Outside the scope of our practice: an unexpected thoracoscopy and pleurocentesis during gastroscopy

A 56-year-old man described 2 weeks of regurgitation of ingested liquids, dyspnea, and chest pain. He had undergone laparoscopic esophagectomy with cervical anastomosis 1 year previously for esophageal adenocarcinoma; this had been complicated by a stricture at the esophagogastric anastomosis that required serial endoscopic dilations. Shortly after admission, a computed tomography (CT) scan demonstrated a dilated, fluid-filled intrathoracic stomach. There was obstruction to the passage of oral contrast at the level of the intrathoracic duodenum, and a left-sided pleural effusion was seen ([Fig. 1]).

Fig. 1 Computed tomography (CT) scan showing the dilated, fluid-filled intrathoracic stomach and a left-sided pleural effusion.

At gastroscopy, 1 L of fluid was aspirated from the intrathoracic stomach. There was an angulated deformity of the intrathoracic junction of the first and second part of the duodenum in association with a perforated ulcer on the posterior duodenal wall ([Fig. 2 a]). The gastroscope was inserted through this perforation and into the left pleural space, from which 2 L of turbid fluid were aspirated ([Fig. 2 b]). Fibrinopurulent exudate ([Fig. 2 c]) was seen on the surfaces of the lung and diaphragm ([Fig. 2 d]; [Video 1]). The pleural cavity was lavaged with sterile saline ([Fig. 2 e]). A percutaneous pleural drain and a nasogastric tube were then inserted. The perforation was closed at thoracotomy and a transdiaphragmatic omental patch was mobilized to cover the defect. The patient was discharged 2 weeks after admission.

Fig. 2 Endoscopic views showing: a a perforated ulcer in the posterior wall of the intrathoracic first part of the duodenum; b turbid fluid in the pleural space; c fibrinopurulent exudate in the pleural space; d the left lung, diaphragm, and pleural space as visualized during the gastroscopy; e sterile saline lavage of the pleural space being performed.

This video taken during gastroscopy begins with views of the left pleural space containing turbid fluid and fibrinopurulent exudate. At time 0:28, the gastroscope is withdrawn through the perforated duodenal ulcer back into the intrathoracic stomach, before being re-inserted into the pleural space at 1:00.

Intrathoracic leakages are well described post-esophagectomy [1] [2], as well as post-gastrectomy [3], usually due to breakdown of the anastomosis. In this unusual case, perforation occurred 1 year post-operatively through an ulcer in the intrathoracic duodenum, such that the pleural space was accessible with a gastroscope, which therefore enabled pleurocentesis and lavage to be performed. While therapeutic insertion of flexible endoscopes into the pleural space via percutaneous drainage tubes has been described [4], we report the first case in the literature where this has occurred via the upper gastrointestinal tract.

Endoscopy_UCTN_Code_CCL_1AB_2AG

• References

• 1 Profili S, Feo CF, Cossu ML et al. Effective management of intrathoracic anastomotic leak with covered self-expandable metal stents. Report on three cases. Emerg Radiol 2008; 15: 57-60
• 2 Alanezi K, Urschel J. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2008; 10: 71-75
• 3 Yonggang L, Yuan S, Yun J et al. Management of intrathoracic leakage after radical total gastrectomy. J Thorac Dis 2010; 2: 180-184
• 4 Wang Z, Wang L, Jian H. Electronic endoscope insertion into a thoracic drainage tube is a new technique in the treatment and diagnosis of pleural disease. Surg Endosc 2009; 23: 1671-1673