Fecopneumothorax due to gangrene and perforation of the colon in post-esophagectomy diaphragmatic hernia

Diaphragmatic hernia is an incidental imaging finding that may be due to congenital, traumatic, or iatrogenic causes [1]. The condition is usually benign and presents with chronic symptoms including epigastric pain, postprandial fullness, nausea, and even respiratory symptoms such as dyspnea. However, as unusual rare cases, acute respiratory distress may occur due to massive diaphragmatic hernia [2].
Post-operative diaphragmatic hernia after esophageal cancer surgery is a condition with notable morbidity and mortality. The rate of diaphragmatic hernia is especially higher in those who undergo minimally invasive esophagectomy. The condition is usually diagnosed through oncologic follow-ups for esophageal cancer [3].
The herniation of the colon in this patient may lead to strangulation of the herniated loop. In this situation, perforation of the necrotic loop and infiltration of the fecal materials are predicted. With this regard, a fecopneumothorax may happen [4, 5]. Here, we present a case of fecopneumothorax in an old man that was caused by gangrene and perforation of a herniated loop of the transverse colon.
A 73-year-old man presented at the emergency room (ER) with dyspnea and chest pain that radiated to the left shoulder. He also reported a periumbilical and also hypogastric pain during the last week. However, the defecation and gas passing were normal as his routine. The assessment of past medical history revealed that the patient had undergone trans-hiatal esophagectomy along with gastric pull up surgery because of evident esophagus cancer 2 years ago. He also had a history of 30 courses of radiotherapy and 6 courses of chemotherapy. Physical examination showed that the patient had tachypnea, tachycardia, and hypotension, with no fever. The patient was previously referred to an outpatient clinic during the day of his admission to the ER and he had a high resolution computed tomography (HRCT) scan, which provided clues of a massive pneumothorax (Figure 1). Considering the imaging findings with clinical signs, a tension pneumothorax was detected. An emergency chest tube was inserted for the patient in the operating room (OR). As the patient had a diaphragmatic hernia, the tube was inserted at a higher level than usual in the fourth intercostal region and anterior axillary line. Upon the use of the chest tube, the patient’s respiratory symptoms resolved. There was no evident secretion in the chest bottle during this procedure. The...


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