Ischemic necrosis of gastric tube due to intercostal drainage tube causing delayed gastropleural fistula – Rare case report

Prriya Eshpuniyani; Ramakant Deshpande; Shravan Shetty; Keyur Sheth

doi:10.4103/bjhs.bjhs_64_20

CASE REPORT

Year : 2021 | Volume : 6 | Issue : 1 | Page : 87-89

Ischemic necrosis of gastric tube due to intercostal drainage tube causing delayed gastropleural fistula – Rare case report

Prriya Eshpuniyani¹, Ramakant Deshpande¹, Shravan Shetty¹, Keyur Sheth²
¹ Department of Surgical Oncology, Asian Cancer Institute, Mumbai, Maharashtra, India
² Department of Gastroenterology, Asian Cancer Institute, Mumbai, Maharashtra, India

Date of Submission	06-Jul-2020
Date of Acceptance	17-Aug-2020
Date of Web Publication	08-Apr-2021

Correspondence Address:
Dr. Prriya Eshpuniyani
Department of Surgical Oncology, Asian Cancer Institute, Mumbai - 400 022, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/bjhs.bjhs_64_20

Abstract

Gastropleural fistula is a rare complication of a number of disease processes, much less as a reported complication of pressure necrosis of a drainage tube. We present a patient of carcinoma esophagus having developed such a posttransthoracic esophagectomy complication with cervical esophagogastric anastomosis due to the ischemic pressure necrosis due to the tip of the normally place intercostal drainage tube on the gaseous distended stomach tube.

Keywords: Gastro pleural fistula, intercostal drainage tube, ischemic necrosis, postesophagectomy complication

How to cite this article:
Eshpuniyani P, Deshpande R, Shetty S, Sheth K. Ischemic necrosis of gastric tube due to intercostal drainage tube causing delayed gastropleural fistula – Rare case report. BLDE Univ J Health Sci 2021;6:87-9

How to cite this URL:
Eshpuniyani P, Deshpande R, Shetty S, Sheth K. Ischemic necrosis of gastric tube due to intercostal drainage tube causing delayed gastropleural fistula – Rare case report. BLDE Univ J Health Sci [serial online] 2021 [cited 2022 Jul 2];6:87-9. Available from: https://www.bldeujournalhs.in/text.asp?2021/6/1/87/313360

Gastro pleural fistula (GPF) forms in a variety of pathological conditions. Markowitz and Herter in 1960^[1] described three situations that result in GPF formation: (1) when the intrathoracic portion of the stomach is perforated in the setting of esophageal hiatal hernia; (2) as a direct result of trauma, or after diaphragmatic hernia formation; and (3) when the stomach in normal intra-abdominal position is perforated, and a resultant subphrenic abscess erodes and eventually perforates the diaphragm.

However, GPF has been reported in various other rare causes: intractable postoperative nausea and vomiting, esophageal surgery, congenital diaphragmatic hernia, gastric operation for obesity, and pulmonary resection.^{[2],[3],[4],[5]}

Case Report

A 55-year-old man with middle third esophageal squamous cell carcinoma was subjected to transthoracic Esophagectomy with cervical esophagogastric anastomosis with right thoracic intercostal drainage (ICD) tube placement uneventfully after two cycles of neoadjuvant chemotherapy. He had postoperative mildly dilated gastric tube on X-ray chest. ICD was retained for longer period due to persistent lymphatic daily drainage over 200 ccs/day. A contrast study on postoperative day 8 showed good anastomotic healing and gastric emptying with no leakage anywhere of the contrast passing beyond the gastric tube in the small bowel [Figure 1]. He was started on liquids on the 8^th POD and semisolids on the 10^th POD. On the 11^th day mucky material was noticed in the right ICD bottle. Repeat contrast study showed GPF with the gastric rent to be around 1 cm [Figure 2]. Upper gastrointestinal (UGI) endoscopy confirmed the rent with the size and character exactly same as the ICD tip seen right beyond it [Figure 3]. Throughout his vitals were stable with no fever and normal blood reports.

Figure 1: First contrast study on postoperative day 9 showing normal transit of contrast through the gastric tube

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Figure 2: Contrast study on postoperative day 11 – Rent in gastric tube with contrast in the intercostal drainage tube

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Figure 3: Upper gastrointestinal scopy showing rent in gastric tube with intercostal drainage tube seen just beyond the rent with similar characteristics as intercostal drainage tube

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The ICD tip was gently withdrawn by 1inch and kept in situ. The patient was kept nil orally and continued on high protein jejunostomy feeds. Over the next 2 weeks, the ICD drainage decreased and turned clear becoming <50 ccs per day. A repeat contrast study done at this stage - after 2 weeks showed normal transit with no leak in thoracic cavity with the tip of drainage tube far from the lateral wall of the stomach [Figure 4]. The tube was removed and he was started on liquids orally and increased gradually over next 72 h. The patient was discharged on full diet requiring 28 days of hospitalization.

Figure 4: Repeat contrast study after 2 weeks of conservative management: No evidence of leak in the right hemithorax

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Discussion

Markowitz and Herter first described GPF in 1960.^[1] They described three situations that result in GPF formation: (1) when the intra-thoracic portion of the stomach is perforated in the setting of esophageal hiatal hernia; (2) as a direct result of trauma, or after diaphragmatic hernia formation; and (3) when the stomach in normal intra-abdominal position is perforated, and a resultant sub phrenic abscess erodes and eventually perforates the diaphragm.^[1] It has been reported in literature as a rare entity requiring high index of suspicion.

The diagnosis of this condition might require contrast radiology, UGI endoscopy or sometimes is even made on exploratory laparotomy or a diagnostic laparoscopy.^[5],[6] Sudden appearance of mucky material in the ICD raised our suspicion which we confirmed with a contrast study and a UGI endoscopy.

Various causes of this rare entity have been reported such as intra-thoracic perforation of stomach in hiatal hernia, traumatic diaphragmatic hernia with perforation of stomach and intra-peritoneal gastric perforation with erosion of sub phrenic abscess via diaphragm, multiple ICD tube insertions,^[7],[8] esophageal rupture either spontaneously or iatrogenically, gastric malignancy such as lymphomas, trans diaphragmatic gastric penetration after an empyema thoracis,^{[6],[7],[8],[9]} following pneumonectomy, oesophago-gastrectomy, and splenectomy.^[10],[11] List of rare causes also include intractable postoperative nausea and vomiting, esophageal surgery, congenital diaphragmatic hernia, and gastric operation for obesity.^{[2],[3],[4],[5]}

In our patient, there was pressure necrosis of stomach tube due to tip of ICD impinging probably the dilated gastric tube in this postoperative patient of transthoracic esophagectomy. It was confirmed by UGI scopy which revealed the rent in the stomach tube of the same size and character as the tip of the tube which was seen right beyond it.

As such a complication takes some time after surgery to develop the surrounding lung is expected to have developed adhesions around the gastric tube, preventing gastric contents to disseminate widely in the pleural cavity with possible cardio-respiratory de-stabilization, warranting immediate surgical intervention. In the absence of any such systemic septic complications, initial management is routinely conservative to include measures such as continuation of the ICD albeit withdrawal of the tube to introduce a gap between the causative agent of the pressing tip from the gastric wall to permit lung to migrate in between and seal the perforation, intense physiotherapy to help expand the lung, use of appropriate antibiotics, and maintaining nutrition of the patient preferably enteral or parenteral in some cases.^[12] Since our patient had the perforation due to impinging ICD we withdrew the ICD by an inch to stop the pressure and at the same time prevented the retention of the infected material inside by continuing the drainage. We continued high protein feeds through JT and hiked the antibiotics.

As per literature, most patients with GPF require surgical intervention through abdominal and/or thoracic approaches for managing this problem. Being a rare condition no suggestion for an ideal approach are forthcoming.^[12] Hsieh et al.^[13] in their publication describe that the abdominal approach is superior to the thoracotomy approach.

However, as per our observation and opinion, we feel that even a conservative approach is justified in selected circumstances if there is no evidence of content dissemination with sepsis. We therefore suggest an individualized approach in such rare cases.

Conclusion

GPF due to rent in the stomach tube due to pressure necrosis of the ICD tube is a rare entity. To the best of our knowledge, this is the first time it has been reported in the literature. The diagnosis of this condition requires high degree of suspicion and management (conservative or surgical) should be individualized for the best results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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