Giant Mucocele of the Remnant Esophagus: Case Report of a Rare Complication Following a Bipolar Esophageal Exclusion Procedure

We describe a case of a symptomatic mucocele of the esophagus following surgical isolation of the diseased esophagus, which needed surgical resection. A 33-year-old male presented to us with shock, high-grade fever, and breathlessness five days after the onset of sudden, severe lower chest and upper abdominal pain preceded by an episode of retching and vomiting. He was initially managed elsewhere by right intercostal drainage for right-sided pleural effusion, broad-spectrum parenteral antibiotics, and total parenteral nutrition. CT chest showed a right loculated pleural effusion and distal oesophageal perforation with active contrast leak into the right pleural space. He was subsequently referred to us in view of suspected Boerhaave's syndrome and clinical worsening. In view of hemodynamic instability with uncontrolled sepsis, he was planned for surgery. Intraoperatively, there was a 4 cm long distal oesophageal perforation, 4 cm above the esophagogastric junction on the right, with an unhealthy apex, communicating with a large abscess cavity in the right pleural space with thick purulent contents. End cervical esophagostomy with esophagogastric junction stapling and feeding jejunostomy was performed in addition to transhiatal drainage of the abscess at the lower end of the esophagus and the placement of an additional intercostal drain. The postoperative period was uneventful, and he was discharged. After two months, he was assessed for possible esophagectomy and gastric pullup. Dense adhesions at thoracoscopy precluded any esophageal delineation and dissection. Attempted transhiatal dissection of the esophagus was unsuccessful in view of cicatrization, and it was decided to forego esophagectomy and proceed with bypass alone by a retrosternal gastric pull-up and cervical esophagogastrostomy. He was discharged following an uneventful postoperative period of recovery. Three months later, the patient presented with complaints of pain in the chest for three weeks, associated with hiccups. He was diagnosed to have a mucocele of the remnant esophagus based on a CT scan. The esophageal mucocele was excised by a transthoracic approach and, he was relieved of the pressure symptoms. Following the esophageal exclusion procedure, a mucocele of the remnant esophagus can develop due to the accumulation of secretions leading to subsequent dilatation. Small mucoceles are usually asymptomatic and often go unnoticed. However, in rare cases, it may enlarge to cause compression symptoms such as respiratory distress, chest pain, cough, hiccups, and an inability to swallow. Cross-sectional imaging clinches the diagnosis, and definitive surgery consists of surgical resection by a transthoracic approach.