fifteen years earlier , she had undergone left modified radical mastectomy for infiltrating ductal carcinoma of the breast ( pathologic stating of t1n0m0 , according to the american joint committee on cancer [ ajcc ] tumor - node - metastasis [ tnm ] classification for breast cancer ) .
thereafter , she received chemotherapy twice and underwent radiation therapy ( rt , 55 gy ) for recurrence at the cervical , axillary , and internal mammary lymph nodes . a thorough work - up for dysphagia revealed squamous cell carcinoma at the mid - thoracic portion of the esophagus 26 to 30 cm from the upper incisor .
transthoracic esophagectomy with mediastinal lymphadenectomy and reconstruction using a gastric tube according to the ivor lewis procedure was performed in the usual manner with hand - sewn anastomosis .
because the apical portion of the right upper lobe was fibrotic and tightly attached to the parietal pleura , it was injured during dissection and wedge resection was done .
the final pathologic report cited moderately differentiated squamous cell carcinoma that had invaded to the adventitia without metastasis to mediastinal ( 0/12 ) or perigastric lymph nodes ( 0/30 ) ; pathologic staging of t3n0m0 ( stage iib ) according to the 7th edition of the ajcc tnm classification for esophageal cancer . in the wedge - resected portion of the lung , atrophy and diffuse sclerosis was noted .
serous fluid was drained through a chest tube at the rate of approximately 300 to 400 ml / day .
on postoperative day 3 , the patient complained of a sudden onset of dyspnea and continuous cough with a marked inspiratory and expiratory wheezing sound . on the chest x - ray ,
upper mediastinal widening was detected , but it was first thought to be related to the gastric conduit and was not different from the chest x - ray checked before . because respiratory distress was aggravated remarkably , endotracheal intubation followed by mechanical ventilation was applied , but her respiratory symptoms did not improve much in spite of the fact that the endotracheal tube was placed appropriately ( fig .
2 ) with intravenous contrast demonstrated a large mediastinal fluid collection from the thoracic inlet to the inferior pulmonary vein level that caused marked luminal compression on the trachea and the gastric conduit .
mediastinitis with abscess formation due to leakage at the anastomosis site was first considered , but leakage was not detected through a chest tube by using the methylene blue dye swallowing test .
on explorative thoracotomy , inflammatory signs were not prominent in the pleural cavity . while mobilizing the gastric conduit , the clear serous fluid spilled out from the space between the trachea and the gastric conduit . even after draining the fluid completely ,
the space was not obliterated , which was assumed to be caused by rt - induced thickened and fibrotic mediastinal pleura .
the esophagogastric anastomosis portion and the gastric conduit were preserved well without any infection or dehiscence .
no leakage from the mediastinum was found after instillation of 100 ml of milk through a levin tube . upon placing the chest tube into this space , we considered the operation completed .
the patient s respiratory - related symptoms all improved , and she was ready to be transferred to the general ward the next day .
eight days after esophagectomy , a gastrografin ( berlimed sa , madrid , spain ) swallow study revealed that minor leakage was suspected at the esophagogastric anastomosis site .
enteral feeding through a jejunostomy tube was started , and the next day , about 1,000 ml of a turbid fluid was drained , which was confirmed as chyle by a biochemical analysis of triglyceride contents .
total parenteral nutrition was started again , and ten days later , drainage of chyle was no longer observed .
, pyeongtaek , korea ) was delivered for aggravated focal dehiscence at the anastomosis site on the follow - up ct scan .
the patient was discharged 2 months later ; then , she was eating a regular diet and had a mini pigtail drainage catheter ( 10fr ; uresil , skokie , il , usa ) for empyema in the apex .
although airway obstruction is a well - recognized complication of the anterior mediastinal mass in infants and children whose airways are compressible , it is quite rare in the adult population after esophageal surgery , and few such cases have been reported .
three cases of tracheal compression have developed after transhiatal esophagectomy ( the ) with a gastric pull - up procedure [ 35 ] .
the distended transposed stomach compressed the trachea in a 58-year - old male patient of achalasia , and another case of tracheal compression developed in a 61-year - old male patient with esophageal cancer who had undergone neo - adjuvant chemoradiotherapy .
ikeda et al . reported a case of tracheal compression after the in a 66-year - old female patient with ankylosing spondylitis , implying that the possible causes were the small distance between the sternum and the vertebrae , and the loss of flexibility of the thorax and the mediastinum .
because the is composed of blunt dissection and unintentional repositioning of the stomach within a limited space , the membranous portion of the trachea can be compressed by a transposed stomach , particularly when the space provides little capacity for them .
it is more likely to occur when the mediastinal pleura around the esophagus is thickened or fibrotic .
in contrast , during the ivor lewis operation , because the mediastinal pleura over the esophagus is dissected and the transposed gastric tube is rearranged in the space of the resected esophagus and the right pleural cavity , the trachea will not usually be compressed by the stomach , except upon the sudden onset of distension by bleeding . one case of tracheal compression after the ivor lewis operation was reported , which occurred due to intramural hematoma of the gastric tube in a patient of anticoagulation therapy for atrial fibrillation .
in addition , an airway can be compressed by mediastinitis induced by intramural perforation and a peritracheal abscess , and mediastinal chyloma after a successful conservative treatment of chylothorax . in these cases ,
regretfully , the author did not perform a biochemical analysis during re - operation to confirm the diagnosis , but the possibility of chyloma was very high because chylothorax developed eventually , although the volume of drainage was limited and the nature had been clear until jejunostomy feeding despite instillation of milk during the re - operation .
the chest ct scan was the most valuable test for the exact diagnosis , because the serial chest x - ray did not show tracheal obstruction even when respiratory distress developed .
however , above all , the possibility of airway obstruction should always be considered when a patient with mediastinal pathology complains of the sudden onset of respiratory deterioration .
the decision on how to manage the obstruction should be made as soon as possible , because complete obstruction can occur suddenly despite an appropriately positioned tracheal tube and mechanical ventilation when the endotracheal tube does not pass through the narrowed portion . in the case
reported here , exploration was decided upon be cause a long segment of the trachea was compressed and mediastinal abscess with leakage was suspected .
this case illustrates that the possibility of tracheal compression be considered in a patient who complains of respiratory deterioration after esophagectomy , even without abnormal findings on the serial chest x - ray .
the author recently experienced a case of tracheal compression by loculated effusion after the ivor lewis operation and reports on this case along with a review of the related literature .
 airway obstruction after esophageal surgery is quite rare , and few such cases have been reported . 
 a 57-year - old woman who underwent the ivor lewis procedure for esophageal carcinoma complained of a sudden onset of severe dyspnea on postoperative day 3 . 
 chest computed tomography scan revealed that the collection of a large volume of mediastinal fluid caused marked luminal compression on the trachea and the gastric conduit . 
 explorative thoracotomy revealed a clear serous fluid in the space between the trachea and the gastric conduit , and all respiratory symptoms were relieved after the fluid was drained . 
 the possibility of tracheal compression by loculated effusion , such as chyloma , should be considered in a patient who complains of respiratory deterioration after esophageal surgery . 
CASE REPORT
DISCUSSION