Thoracoscopic management of oesophageal mucocele: Old complication, new approach.

Oesophageal mucocele is an uncommon complication of bipolar exclusion of oesophagus. Traditionally, this condition is managed through thoracotomy which is associated with significant morbidity. The present report outlines the thoracoscopic management of oesophageal mucocele following surgical exclusion for oesophageal perforation. Left thoracoscopic oesophagectomy for oesophageal mucocele described in this report has not been published earlier.

INTRODUCTION

Surgical exclusion of the thoracic oesophagus is a commonly performed procedure for patients who present late with thoracic oesophageal perforation. An uncommon complication of oesophageal exclusion is oesophageal mucocele (EMC).[12] It occurs due to the accumulation of mucosal secretions in the excluded segment. Symptomatic EMC needs treatment as life-threatening respiratory distress and fistulisation secondary to large EMC have been reported.[34] Traditionally, resection of the EMC is done through right thoracotomy which is associated with significant post-operative pain and respiratory complications.[1234] Minimally invasive oesophagectomy using right-sided thoracoscopy has been commonly used for benign and malignant oesophageal tumours.[5] Use of thoracoscopy, especially left-sided thoracoscopic oesophagectomy, for EMC has not been reported earlier.

CASE REPORT

A 22-year-old female who developed sudden-onset chest pain and respiratory distress after ingestion of chicken bone was referred to our centre as a case of right hydropneumothorax 4 days after the onset of symptoms. Intercostal chest drain placed in the right pleural cavity drained pus with food residues. Contrast-enhanced computed tomography (CECT) of the neck, thorax and abdomen confirmed uncontrolled oesophageal perforation. Given late presentation and sepsis, she underwent thoracoscopic decortication of the right lung, laparoscopic oesophageal bipolar exclusion, cervical oesophagostomy and feeding jejunostomy. Six weeks later, the patient underwent laparoscopic-assisted retrosternal gastric bypass with single-stapled cervical oesophago-gastric anastomosis. One year later, the patient presented with complaints of tightness in the chest and dyspnoea with the weight loss of 10 kg secondary to the inadequate oral intake. CECT thorax and abdomen showed dilated native oesophagus suggestive of EMC [Figure 1a]. After nutritional optimisation, she was taken up for thoracoscopic excision of the EMC in the prone position. Right-sided thoracoscopic approach was not feasible owing to dense adhesions between the right lung and parietal pleura. Hence, left-sided approach was used. Four ports were placed; a 12 mm camera port in the 7th intercostal space (ICS) between mid and posterior axillary line, a 12 mm working port in 9th ICS along scapular line, a 5 mm working port in the 5th ICS along scapular line and another 5 mm port in 4th ICS along the medial border of scapula. Distended lower end of the oesophagus was visualised after opening mediastinal pleura. The oesophagus was dissected from aorta posteriorly and from pericardium anteriorly and looped with endoloop for traction [Figure 1b]. Subtotal oesophagectomy was done retaining only the highest portion of the proximal thoracic oesophagus [Figure 2a and b]. The residual mucosa was ablated with electrocautery. She had an uneventful post-operative course and discharged on the 3rd post-operative day. At 9-month follow-up, the patient is asymptomatic.

Figure 1

(a) Axial cut of contrast-enhanced computed tomography thorax showing oesophageal mucocele (black arrow) and the retrosternal gastric conduit (white arrow). (b) Oesophagus looped with endoloop to provide traction during dissection

Figure 2

(a and b) Whitish mucocele fluid drained and subtotal oesophagectomy being performed

DISCUSSION

The formation of EMC indicates partial destruction of the oesophageal wall. Hence, EMC is relatively more common after exclusion for spontaneous or foreign body-induced oesophageal perforation, achalasia cardia or congenital oesophageal atresia compared to caustic strictures.[3] Symptomatic mucocele should be treated to prevent mucocele-related complications such as tracheal compression, fistulisation into tracheobronchial tree and neck or abdominal abscess secondary to upper or lower end blowout.[34]

The definitive treatment of a symptomatic EMC is excision of the oesophageal remnant. In the majority of the reported cases, it is done through thoracotomy which is associated with significant post-operative morbidity.[14] In the current era, a thoracoscopic approach is preferred for the treatment of benign and malignant oesophageal diseases as it minimises post-operative morbidity.[5] At our centre, we routinely perform thoracoscopic oesophagectomy for oesophageal cancer. Thoracoscopic oesophagectomy can be done in the left lateral or prone position. In addition to the described advantages of prone position such as gravity-assisted oesophageal exposure, avoidance of single lung ventilation and less interference due to pooling of blood, it has distinct benefits in patients with EMC, complicating exclusion for oesophageal perforation.[5] Extensive pleural and mediastinal adhesions are a common finding in these patients. Usually, the adhesions are restricted to one side; right side in patients with mid-oesophageal perforation and left side in patients with Boerhaave syndrome. However, it can be bilateral with varying severity in some patients. The prone position provides an opportunity to explore from both sides. In the present report, thoracoscopy was attempted from the right side as oesophagectomy from the right side is technically easier. However, extensive adhesions prevented adequate port placement. Prone position facilitated exposure from the left side without changing the patient's position. Use of left-sided thoracoscopic approach for the treatment of EMC has not been previously reported in literature. One limitation of the left-sided approach is oesophageal dissection above the level of the aortic arch is technically difficult. Hence, a subtotal oesophagectomy with ablation of the residual oesophageal mucosa was done.

As management of EMC is complex, efforts should be made to prevent its formation. Whenever possible, bipolar exclusion should be avoided. However, in haemodynamically unstable patients with oesophageal perforation not fit for oesophagectomy, bipolar exclusion is a safer option. In patients who underwent oesophageal exclusion, an attempt should be made to perform oesophagectomy during second-stage oesophageal bypass surgery. Given the poor general condition of the patient in our case, oesophagectomy was not attempted to reduce the magnitude of second-stage surgery. The present report highlights the feasibility of minimally invasive thoracoscopic approach for the management of EMC. Thoracoscopic surgery should be the preferred approach as it significantly reduces post-operative morbidity and facilitates quick recovery in these frail patients.

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Conflicts of interest

There are no conflicts of interest.