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. |