Abstract Introduction Esophagopleural fistula (EPF) is an uncommon but serious condition characterized by an abnormal communication between the esophagus and pleural cavity. It carries significant morbidity and mortality due to the risk of severe infection, sepsis, and respiratory compromise. Etiologies include trauma, infection, iatrogenic injury, and malignancy, while postoperative cases remain rare. Clinical presentation is often nonspecific. In postoperative patients, particularly those with recent foregut surgery, pleural fluid amylase measurement can provide a crucial early diagnostic clue before imaging confirmation. Diagnosis requires a high index of suspicion and is typically confirmed through imaging with oral contrast or endoscopy. The following case illustrates a postoperative EPF after paraesophageal hernia repair, highlighting the importance of early recognition and multidisciplinary management. Case Description An 82-year-old man with hypertension, hyperlipidemia, and anxiety presented with two days of progressive dyspnea and weakness, two weeks after robotic paraesophageal hernia repair complicated by COVID-19 pneumonia requiring intensive care. On EMS arrival, he was tachypneic and hypoxic, improving with a non-rebreather. Initial labs revealed leukocytosis, acute kidney injury, and non-anion gap metabolic acidosis. Chest imaging showed near-complete opacification of the right hemithorax; CT abdomen/pelvis demonstrated a large right pleural effusion with compressive atelectasis, right-sided pericardial fluid, and a distended esophagus. He was admitted for sepsis and acute hypoxemic respiratory failure secondary to suspected pneumonia with parapneumonic effusion and started on intravenous fluids and antibiotics. Pulmonary consultation led to thoracentesis yielding 1.2 L of serous fluid. Pleural studies showed an exudative effusion with elevated amylase, prompting CT with oral contrast, which revealed distal esophageal contrast extravasation consistent with EPF. Cardiothoracic surgery performed robotic-assisted right thoracoscopy with decortication, mediastinal debridement, esophageal stent placement, and gastrojejunostomy tube insertion. Postoperative diagnosis confirmed gastric perforation. The patient’s course was notable for extubation, vasopressor weaning, initiation of oral intake, and eventual discharge to rehabilitation. Discussion EPF is a rare but potentially fatal condition that is difficult to diagnose due to nonspecific symptoms and overlap with other thoracic diseases. Elevated pleural amylase is a key clue suggesting an esophageal or pancreatic source and warrants prompt evaluation. CT with oral contrast is valuable for confirming diagnosis. In this case, paraesophageal hernia repair and postoperative infection likely contributed to the fistula. Effective management requires a multidisciplinary approach involving surgery, debridement, stenting, or alternative feeding routes. This case emphasizes early suspicion and coordinated care in postoperative patients with unexplained pleural effusion and elevated amylase to improve outcomes. This abstract is funded by: None
Mobeen et al. (Fri,) studied this question.