DOI:10.2214/AJR.05.0297
AJR 2006; 186:1627-1629
© American Roentgen Ray Society
Esophagopleural Fistula Secondary to Esophageal Wall Ballooning and Thinning After Pneumonectomy: Findings on Chest CT and Esophagography
Peter S. Liu,
Marc S. Levine and
Drew A. Torigian
Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
Received February 21, 2005;
accepted after revision March 14, 2005.
Address correspondence to M. S. Levine
(marc.levine{at}uphs.upenn.edu).
Keywords: CT • esophageal disease • esophagography
Case Report
Esophagopleural fistula is an uncommon complication of pneumonectomy
associated with a high morbidity and mortality because of ensuing empyema and
nutritional debilitation [1].
We encountered a patient with an esophagopleural fistula after pneumonectomy
in whom chest CT and esophagography revealed focal ballooning and thinning of
the esophageal wall in the region of the operative bed; this phenomenon
presumably was responsible for the fistula. To our knowledge, such findings
have not been described previously on CT in patients who developed
esophagopleural fistulas. We therefore report the clinical and imaging
features in our case and discuss their importance. We also report the chest CT
and fluoroscopic imaging findings in a second patient with focal esophageal
wall ballooning and thinning without fistula formation.
Case 1
A 48-year-old woman with biopsy-proven non-small cell carcinoma of the left
lung underwent a left pneumonectomy. At surgery, tumor was found to be
invading the wall of the mid esophagus as far as the muscularis propria. Tumor
was carefully dissected from the esophageal wall, necessitating resection of
the outer half of the muscularis propria over a 6-cm-long segment of the mid
esophagus. (The inner half of the muscularis propria was not violated.) The
patient tolerated the surgery well, and a postoperative upper gastrointestinal
examination with water-soluble contrast material (diatrizoate meglumine and
diatrizoate sodium [Gastroview, Mallinckrodt]) revealed no evidence of
esophageal perforation or fistula formation.
After receiving postoperative chemotherapy and mediastinal irradiation, the
patient complained of substernal dysphagia. A repeat esophagram 5 months after
surgery revealed asymmetric ballooning of the left lateral wall of the mid
esophagus, presumably because of surgical absence of the muscularis propria in
this region (Fig. 1A). A chest
CT also revealed eccentric ballooning and marked thinning of the left lateral
wall of the mid esophagus in comparison to the remainder of the esophageal
wall circumference (Fig.
1B).
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Fig. 1A —48-year-old woman with esophagopleural fistula secondary to
esophageal wall ballooning and thinning after pneumonectomy. Frontal image
from single-contrast esophagram 5 months after pneumonectomy shows asymmetric
ballooning (arrows) of left lateral wall of mid esophagus.
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Fig. 1B —48-year-old woman with esophagopleural fistula secondary to
esophageal wall ballooning and thinning after pneumonectomy. Axial
contrast-enhanced CT image shows postsurgical changes from left pneumonectomy
with asymmetric ballooning and thinning (arrow) of left lateral wall
of mid esophagus. Note thickness of normal right lateral and anterolateral
walls (arrowheads) of mid esophagus for comparison.
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The patient developed a high fever and productive cough 10 months after
surgery, and chest radiographs revealed a left-sided hydropneumothorax with an
air-fluid level in the left pleural space. A repeat esophagram with
water-soluble contrast material (Gastroview) revealed an esophagopleural
fistula with focal extravasation of contrast material from the site of
esophageal ballooning into the left pleural space
(Fig. 1C). A repeat chest CT
with oral contrast material also revealed an esophagopleural fistula at the
site of esophageal wall ballooning and thinning, with oral contrast material
and air in the left pleural space (Fig.
1D). The patient underwent an emergent esophagogastrectomy and
gastric pull-through. Her postoperative course was uneventful, and she was
discharged from the hospital in satisfactory condition.
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Fig. 1C —48-year-old woman with esophagopleural fistula secondary to
esophageal wall ballooning and thinning after pneumonectomy. Frontal image
from single-contrast esophagram with water-soluble contrast material 10 months
after surgery shows leakage (L) of oral contrast material from left lateral
wall (arrow) of ballooned mid esophagus into left pleural space,
indicating esophagopleural fistula.
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Fig. 1D —48-year-old woman with esophagopleural fistula secondary to
esophageal wall ballooning and thinning after pneumonectomy. Axial
contrast-enhanced CT image also shows esophagopleural fistula (short
arrow) at site of esophageal wall ballooning and thinning with oral
contrast material (long arrow) and air in left pleural
space.
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Case 2
A 50-year-old man with dysphagia underwent surgical enucleation of a
biopsy-proven esophageal leiomyoma. The patient developed recurrent dysphagia
3 years later, and an esophagram showed eccentric ballooning of the right
lateral wall of the distal esophagus in the region of the myomectomy
(Fig. 2A). Chest CT also
revealed asymmetric ballooning and thinning of the right lateral wall of the
distal esophagus in comparison to the remainder of the esophageal wall
circumference, presumably because of disruption of the muscular layer from the
myomectomy (Fig. 2B). The
patient underwent repeat surgery with resection of the abnormal esophageal
segment.
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Fig. 2A —50-year-old man with esophageal wall ballooning and thinning after
resection of leiomyoma. Frontal image from single-contrast esophagram 3 years
after surgery shows asymmetric ballooning (arrows) of right lateral
wall of distal esophagus.
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Fig. 2B —50-year-old man with esophageal wall ballooning and thinning after
resection of leiomyoma. Axial contrast-enhanced CT image shows ballooning and
thinning (arrows) of right lateral wall of distal esophagus with
retained oral contrast material and debris in lumen. Note thickness of normal
left lateral wall (arrowhead) of distal esophagus for comparison.
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Discussion
Esophagopleural fistula is an uncommon complication of pneumonectomy,
occurring in up to 1% of patients
[2]. Affected individuals may
present with signs and symptoms of empyema, such as chest pain, high fever,
and hypotension. Additional symptoms of dysphagia, odynophagia, or
foul-tasting regurgitations should suggest the possibility of an
esophagopleural fistula [3].
The presence of food particles or gastric contents in the pleural space
confirms this diagnosis [1].
Such fistulas can develop during the early or late postoperative periods after
pneumonectomy [1,
4]. Early fistulas may result
from direct injury to the esophagus at surgery, particularly if tumor is
dissected from the esophageal wall, as in our patient
[3,
5]. Indirect esophageal injury
may also occur as a result of devascularization of the esophagus after
mediastinal lymphadenectomy or excessive electrocauterization
[5,
6]. In contrast, late fistulas
are usually caused by recurrent tumor or chronic infection
[1-5].
Nonoperative management of esophagopleural fistulas is associated with
mortality rates approaching 100%
[5], whereas surgical repair is
associated with mortality rates of approximately 50%
[1]. Early diagnosis and
treatment of esophagopleural fistulas therefore is essential for these
patients.
In our first patient, an esophagram and chest CT after pneumonectomy
revealed marked esophageal ballooning where tumor was dissected from the
esophageal wall and the outer layer of the muscularis propria was resected.
Similarly, in our second patient, these two imaging studies revealed focal
ballooning of the distal esophagus, this time after esophageal myomectomy.
Asymmetric ballooning of the distal esophagus has also been described on
barium studies after Heller myotomy for achalasia
[7]. Thus, focal ballooning of
the esophageal wall appears to be a sign of surgical disruption of the
muscularis propria, regardless of the indication for surgery.
In both patients, CT scans also revealed marked thinning of the involved
esophageal wall in comparison to the remainder of the esophageal wall
circumference, a finding that indicated surgical disruption of the muscular
layer. Our first patient subsequently presented with a high fever and a left
hydropneumothorax on chest radiographs; both an esophagram and chest CT
revealed an esophagopleural fistula at the site of esophageal ballooning and
wall thinning, which presumably predisposed this patient to the development of
a fistula. Radiologists therefore should recognize the possible increased risk
of esophageal breakdown and esophagopleural fistula formation when CT and
esophagography reveal asymmetric ballooning and thinning of the esophageal
wall after pneumonectomy or other types of surgery in which the muscularis
propria is disrupted.
In conclusion, we report characteristic findings of eccentric ballooning
and thinning of the esophageal wall on chest CT and esophagography after
surgical disruption of the muscularis propria in two patients. This esophageal
wall thinning may predispose patients to the development of potentially
life-threatening esophagopleural fistulas. Radiologists therefore should be
aware of the characteristic findings on CT and esophagography in these
patients.
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RadioGraphics 2002;22
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Case Report
Discussion
