Clinical
Presentation
A 43 year old female presented with signs and symptoms of
gastroesophageal reflux disease (GERD). Endoscopic
examination revealed the presence of a hiatal hernia and
an esophageal diverticulum. Surgery was performed to
repair the hiatus hernia and excise of the 2.5 cm
esophageal diverticulum via a left sided thoracotomy. Hospital
Course
After surgery, the patient was placed on prophylactic
antibiotics. One day after surgery she developed fever
and leukocytosis and was reluctant to cough and deep
breathing because of pain. Six days after surgery she
developed bronchopneumonia. Cultures of the tracheal
aspirate showed a mixed flora of gram positive and gram
negative bacilli. She was placed on IV (intravenous)
antibiotics. On the seventh postoperative day, she was
cyanotic and incoherent. She was placed on assisted
ventilation with 100% oxygen. The patient's condition
worsened and nine days after surgery she developed wound
infection and dehisence as well as an associated left
sided empyema. Cultures grew anaerobes from the surgical
wound and from the blood. The patient become comatose,
developed septic shock and died sixteen days after
surgical resection of the esophageal diverticulum and
repair of the hiatal hernia.
Autopsy Examination
The main autopsy findings were a partial dehiscence of
the esophageal surgical wound followed by an
esophagothoracic fistula, mediastinitis and empyema of
the the left pleural cavity with extension in the the
abdominal cavity. Pre-mortem cultures from the empyema
grew Bacteroides fragilis and Peptostreptococcus.
Other autopsy findings showed hemorrhagic necrosis of
both adrenal glands and severe myeloid hyperplasia of the
bone marrow. The cause of death was attributed to gram
negative septic shock due to a post surgical esophageal
wound dehiscence.
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