The Fishbone Lady

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The Fishbone Lady!

• Nick Maynard MS FRCSConsultant UGI
  SurgeonOxford Oesophagogastric Unit

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• 57 yr old lady attended AE of a District General
  Hospital with central chest pain after eating
  fish with bones.
• Examination, bloods, CXR all normal and she was
  discharged
• 4 days later, readmitted with worsening chest
  pain
• Examination normal, WCC 16.29, CXR showed
  pneumomediastinum
• Diagnosis oesophageal perforation secondary to
  fishbone.

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• Discussed with specialist OG Unit advised
  urgent transfer
• Bed manager prevented transfer due to lack of
  beds!
• 10 hrs later, still not transferred, respiratory
  arrest at 4am
• Intubation difficult tracheal stenosis just
  beyond cords
• Emergency CT scan carried out at DGH
• Further discussion with Specialist OG Unit
• Immediate transfer via blue light ambulance
• Diagnosis mediastinal abscess secondary to
  oesophageal perforation leading to tracheal
  compression

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Pre-contrast CT scan
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Post-Contrast CT scan
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• Pre Contrast CT scan Gas filled collection
  around oesophagus in superior mediastinum, with
  tracheal compression
• Post Contrast CT scanContrast seen (in
  retrospect) in abscess cavity. Aortic injury not
  initially suspected!
• Increasingly difficult to ventilate so taken to
  theatre for emergency thoracotomy

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Emergency Thoracotomy 1

• Right 5th rib posterolateral thoracotomy
• Grossly thickened pleura 8 mm
• Tense collection of pus in superior mediastinum
• Collection incised to drain thick pus followed by
  arterial blood at high pressure!
• Diagnosis - Mycotic rupture of arch of aorta

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Emergency Thoracotomy 2

• Digital pressure control of bleeding
• Thoracotomy extended anteriorly and pericardium
  opened
• Cardio-pulmonary bypass ascending aorta to
  right atrium and hypothermic circulatory arrest
• Repair of 1cm necrotic hole in aortic arch with
  homograft aortic patch
• Oesophagectomy stapled at hiatus and at
  thoracic inlet

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Following stabilization on ICU

• Two days later
• Laparotomy Tunnelled feeding jejunostomy
• Cervicotomy Proximal cervical oesophagostomy
• Discharge home day 20

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4 months later admitted for reconstruction

• Resection of manubrium sternum
• Mobilisation of oesophagostomy
• Gastric tube mobilised on right gastroepiploic
  pedicle
• Substernal anterior mediastinal tunnel
• Single layer handsewn anastomosis 3/0 PDS
• Discharge home day 10 eating and drinking

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Oesophageal Reconstruction
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Oesophagogastric Anastomosis