{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T22:34:53Z","timestamp":1774478093574,"version":"3.50.1"},"reference-count":0,"publisher":"BMJ","issue":"1","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Trauma Surg Acute Care Open"],"accepted":{"date-parts":[[2019,3,3]]},"published-print":{"date-parts":[[2019,3]]},"abstract":"<jats:sec><jats:title\/><jats:p>A 48-year-old man was admitted for medical management of recurrent<jats:italic>Clostridium difficile<\/jats:italic>(C-dif) colitis. One month prior to presentation, he underwent right thoracotomy and lower lobectomy for a carcinoid tumor at another hospital. His postoperative course was complicated by C-dif colitis, gastroesophageal reflux, and epigastric pain. He underwent two esophagogastroduodenoscopy (EGD) procedures demonstrating mild esophagitis on the first procedure, followed by a linear ulcer on the second procedure 2 weeks later. On hospital day 9 of his current admission, he developed an acute abdomen and underwent an urgent exploratory laparotomy for presumed fulminant colitis. Findings included a healthy-appearing colon with only moderate distension, so a loop ileostomy was created for antegrade colonic irrigation. Postoperatively, a chest X-ray demonstrated a tension-appearing left pleural effusion, prompting tube thoracostomy placement. Initial output was greater than 2L of thin dark-brown fluid. An esophagram demonstrated a distal esophageal perforation (EP) and EGD was performed. Two medium-sized EPs were identified which appeared to arise from chronic-appearing ulcerations, one at 39 cm and one at 45 cm from the incisors (figure 1). A single 19mm\u00d7100 mm EndoMAXX fully covered stent was placed. Video-assisted thoracoscopic (VATS) drainage of the left hemithorax was performed in addition to placement of a right tube thoracostomy. Due to continued high output from the left thoracostomy tube, the stent was exchanged for a longer 23mm\u00d7100mm EndoMAXX fully covered stent. The patient stabilized for several days but again developed worsened sepsis, with EGD demonstrating inadequate coverage of the proximal perforation.<\/jats:p><jats:fig position=\"float\" id=\"F1\" orientation=\"portrait\"><jats:label>Figure 1<\/jats:label><jats:caption><jats:p>Endoscopic photograph showing left-sided esophageal perforation\/fistula (black arrow). Gastroesophageal junction indicated by white arrow. NG, Nasogastric tube.<\/jats:p><\/jats:caption><jats:graphic xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"tsaco-2018-000206f01\" position=\"float\" orientation=\"portrait\"\/><\/jats:fig><\/jats:sec><jats:sec><jats:title>What would you have done?<\/jats:title><jats:list list-type=\"alpha-upper\"><jats:list-item><jats:p>Repeat esophageal stenting with wide drainage of the thoracic cavity.<\/jats:p><\/jats:list-item><jats:list-item><jats:p>Esophageal T-tube placement and wide drainage of the thoracic cavity.<\/jats:p><\/jats:list-item><jats:list-item><jats:p>Esophageal resection with gastrostomy drainage and proximal diversion.<\/jats:p><\/jats:list-item><jats:list-item><jats:p>Bilateral tube thoracostomies and antibiotic\/antifungal therapy.<\/jats:p><\/jats:list-item><\/jats:list><\/jats:sec>","DOI":"10.1136\/tsaco-2018-000206","type":"journal-article","created":{"date-parts":[[2019,3,28]],"date-time":"2019-03-28T10:50:21Z","timestamp":1553770221000},"page":"e000206","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Esophageal perforations: one is bad, two is worse"],"prefix":"10.1136","volume":"4","author":[{"given":"Dustin","family":"Price","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Skarupa","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2019,3,27]]},"container-title":["Trauma Surgery &amp; Acute Care Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/tsaco-2018-000206","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,9,21]],"date-time":"2024-09-21T12:05:19Z","timestamp":1726920319000},"score":1,"resource":{"primary":{"URL":"https:\/\/tsaco.bmj.com\/lookup\/doi\/10.1136\/tsaco-2018-000206"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,3]]},"references-count":0,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2019,3,27]]},"published-print":{"date-parts":[[2019,3]]}},"alternative-id":["10.1136\/tsaco-2018-000206"],"URL":"https:\/\/doi.org\/10.1136\/tsaco-2018-000206","relation":{},"ISSN":["2397-5776"],"issn-type":[{"value":"2397-5776","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,3]]}}}