DOI: http://dx.doi.org/10.18203/2349-2902.isj20214389

Iatrogenic esophageal perforation with mediastinitis, multidisciplinary management: a case report

Juliana Mancera, Anibal M. Ariza, Mauricio Pelaez, Sebastian Benavides, Alfonso C. Márquez

Abstract


Acute mediastinitis is a low incidence pathology, but it is associated with a high mortality rate. Iatrogenic lesions are the most common cause of mediastinitis secondary to esophageal perforation. Early diagnosis and surgical treatment are the most important factors in the treatment of patients with this condition.  83-year-old female patient, with a history of left saphenectomy due to venous insufficiency with difficult intubation two days prior to the emergency consultation. She was admitted to the emergency room due to dyspnea, hemoptysis, chest pain, and right hemifacial edema. A chest tomography was performed with findings suggestive of esophageal perforation or airway injury. Later, in an upper digestive tract study, extravasation of the contrast medium was documented in the right posterolateral wall of the cervical esophagus with a collection in the middle mediastinum. The patient was taken for drainage of mediastinitis by right thoracoscopy and the presence of a perforation in the cervical esophagus was confirmed with an intraoperative endoscopy. Esophageal repair was performed, with drainage of the prevertebral space and the superior mediastinum by a left longitudinal cervicotomy. Postoperatively, she received antibiotic and enteral nutritional support by a nasojejunal tube. Low output fistula of the cervical esophagus, organized by a drain, was documented, which closed after 4 weeks of conservative management. Iatrogenic esophageal perforation with mediastinitis is a very rare entity with a high mortality. Early surgical treatment is the most important prognostic factor in patients with mediastinitis due to esophageal perforation.


Keywords


Esophagus, Mediastinitis, Esophageal perforation, Thoracoscopy, Esophageal fistula

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References


Zelada I, Farina C, Lee C, Agüero Á. Acute Mediastinitis. Retrospective Analysis of 12 Cases. Cir Paraguaya. 2019;43(1):12-5.

Kiernan PD, Hernandez A, Byrne WD, Bloom R, Dicicco B, Hetrick V, et al. Descending cervical mediastinitis. Ann Thorac Surg. 1998;65(5):1483-8.

Dajer-Fadel WL, Ibarra-Pérez C, Sánchez-Velázquez LD, Borrego-Borrego R, Navarro-Reynoso FP, Argüero-Sánchez R. Descending necrotizing mediastinitis below the tracheal carina. Asian Cardiovasc Thorac Ann. 2014;22(2):176-82.

Martínez Vallina P, Espinosa Jiménez D, Pérez LH, Triviño Ramírez A. Mediastinitis. Arch Bronconeumol. 2011;47(8):32-6.

Misiak P, Jabłoński S, Piskorz Ł, Dorozała L, Terlecki A, Wcisło S. Oesophageal perforation - Therapeutic and diagnostics challenge. Retrospective, single-centre case report analysis (2009-2015). Pol Prz Chir Polish J Surg. 2017;89(4):1-5.

Giménez A, Franquet T, Erasmus JJ, Martínez S, Estrada P. Thoracic complications of esophageal disorders. Radiographics. 2002;22.

Ohri SK, Liakakos TA, Pathi V, Townsend ER, Fountain SW. Primary repair of iatrogenic thoracic esophageal perforation and Boerhaave’s syndrome. Ann Thorac Surg. 1993;55(3):603-6.

Burnett CM, Rosemurgy AS, Pfeiffer EA. Life-threatening acute posterior mediastinitis due to esophageal perforation. Ann Thorac Surg. 1990;49(6):979-83.

Seal KA, Kini S. Esophageal perforation and mediastinitis. Pract Emerg Resusc Crit Care. 2013;278-83.

Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg. 2004;77(4):1475-83.

Cross MR, Greenwald MF, Dahhan A, Esposito S. Esophageal perforation and acute bacterial mediastinitis: Other causes of Chest Pain That can be easily missed. Med (United States). 2015;94(32).

Jabłoński S, Brocki M, Kordiak J, Misiak P, Terlecki A, Kozakiewicz M. Acute mediastinitis: evaluation of clinical risk factors for death in surgically treated patients. ANZ J Surg. 2013;83(9):657-63.

Cho JS, Kim YD, Hoseok I, Lee SK, Jeong YJ. Treatment of mediastinitis using video-assisted thoracoscopic surgery. Jeong Su Cho.Eur J Cardiothorac Sur. 2008;34(3):520-4.

Pastene B, Cassir N, Tankel J, Einav S, Fournier PE, Thomas P, et al. Mediastinitis in the intensive care unit patient: a narrative review. Clin Microbiol Inf. 2020;26(1):26-34.