Esophagopleural fistula due to esophageal injury during pulmonary resection for lung abscess successfully treated by open-window thoracotomy followed by negative pressure wound therapy-A case report

Esophagopleural fistula caused by iatrogenic injury during pulmonary resection is a severe complication. Although a variety of treatments exist, management of the fistula must be individualized because of the diversity of patient's conditions and specific characteristics of the fistula. We report a case of esophagopleural fistula related to an intraoperative esophageal injury during pulmonary lobectomy for a chronic lung abscess, which was successfully treated by open-window thoracotomy followed by Negative Pressure Wound Therapy (NPWT). A 72-year-old man was referred to our hospital with persistent cough and recurrent fever. He was diagnosed with chronic lung abscess in the right lower lobe and underwent right lower lobectomy. An esophageal injury occurred during adhesiolysis around the lung as the lower lobe rigidly adhered to the esophagus and the boundary between these two organs was unclear. The injured esophagus was directly repaired and reinforced with a pericardial fat pad flap. Five days after surgery, empyema developed due to the suture line leak. We immediately performed a re-thoracotomy. The residual lung lobes had not adhered to the chest wall;therefore, the injured part of the esophagus was resutured after debridement of the damaged tissue, and then the patient was mechanically ventilated for 5 days to localize the empyema cavity. An open-window thoracotomy was performed to drain the cavity soon after the esophageal fistula had been confirmed by a contrast study 11 days after the second surgery, and the cavity was irrigated two times daily with saline. To optimize the caloric intake, parenteral nutrition was used together with enteric feeding via a nasojejunal tube. We used NPWT to facilitate granulation and reduce the size of the cavity after the fistula had healed. The wound was closed directly without any flap transplantation 46 days after the open-window thoracotomy. The patient was discharged in a favorable condition.