstrated calcified right infrahilar and subcarinal soft tissue with avid FDG uptake. Infectious workup was negative, including histoplasma and mycobacterium testing. Bronchoscopy demonstrated mucosal inflammation around the bronchus intermedius. Endobronchial biopsies and EBUS-TBNA were negative for malignancy. Symptoms persisted despite multiple courses of antibiotics and prednisone. Repeat CT showed evolving mediastinal fluid collection and gas. The patient underwent right lower lobectomy and mediastinal lymphadenectomy which showed broncholithiasis, necrotizing granulomas as well as fibrinous and organizing inflammation. Following surgery, he developed right hydropneumothorax requiring chest tube placement with polymicrobial growth consistent with empyema. He was treated with IV antibiotics with subsequent resolution of his symptoms. DISCUSSION: Broncholithiasis is an exceedingly rare cause of chronic cough. Tuberculous and histoplasma necrotizing granulomatous lymphadenitis are the most common causes. Lithoptysis is an uncommon, but a unique symptom of broncholithiasis. Mediastinal abscess is a rare complication as seen in this case. Diagnosis is established by CT imaging and bronchoscopy plays and important role. Depending on disease severity, management options range from observation to bronchoscopic extraction to surgical resection. Caution is advised when bronchoscopic treatment is considered due to the risk of massive bleeding upon manipulation of broncholiths. CONCLUSIONS: Broncholithiasis is a rare complication of mediastinal granulomatous processes that can present with chronic cough, hemoptysis as well as mediastinal abscess. DISCLOSURE: Nothing to declare.

RETROPHARYNGEAL ABSCESS WITH MEDIASTINITIS REQUIRING VIDEO-ASSISTED THORACOSCOPIC SURGERY

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Retropharyngeal abscesses are rare in adults. We present a case of anterior and posterior mediastinitis and empyema secondary to retropharyngeal abscess requiring video-assisted thoracoscopic surgery (VATS) and median sternotomy. CASE PRESENTATION: A 58-year-old male with chronic obstructive pulmonary disease presented to the ED with 2 days of right sided pleuritic chest pain with associated worsening dyspnea on exertion, odynophagia/dysphagia, hoarseness, and night sweats over the past two weeks. He had two prior ED visits with milder symptoms where he was cleared by ENT and sent home with oral corticosteroids. No history of immunosuppression, recent drug use, or odontogenic procedures. He was afebrile, tachycardic, and saturating 95% on 2 L nasal cannula. Exam was significant for neck swelling with tenderness of the submandibular region and right chest wall along with expiratory coarse prolonged wheezes. Labs were notable for leukocytosis with neutrophilia and bandemia. He was started on corticosteroids and broad spectrum antibiotics. Computed tomography (CT) of the neck showed a rim enhancing hypodensity around the post cricoid region of the hypopharynx with extension into the anterior mediastinum (Figure 1). He had emergent incision & drainage by ENT and thoracic surgery where a Jackson-Pratt drain was placed. Repeat imaging revealed progression with a loculated empyema and mediastinal tracking which required VATS with right pleural decortication (Figure 2 & 3). Two days later, the patient's clinical status did not improve despite broad spectrum antibiotics and drainage and he required a median sternotomy with washout of the anterior/posterior mediastinal fluid collections and three chest tubes. Abscess cultures were positive for Streptococcus parasanguinis, Rothia mucilaginosa, and Candida glabrata. All drains were removed after minimal drainage. On discharge, he was requiring oxygen with exertion and went to a long term acute care hospital to continue broad spectrum antibiotics. DISCUSSION: Retropharyngeal abscess can be associated with high mortality and morbidity (1). It may be secondary to accidental penetrating trauma, iatrogenic, or spread of oropharyngeal infection (2). This case is unique in that there was no clear etiology for the retropharyngeal abscess. Deep neck infections tend to follow the path of least resistance of the well-defined cervical fascial planes and can lead to pericardial and pleural effusions. High index of suspicion should be entertained for patients presenting with fevers, sore throat, and dysphagia. Contrast enhanced CT imaging is utilized to characterize the extent of the abscess. Management typically requires surgical intervention and intravenous antibiotics. CONCLUSIONS: Descending mediastinitis can be life-threatening if not diagnosed promptly. Early intervention with surgical management and antibiotics is vital to improved outcome. Reference #1: Jain H, Knorr TL, Sinha V. Retropharyngeal Abscess. In: StatPearls. StatPearls Publishing; 2020. Accessed May 30, 2020. http://www.ncbi.nlm.nih.gov/books/NBK441873/ Reference #2: Mark R, Song S, Mark P. Taking heed of the ‘danger space’: acute descending necrotising mediastinitis secondary to primary odontogenic infection. Case Rep. 2018;2018:bcr-2018-225019. doi:10.1136/bcr-2018-225019 DISCLOSURES: no disclosure on file for Frank Ajatta; No relevant relationships by Venkata Bandi, source=Web Response No relevant relationships by Lorraine Cornwell, source=Web Response No relevant relationships by Kalpalatha Guntupalli, source=Web Response My spouse/partner as a Consultant relationship with Abbvie Please note: $1-$1000 Added 05/27/2020 by Ebtesam Islam, source=Web Response, value=Consulting fee No relevant relationships by Sarah Jaroudi, source=Web Response

Management of Mediastinal Pancreatic Fluid Collections by Endoscopic Pancreatic Ductal Decompression

Weijie Yao1, Shiyang Ma2, Wenping Bo1 and Zuozheng Wang1* Author Affiliations 1Department of Hepatobiliary Surgery of the General Hospital of NingXia Medical University, China 2Department of Gastroenterology, the Second Affiliated Hospital of Xi’an Jiaotong University, China Received: June 11, 2020 | Published: June 22, 2020 Corresponding author: Zuozheng Wang, Department of Hepatobiliary Surgery, General Hospital of Ningxia Medical University, China DOI: 10.26717/BJSTR.2020.28.004650

Direct and indirect CT imaging features of esophago-airway fistula in adults.

BackgroundEsophago-airway fistula (EAF) is an abnormal connection between the esophagus and the trachea or a major bronchus. While contrast esophagography remains the primary radiographic tool for the diagnosis of EAF, computed tomography (CT) is often employed in its evaluation. A systematic analysis of CT findings of EAF in adults has not been previously published. The goal of our study is to determine the direct and indirect CT findings of EAF in adults.MethodsWe identified patients with EAF detected on CT at our institution between January 1, 2001 and December 31, 2019, with endoscopic or surgical confirmation. We collected patient clinicopathologic characteristics and assessed CTs for direct and indirect imaging features of EAF in these patients.ResultsTwenty-six patients (median age: 56 years; range, 25–79 years; F=13, 50% and M=13, 50%) with confirmed EAF were identified. Half of the patients had an underlying malignancy. On CT, a direct connection between the esophagus and the airway was identified in most cases (22/26; 85%). Common indirect CT findings of EAF included esophageal wall thickening (21/26, 81%), mediastinal fatty stranding (21/26, 81%), airway wall thickening (20/26, 77%), fluid or debris within the airways (17/26, 65%), and focal or diffuse esophageal dilation with air (17/26, 65%). Mediastinal fluid collections were infrequently seen (4/26, 15%), but findings of aspiration or other pneumonia were common (19/26, 73%).ConclusionsCT plays an essential role in both the primary and secondary evaluation of adult EAF resulting from both malignant and benign etiologies. CT may be the first diagnostic exam to suggest and detect the presence of EAF and may precede clinical suspicion, and it can detect a subset of fistulas not demonstrated on esophagography. There are several direct and indirect imaging findings on CT that can help in the detection of EAF.

Cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy: a case report and review of the literature

BackgroundObesity is considered a chronic disease with an increasing prevalence worldwide during the last decades. Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure, due to its relative safety and long-term efficacy. The use of bougie to ensure correct size of the gastric tube is part of the standard operation, usually placed by the anesthesiologist and with a very low rate of complications. We report the first case, to our knowledge, of a cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy.Case presentationThe complication occurred in a previously healthy 42-year old female patient who underwent laparoscopic sleeve gastrectomy for class 1 obesity (BMI 31 kg/m2) and was diagnosed the first post-operative day. She was subsequently treated with an emergency thoracoscopy and evacuation of a mediastinal fluid collection, with additional neck incision for primary closure of the esophageal defect which was reinforced with a sternocleidomastoid muscle flap. The post-operative course was uneventful.ConclusionsWe made a literature review to better understand the options considering the diagnosis and treatment in case of very proximal iatrogenic esophageal perforations. The risks related to the use of bougie during surgery should not be underestimated, and its insertion must be done with extreme caution. Esophageal perforation is still a challenging, life threatening complication where prompt diagnosis and adequate treatment are essential.

1431 A Bad Connection: Chronic Pancreatitis Leading to a Pancreticopleural Fistula

INTRODUCTION: Pancreatic-pleural/mediastinal fistulas are a rare complication of chronic pancreatitis. Fistulous connections occur through fenestrations in the diaphragm. Pancreatic ductal stenting can be valuable, though medical and surgical options may still be required. We describe a case of pancreatic-pleural fistula with mediastinal tracking successfully treated with combined endoscopic and medical management. CASE DESCRIPTION/METHODS: The patient is a 53-year-old male with a history of chronic pancreatitis secondary to alcohol abuse, a pancreatic pseudocyst, and compensated heart failure. The patient was admitted with new onset shortness of breath and epigastric abdominal pain. CT showed acute on chronic pancreatitis with a pseudocyst in the uncinate process, lower mediastinal inflammatory changes, and bilateral pleural effusions. Thoracentesis was performed, demonstrating an amylase of >7500. Though MRCP did not show a discrete connection, the clinical presentation was consistent with pancreatic-pleural fistula. ERCP was performed, but the endoscopist was unable to cannulate the pancreatic duct. Patient was placed on octreotide and continued to undergo therapeutic thoracenteses as needed. Patient returned 1 month later with complaints of neck fullness, continued shortness of breath, and abdominal pain. CT was significant for a fluid collection extending from pancreatic head to the mediastinum tracking along the anterior aspect of the esophagus and persistent pleural effusions. MRCP was performed and revealed a fistulous connection between the pseudocyst, pleural space, and mediastinum. Repeat ERCP was done with successful pancreatic stent placement. Patient subsequently had resolution of both mediastinal and pleural fluid collections. The pancreatic stent was removed with durable resolution of fluid collections. DISCUSSION: Pancreatic fistulas are reported to resolve with supportive care alone in 80% of external and 50-65% of internal fistulas. In our case, supportive care including octreotide use was insufficient for fistula resolution. The patient was ultimately treated successfully with pancreatic stenting. Had this failed, alternative approaches could have included nasojejunal feeding, endoscopic sealants, or surgical correction. This case highlights a rare, but serious complication of chronic pancreatitis and management options to be considered.

1264 Mediastinal Pancreatic Pseudocyst With Expansion Into Bilateral Pleural Spaces

INTRODUCTION: Pseudocysts are a common complication of both acute and particularly chronic pancreatitis. Uncommonly, pseudocysts may communicate with thoracic cavities, including the mediastinum. We describe a case of acute pancreatitis complicated by a mediastinal pseudocyst with bilateral pleural space involvement. CASE DESCRIPTION/METHODS: A 51-year-old male with a history of alcohol abuse presented shortly after discharge from a prolonged hospitalization for his first lifetime episode of acute alcohol-induced pancreatitis. A CT of the chest ordered on admission for new onset respiratory distress demonstrated bilateral pleural effusions. Fluid analysis showed a right sided empyema and left sided aseptic exudative effusion. The right empyema resolved after chest tube placement but there was rapid recrudescence of a right pleural effusion after chest tube removal. Repeat fluid analysis was significant for a pancreatic specific amylase level of 2620. Repeat CT imaging demonstrated a posterior mediastinal fluid collection that arose from the pancreas, extended through the esophageal hiatus and was contiguous with new fluid collections in both pleural spaces and this was confirmed with MRCP. The mediastinal pseudocyst was deemed not amenable to endoscopic drainage so ERCP was performed with stent placement to the ventral pancreatic duct along with chest tube placement for the larger right sided fluid collection and subcutaneous octreotide administration, with eventual reduction of pseudocyst size. DISCUSSION: Mediastinal pseudocysts are a rare complication of acute pancreatitis more commonly seen in chronic pancreatitis, though exceedingly rare in general. It is theorized that mediastinal pseudocysts occur based on ease of pancreatic fluid movement. The pararenal and pelvic extraperitoneal spaces are typically the easiest spaces for this fluid to penetrate but conditions that create inflammatory fibrosis of these areas may make ascending flow into the mediastinum the path of least resistance. On CT scan and on MRCP, our patient had a mediastinal pseudocyst that communicated directly and inseparably with both the right and left pleural space. To our knowledge, this has not been previously seen in the limited case reports of mediastinal pseudocysts. Despite not being amenable to endoscopic drainage based on location, the use of octreotide coupled with pancreatic duct stenting proved effective in reducing the caliber of this mediastinal pseudocyst on interval imaging.

Fetal chest malformations

Congenital anomalies of the fetal chest typically consist of lung lesions that are echogenic on ultrasound. These lesions comprise congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestrations (BPS), bronchial atresia, bronchogenic cysts, congenital lobar emphysema, and congenital high airway obstruction syndrome (CHAOS). CPAM and BPS account for a majority of these anomalies. Although rare, the apparent incidence of these echogenic lung lesions has increased recently, with CPAMs now occurring at a rate of 0.94 per 10,000 live births. This increase is likely a product of the improved resolution of ultrasound equipment, and the increasing uptake of routine fetal anomaly scanning in the second trimester. In utero, fetal echogenic lung lesions can result in mediastinal shift, fluid collections and hydrops. Following birth, they can cause substantial neonatal respiratory compromise. Determining the type of lesion prenatally can be challenging, even with complementary imaging such as MRI scanning, and the final histopathological diagnosis – where available – is often different to that suspected prior to birth. Of greater importance to prospective parents, however, is the likelihood of a favourable outcome, and the need for fetal intervention and/or intensive neonatal care. A range of sonographic predictors has been proposed for this purpose, but the best studied index is the CPAM-volume ratio – the ratio of the volume of the lesion (calculated as a prolate ellipse) to the fetal head circumference, to normalise for gestation. This presentation will review the performance of the CVR in the prediction of a range of fetal and neonatal concerns, including in a series from the author's own institution. It will also compare this index with other predictors, none of which has shown sufficient utility to replace the CVR at this stage. It will conclude with suggestions regarding future research in this field.

Esophageal Rupture After Ghost Pepper Ingestion

BackgroundThe ghost pepper, or “bhut jolokia,” is one of the hottest chili peppers in the world. Ghost peppers have a measured “heat” of > 1,000,000 Scoville heat units (SHU), more than twice the strength of a habanero pepper. To our knowledge, no significant adverse effects of ghost pepper ingestion have been reported. Case ReportA 47-year-old man presented to the Emergency Department (ED) with severe abdominal and chest pain subsequent to violent retching and vomiting after eating ghost peppers as part of a contest. A subsequent chest x-ray study showed evidence of a left-sided pleural effusion and patchy infiltrates. A computed tomography scan of the abdomen and pelvis showed pneumomediastinum with air around the distal esophagus, suggestive of a spontaneous esophageal perforation and a left-sided pneumothorax. The patient was intubated and taken immediately to the operating room, where he was noted to have a 2.5-cm tear in the distal esophagus, with a mediastinal fluid collection including food debris, as well as a left-sided pneumothorax. The patient was extubated on hospital day 14, and was discharged home with a gastric tube in place on hospital day 23. Why Should an Emergency Physician Be Aware of This?Spontaneous esophageal rupture, Boerhaave syndrome, is a rare condition encountered by emergency physicians, with a high mortality rate. This case serves as an important reminder of a potentially life- threatening surgical emergency initially interpreted as discomfort after a large spicy meal.

A rare case of oesophageal rupture: Boerhaave's syndrome.

A 70-year-old patient was referred to our emergency department with severe retrosternal pain after forceful vomiting. Computed tomography (CT) scan revealed a left-sided oesophageal rupture with accompanying pneumomediastinum and bilateral pleural effusions. Conservative treatment with cessation of oral intake, intravenous broad-spectrum antibiotics, parenteral fluids and nutrition and left sided tube thoracostomy was initiated initially. After 5 days, however, the patient deteriorated. Follow-up CT scan demonstrated a mediastinal fluid collection as well as loculated pleural empyema. Open thoracotomy with mediastinal debridement and pleural drainage was performed, after which he made a slow but full recovery. Spontaneous oesophageal rupture due to an abrupt rise in intraluminal pressure caused by vomiting is also known as Boerhaave's syndrome. It is a rare but potentially life-threatening condition. Many patients present with atypical symptoms, and therefore, physicians should have a high index of suspicion in any patient presenting with vomiting and retrosternal pain. When Boerhaave's syndrome is suspected, a CT scan of the thorax and upper abdomen should be performed since treatment depends on clinical and radiological findings. Conservative management (cessation of oral intake, nasogastric decompression, administration of intravenous fluids and parenteral nutrition, intravenous broad-spectrum antibiotics and proton pump inhibitors and tube thoracostomies) may only be considered in patients with a contained rupture without systematic symptoms of infection. In these patients, endoscopic bridging of the tear with a self-expandable stent is also an option. Primary surgical repair (either by thoracotomy or by video assisted thoracoscopy (VATS)) should be considered when patients present with sepsis and/or large non-contained leaks or with severe mediastinal decontamination.

Tracheal Laceration Related to Endotracheal Intubation

Tracheal laceration is a complication of general endotracheal anesthesia. Tracheal laceration during intubation is uncommon but fatal, and is difficult to recognize. Therefore, we have to pay considerable attention to the symptoms of tracheal laceration. We report a case of tracheal laceration after a simple plastic surgery operation. A 44-year-old woman (height, 151 cm; weight, 55 kg) who had a nasal bone fracture was scheduled to undergo a closed reduction under general endotracheal anesthesia. She had no underlying disease. However, 48 hours after the operation, she had dyspnea along with subcutaneous emphysema on her shoulder (Fig. 1). Diagnostic bronchoscopy revealed an approximately 1.5-cm-sized vertical tracheal laceration above the carina with split thickness (Fig. 2). She was started on antibiotics, O2 inhalation, expectorants and non-per oral. The emphysema spontaneously resolved. The patient was discharged uneventfully on postoperative day 7. Fig. 1 (A) Chest X-ray 1 day after admission. Subcutaneous emphysema can be observed on both shoulders. (B) Chest X-ray 2 days after admission. The previous subcutaneous emphysema has disappeared. Fig. 2 Diagnostic bronchoscopy. A lacerated wound (white arrow) can be observed above the carina. It is approximately 1.5 cm vertically and has split thickness. Many operations in plastic surgery are simple and quick. However, general endotracheal intubation may be required for various reasons. Therefore, it is important for a plastic surgeon operating on the face to be familiar with the complications of intubation. The incidence of postintubation tracheal laceration is reported to be approximately 1/20,000 [1]. Thus far, the cause of this laceration has not been definitely established, but the condition is generally attributed to pre-existing tracheal wall weakness, difficult intubation, emergency intubation, inexperience of the health professional, a double-lumen tube, and movement of the head and neck while the patient is intubated [2,3]. A higher incidence is observed in patients who have a chronic use of steroids, are of advanced age, are female [4] and/or have other inflammatory lesions of the trachea. The common symptoms of postintubation tracheal laceration are chest discomfort, dyspnea, dysphonia, cough, hemoptysis, mediastinal emphysema, subcutaneous emphysema, and pneumothorax. The tracheal laceration is detected early when the laceration is large and deep. In these cases, it is usually detected intraoperatively. However, smaller tears are detected during the postoperative period. The exact site and size of the abovementioned laceration is determined by bronchoscopy; this knowledge helps in planning the therapeutic approach. Nonoperative indications are stable vital signs, no difficulty ventilating while intubated or respiratory distress while extubated, no evidence of esophageal injury, minimal mediastinal fluid collection, nonprogressive pneumomediastinum or subcutaneous emphysema, and no signs of sepsis [5]. In our case, the tracheal laceration could have arisen after elective operation or uncomplicated intubation, as the patient had no underlying diseases. Her risk factors were only the head and neck surgery and her gender. These risk factors are common in patients who undergo operations in plastic surgery. We assume two possible causes in this case. First, potadine and bleeding could have irritated the trachea and triggered a cough and gag reflex. Secondly, repeated sterilization for reuse may have increased the stiffness of the intubation tube. A plastic surgeon must be familiar with the causes and the symptoms of tracheal laceration. In particular, such a laceration could have occurred during a short operation such as a closed reduction of the nasal bone. For the prevention of tracheal laceration, we need to determine a patient's underlying disease. Further, plenty of irrigation is required for the removal of the potadine and blood before extubation.

Endoscopic Management of a Perforated Esophageal Adenocarcinoma

Purpose: Esophageal perforation secondary to dilation of esophageal malignancy can be a catastrophic event. Mediastinitis that results from the perforation can rapidly progress to purulent mediastinal collections and due to the close anatomic proximity between the esophagus and pleura, esophago-pleural fistula and empyema ensues. Surgical options are limited in this situation due to significant morbidity and mortality. We describe endoscopic management of such case with optimal clinical outcome. A 67-year-old gentleman presented to our ER with fever, right sided chest and back pain. An EGD was performed by a referring surgeon 3 days prior to presentation due to progressive solid food dysphagia and weight loss. A 5-cm malignant appearing mass was found in the mid to distal esophagus that was balloon dilated and biopsies confirmed a poorly differentiated adenocarcinoma. He felt back pain after the endoscopy however was reassured and sent home. Within 12 hours of the procedure he developed spiking fevers and pleuritic chest pain that radiated to his back. On admission BP was 80/60 mmHg and temperature, 39.3°C. CT scan revealed pneumomediastinum, an empyema in the right lung, and mediastinal fluid collection around aorta and heart with a free extravasation of contrast between esophagus and the fluid collection. An emergent EGD confirmed a 2.5-cm trans-mural perforation through the right esophageal wall with a clearly visible mediastinum. A partially covered wall flex metal stent was placed successfully across the defect. A subsequent CT scan confirmed completely sealed defect with no contrast extravasation. He underwent a trans-hiatal esophagectomy, pathology indicating a 5.5 cm invasive poorly differentiated T3 adenocarcinoma. His hospital course was finally complicated by development of a left pleural empyema which required decortication. After responding to antibiotics, he was discharged for palliative chemotherapy and radiation. Esophageal perforation requires emergent detection as it is crucial in a favorable clinical outcome. Empyema is diagnosed clinically with CT chest and pleural fluid studies which reveal leukocytosis, low pH (<7.20), low glucose (<60 mg/dL), a high LDH (lactate dehydrogenase), elevated protein and culture for pathogens. Definitive therapy entails emergent drainage and IV antibiotics. The prognosis of pleural empyema in the setting of malignancy is dependent on detection and expeditious closure of the anatomic defect.

Volumetric Computed Tomography Angiography in the Evaluation of Mediastinal Fluid Collections following Congenital Cardiac Surgery

We present 3 patients with 4 causes of mediastinal fluid collection after congenital cardiac surgery in this extended case report. Volumetric computed tomography played an essential role in diagnosing causes and extent, relevant to subsequent management. Recent advances in volumetric computed tomography allow fast and accurate imaging of cardiovascular and extravascular structures in children with acceptable radiation dose, providing a powerful imaging tool for the evaluation of complications after congenital cardiac surgery.

Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome

Giant hiatus hernia (GHH) are difficult to manage effectively. This study reports a laparoscopic, prosthesis-free technique to repair of GHH. Retrospective analysis of a prospectively populated database of a single surgeon's experience of GHH (>30 % intrathoracic stomach) repair using a novel, uniform technique was performed. Routine postoperative endoscopy, quality of life (QOL), and Visick scoring was conducted. Surgery was conducted in 100 patients (70F, 30 M). Mean (standard deviation [SD]) age was 69.1 (±11.4), median (interquartile range) ASA was 2 (range, 2-3), and mean (SD) body mass index (BMI) was 29.1 (±4.5). Mean follow-up was 574.1 (±240.5) days. One (1 %) patient was converted to an open procedure due to technical issues. Median stay was 2.5 days (range, 2-4). One postoperative death occurred secondary to respiratory sepsis. Eight (8 %) patients had perioperative complications: 4 major (PE, non-ST elevation MI, postoperative bleed managed conservatively, infected mediastinal fluid collection); and 4 minor (pneumothorax, asymptomatic troponin leak, subacute small bowel obstruction, and urinary retention). Ninety-nine (99 %) patients had objective screening for recurrence at 3-6 months. Two (2 %) patients have had symptomatic recurrence of their hiatus hernia; both involved a recurrent fundal herniation. Another seven (7 %) had small (<2 cm), asymptomatic recurrences diagnosed only on routine follow-up. Seven (7 %) patients have required reintervention for dysphagia with endoscopic dilatation conducted to good effect in all cases. Two (2 %) patients have required revisional surgery: one for a symptomatic recurrence at 3 months and a second for recurrent mediastinal collection. The Visick score fell from a mean (SD) of 3 (±1.1) to 1.7 (±0.8) postoperatively (p < 0.0001). The mean (SD) QOL preoperatively was 87.8 (±24) versus 109.1 (±22.3) postoperatively (p < 0.0001). GHH can be managed safely and effectively laparoscopically, without the use of a prosthesis.

Esophageal Fistualization: 3 Rare Cases

Purpose: Esophageal fistualization occurs secondary to infection, malignancy, mechanical perforation, radiation injury, congenital abnormalities, or surgical procedures. We present three uncommon etiologies of esophageal fistulas with interesting presentations. Methods: A 48 year old male with medical history of intravenous drug abuse, spinal stenosis, and a prolonged hospitalization with multi-drug resistant bacteremia presented two months after discharge with acute onset of shortness of breath and worsening back pain. He was found to have MSSA vertebral osteomyelitis. CT with contrast of the chest revealed a 2.5x5 cm subcarinal/paraesophageal mass. EGD/EUS showed a complex fluid collection with purulent discharge into a mucosal deformity of the proximal esophageal lumen. MRI showed contiguous spread of a posterior mediastinal abscess resulting in esophageal fistualization. He was treated with surgical drainage and long-term antibiotics. To our knowledge, this is the first reported case of vertebral osteomyelitis and posterior mediastinal abscess resulting in esophagorespiratory fistula. Results: An 81 year old female presented with low grade fevers, productive cough, and paroxysms of choking associated with solids and liquids. She had endoscopic thoracic aneurysm repair (ETAR) one month prior to admission. Videofluorographic swallowing study revealed mild to moderate bolus stasis at the mid to distal esophagus. EGD subsequently showed a mid esophageal non-obstructing stable clot penetrating from the muscular layer. A gastrogaffin UGI series showed a mid to distal esophageal leakage of contrast material, consistent with aorto-esophageal fistula. These findings are consistent with a thoracic aortic aneurysm forming an aortic esophageal fistula (AEF) and a rare cause of gastrointestinal bleeding. This patient subsequently required surgical intervention for AEF repair. AEF cause approximately 0.01- 0.08% of UGIB. Classically, the Chiari triad of AEF is midthoracic pain or dysphagia, a sentinel episode of hematemesis, and fatal exsanguinations. Conclusion: A 53 year old female presented for EUS guided FNA of a submucosal esophageal lesion arising from the muscularis propria. A FNA was performed using a 22g needle was done. One week later the patient developed progressively worsening back pain with debilitating consequences. CT demonstrated a posterior mediastinal fluid collection tracking from the esophagus to the pre-spinal area, suggestive of an epidural abscess with cord compression. The patient was treated with surgical drainage and antibiotics. The cultures were positive for S. viridians and antibiotics were initiated. We feel blood tracking from the FNA tract may have resulted in esophago-spinal fistula.

Descending necrotising mediastinitis: Case report

Desendan nekrotizan mediastinit nadir, fakat yuksek oranda fatal seyreden bir durumdur. Siklikla orofarengeal veya odontojenik siddetli enfeksiyonlara bagli gelisen bir komplikasyondur. Erken tani, uygun antibiyoterapi ve cerrahi girisimle sifa olasidir. Dis apsesi sonrasi gelisen desendan nekrotizan mediastinit olgumuzu ve basarili cerrahi tedaviyi sunmaktayiz. Olgu, 48 yas erkek hasta 7 gun once baslayan sag 2.molar dis apsesi nedeniyle aldigi medikal tedaviye ragmen boyunda artan sisme, ates ve genel durum bozulmasi nedeniyle klinigimize basvurdu. Toraks tomografisinde boyun ve mediastende yaygin hava ve sivi koleksiyonu goruldu. Hastaya ikili antibiyotik tedavisi baslandi ve acil operasyona alindi. Servikal girisim ile boyun drenaji, sag torakotomi ile mediasten drenaji uygulandi. Servikal yoldan mediastene uzatilan drenlerden surekli yikama verildi ve gogus tupunden bu mayinin drenaji saglandi. Bakteriel kulturlerinde ureme olmamasi ve yikama mayisine ek drenaj olmamasi uzerine drenler sonlandirildi. Kontrol tomografisinde ve vital bulgularinda tam iyilesme gozlendi. Desendan nekrotizan mediastinit tedavisinde genis spektrumlu antibioterapi, cerrahi yaklasim gerekmektedir. En sik uygulanan cerrahi servikal yol ve torakotominin kombinasyonudur. Biz erken ve agresif cerrahinin en uygun cerrahi prosedur oldugunu dusunmekteyiz.