Unconventional surgery for thoracic esophageal rupture with empyema and mediastinitis: A case report and literature review

Unconventional surgery for thoracic esophageal rupture with empyema and mediastinitis: A case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Unconventional surgery for thoracic esophageal rupture with empyema and mediastinitis: A case report and literature review Yong-jun Deng, Huan-peng Liu, Jian-bin Zou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2115780/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jun, 2023 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 8 You are reading this latest preprint version Abstract Background: Treatment of esophageal perforation or rupture is complicated and controversial, especially in advanced cases. In fact, it is generally accepted that thisdisease must be treated individually according to the location, causes and clinical features of rupture or perforation (such as the length timebetween onset and treatment, the degree of mediastinitis or chest infection, the extent of esophageal injury, concurrent medical conditions and hemodynamic stability). Case presentation: A very rare case was admitted to our department, who was injured 5 days ago by high-pressure gas of a running air compressor and resulted in a long-term longitudinal rupture of the thoracic esophagus. Although the patient suffered from empyema and mediastinitis at the same time, and his condition was very serious, the debridement and desquamation of empyema were still implemented, followed by left thoracic esophagectomy and left neck approach esophagogastrostomy in the same period successfully. The patient got a good result finally. Discussion and Conclusions： Esophageal rupture caused by high- pressure gas is rare, and surgery is an effective treatment option for such disease. It was safe and technically feasible for our treatment strategy to undertake an esophagectomy with an immediate reconstruction with left neck approach esophagogastrostomy for the patient with an extensive thoracic esophageal rupture and concomitant empyema and mediastinitis. Esophageal rupture Surgical treatment High pressure gas Esophagogastrostomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Spontaneous esophageal rupture is a rare but serious disease with a high mortality rate [ 1 ] . The etiology of esophageal rupture can be divided into iatrogenic instrument operation, spontaneous esophageal perforation, foreign body swallowing injury, chest injury, surgical accidental injury, esophageal chemical burns, tumor causes and others. Surgical treatment is the preferred surgical treatment, which can thoroughly remove pleural and mediastinal pollutants, avoid the formation of empyema, repair rupture and promote healing. Esophagus rupture caused by high pressure gas is rare, which is easily to be misdiagnosed at first time, leading to treatment delay; therefore the life-saving rate is still low. Empyema refers to bacteria invading the pleural cavity, producing purulent exudate and accumulating in the pleural cavity, which is a clinical disease with high morbidity and mortality and often treated by surgical. Mediastinitis is mainly a downward necrotizing mediastinitis caused by deep sternal wound infection, esophageal perforation or ENT infection [ 2 ] . Researchers had reported the treatment of thoracic esophageal rupture and with concomitant empyema and mediastinitis [ 3 , 4 ] , but esophagus rupture caused by high pressure gas with concomitant empyema and mediastinitis had never reported. We report a case injured by high pressure gas of a running air compressor, who had a long size of longitudinal rupture of thoracic esophagus and concomitant empyema treated with left thoracic and left neck approach esophagogastrostomy in the same period. Expecting to provide some effective treatment references for esophagus rupture caused by high pressure gas with concomitant empyema and mediastinitis. Case Presentation The patient was a 41-year-old male worker with a main complaint of left s empyema and fever without special history. Five days ago, when he was operating an air compressor, the gas pipe of the running air compressor fell off and intubated his mouth accidentally. The patient suddenly developed acute chest pain and shortness of breath, and he was sent to the local municipal hospital on the same day. Thoracic subcutaneous and mediastinal emphysemas as well as left encapsulated effusion were observed on computed tomography scan, and then closed drainage of his left pleural cavity was performed via the 7th intercostal space on the same day. Although the left lung was dilated after placing the thoracic catheter 2 days later, bubbles and thick pleural effusion were still be observed in the closed thoracic drainage device, and the patient began to fever. Then the patient was transferred to the department of thoracic surgery of our hospital on the 5 th day. After admission, the physical examination, Blood testing and biochemical examination were performed and the results were shown in Table 1 . Table 1 The results of physical examination, Blood testing and biochemical examination Indexes numerical value Height 170 cm Weight 72 kg BP 120/72 mmHg HR 106/min respiratory rate 25/min SpO2 95% WBC 17.3×10 9 /L CRP 26 mg/L serum total protein 53 mg/dl serum albumin 29 mg/dl Esophagography showed an extensive tear on the left side of the middle and lower part of thoracic esophagus, and chest CT displayed pleural effusion (Fig. 1 and Fig. 2 ). Then the patient was diagnosed as a rupture of the thoracic esophagus and empyema. Surgery should be emergently performed in consideration of concomitant serious infection in the left thoracic cavity. Initially, the patient was intubated with a double-lumen tube and then lying in a full right supine position. The left lung was deflated and one-lung ventilation was started. An 18cm left posterolateral incision was made between the 6 th ribs. Pleural fibreboard thickening leads to chest wall adhesion. A large amount of necrotic tissue, pus and residual food were found in the left thoracic cavity and mediastinum, which were surrounded by thickened viscera and parietal pleural fibreboard. A rupture site of about 7 cm was found in the middle and lower left side of the thoracic esophagus, and the rupture edge showed signs of necrosis. Then total thoracic esophagectomy and left cervical esophagogastrostomy were attempted simultaneously. Next, the necrotized substances were removed, empyema debridement and decortication were performed, followed by a large amount of massive irrigation. To facilitate operation and avoid pollution, the ruptured side of esophagus was sutured intermittently. Mobilization of the entire thoracic esophagus was performed from the level of diaphragmatic reflection to the thoracic inlet, and then the whole thoracic esophagus was resected, followed by massive irrigation with normal saline and poseidon iodine repeatedly. Then the diaphragm was cut open and entered the abdominal cavity until the upper abdomen reached the best exposure state. Generally, the stomach was fully active at the small and large curvature of the cardia and stomach. A tubular stomach was constructed by resecting the lesser curvature of the stomach and cardia along a line about 4–5 cm from the edge of the greater curvature using a linear cutting stapler (Covidien, America), while a left cervical incision was made on the anterior edge of the sternocleidomastoid muscle and the cervical esophagus was moved. The tubular stomach was pulled up to the left neck along the esophageal bed, then a left cervical anastomosis was subsequently carried out in an end-to-side fashion close to the greater curvature of the tubular stomach using a 25mm circular stapler (Covidien, America). The diaphragm was sutured and a 32F chest tube was placed via the 7th intercostal space. The overall postoperative performance of the patients was good. An esophagography using meglumine diatrizoate was performed on the 7th postoperative day, which showed no evidence of anastomotic leak. The patient was discharged home on the 11th day after operation. Three months after the operation, the patient developed a symptom of dysphagia, and an anastomotic stenosis was confirmed which was relieved by endoscopic esophageal dilatation. Discussion It has been reported that the most common cause of esophageal rupture or perforation is severe vomiting, accounting for 64%, followed by other mechanical factors, such as trauma, overeating and cough, accounting for 19% [ 5 ] . Traumatic esophageal ruptures accounted for 4–14% of all esophageal perforations [ 6 ] . Both traumatic esophageal rupture and spontaneous esophageal perforation had a low incidence and were associated with significant mortality. Early diagnosis and appropriate intervention were needed to reduce incidence rate and mortality [ 6 , 7 ] . The awareness of this disease and doctor's experience can make the early diagnosis of this disease. Actually, only about 30% of cases were diagnosed as rupture of the esophagus at their first visit to hospital. In case of doubt, esophagography should be performed with an aqueous contrast agent (such as meglumine diatrizoate). When mediastinal or thoracic leakage is observed, the disease can be diagnosed. CT may also be useful in the diagnosis of diseases, especially in these critically ill patients. Endoscopic examination seems to be a relative contraindication owing to need to inject air into the esophagus. For treatment, primary repair can be performed in patients with esophageal perforation or rupture within 24 hours. However, the treatment of late esophagus perforation or rupture remains controversial [ 8 ] . At present there is no consensus on the optimal treatment strategy to handle these patients due to the lack of many randomized controlled trials. Surgery and conservative treatment including thoracic cavity drainage are feasible options, but surgical treatment is safer and better than conservative procedures, and may achieve better results than conservative treatment [ 9 – 11 ] . Fukushima et al., reported that the mortality rates after surgery and conservative treatment were 7.7% and 50.0%, respectively, indicating that the prognosis of the surgical treatment group was good [ 12 ] . If surgical treatment is indicated, what is the choice of primary repair or esophagectomy with or without immediate reconstruction? In fact, it is generally accepted that the treatment of this disease must be individualized according to the location, cause and clinical characteristics of the rupture or perforation (such as the length of time between onset and treatment, the degree of mediastinitis or chest infection, the extent of esophageal injury, concurrent medical conditions and hemodynamic stability) [ 13 ] . The patient not only had a large esophageal rupture, but also had a time interval of more than 24 hours between the occurrence and diagnosis of the rupture. Was it reasonable for the patient to perform thoracic esophagectomy and cervical esophagogastrostomy at the same period under the condition of serious pleural infection? It has been recommended that esophagectomy should be conducted if extensive esophageal rupture occurs [ 9 ] , and the length of esophageal rupture was considered as an indicator of esophagectomy [ 14 ] . Okonta KE suggested that esophagectomy was superior to conservative treatment for delayed benign esophageal perforation (defined as a perforation diagnosed after 24h) [ 10 ] . Although the left thorax of the patient was seriously infected, his nutritional status was good and his hemodynamics was relatively stable. After thoracotomy, the pus and necrotic tissue in the thorax could be completely removed. After repeated large-scale washing with normal saline and Poseidon iodine, the thorax was very clean, almost reaching the level of wound cleaning. So we performed an entire thoracic portion esophagectomy with an immediate reconstruction with left neck approach esophagogastrostomy according to our experience, furthermore the tubular stomach was pulled up to the left neck trans-esophageal bed way, rather than trans-substernal pathway. Because of the simultaneous anastomosis, the patient avoided esophageal rejection and staged surgery, and achieved good results. In conclusion, esophageal rupture caused by high-pressure gas is rare, and surgery is an effective treatment option for such disease. It was safe and technically feasible for our treatment strategy to undertake an esophagectomy with an immediate reconstruction with left neck approach esophagogastrostomy for the patient with an extensive thoracic esophageal rupture and concomitant empyema and mediastinitis. Abbreviations CT Computerized tomography ENT ear-nose-throat Declarations Ethics approval and consent to participate The study was approved by the Ethnic Committee of the Affiliated Hospital of Yunnan University. Consent for publication Written informed consent for publication was obtained from all participants. Availability of data and materials Not applicable. Competing interests The authors declare that they have no competing interests. Funding None. Authors' contributions Yong-jun Deng：the acquisition, analysis, interpretation of data and have drafted the work or substantively revised it. Huan-peng Liu and Jian-bin Zou：the acquisition, analysis Acknowledgements Not applicable. References Hayakawa S, Mitsui A, Kato Y, et al. Laparoscopic transhiatal suture closure for spontaneous esophageal rupture: a case report. Surg Case Rep. 2019;5(1):149. Brisset J, Daix T. Spontaneous community-acquired PVL-producing Staphylococcus aureus mediastinitis in an immunocompetent adult-a case report. 20(1), 354 (2020). Karpitskiĭ AS, Shestiuk AM, Boufalik RI, et al. [A case of successful surgical treatment of spontaneous rupture of the esophagus, complicated by mediastinitis and empyema of the pleura]. Vestn Khir Im I I Grek. 2011;170(1):82–3. Divisi D, Di Tommaso S, Garramone M, et al. Necrotizing mediastinitis linked to Boerhaave's syndrome: a surgical approach. Thorac Cardiovasc Surg. 2009;57(1):57–8. Kijima MAT, Nagao F. Experiences in the diagnosis and treatment of spontaneous rapture of the esophagus. A case of rapture concomitant with a gastric cancer -with a review of preexisting proemetic factors reported in Japan. Jikeikai Med J. 1987;102:1483–987. Bernard AW, Ben-David K, Pritts T. Delayed presentation of thoracic esophageal perforation after blunt trauma. J Emerg Med. 2008;34(1):49–53. Bhatia P, Fortin D, Inculet RI, et al. Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience. Ann Thorac Surg. 2011;92(1):209–15. Khan AZ, Strauss D, Mason RC. Boerhaave's syndrome: diagnosis and surgical management. Surgeon. 2007;5(1):39–44. Altorjay A, Kiss J, Vörös A, et al. The role of esophagectomy in the management of esophageal perforations. Ann Thorac Surg. 1998;65(5):1433–6. Okonta KE, Kesieme EB. Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option? Interact Cardiovasc Thorac Surg. 2012;15(3):509–11. Karstens KF, Bellon E, Tachezy M, et al. Surgical Management of Non-Malignant Esophageal Perforations: A Single-Center Analysis Over a 15-Year Period. Dig Surg. 2020;37(4):302–11. Fukushima JNK, Hanaoka T, et al. Hozontekikaryou de tiryoushita tokuhatuseisyokudouharetsu no 1rei (in Japanese). Kyurin I kaishi. 1988;19:455–60. Keeling WB, Miller DL, Lam GT, et al Low mortality after treatment for esophageal perforation: a single-center experience. Ann Thorac Surg . 90(5), 1669–1673; discussion 1673 (2010). Ochiai T, Hiranuma S, Takiguchi N, et al. Treatment strategy for Boerhaave's syndrome. Dis Esophagus. 2004;17(1):98–103. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Jun, 2023 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Major revision 09 Jan, 2023 Reviews received at journal 23 Nov, 2022 Reviewers agreed at journal 22 Nov, 2022 Reviewers agreed at journal 20 Nov, 2022 Reviewers invited by journal 20 Nov, 2022 Editor assigned by journal 30 Sep, 2022 Submission checks completed at journal 30 Sep, 2022 First submitted to journal 29 Sep, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2115780","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":140842068,"identity":"d4893e01-5151-419d-bc17-cde0416d8137","order_by":0,"name":"Yong-jun Deng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYLACHgY2OQZmUrUYk6yFIbGBaNXyM3IfPnjbxpc+v5334AeGGptogloMbqQbG85tY8vdcJgvWYLhWFouQesMJNLYpHlBWph5DCQYGw4T1iI/I439N1BLunwzj/EPorQw3EhjYwZqSWA4zGNGnC0GZ54xS845x2a4AajFIoEYv8i3pzF+eFN2TF6+/4zxjQ81NkQ4DAQY2Y5BGAlEKQeDPzXEqx0Fo2AUjIKRBwBmZDd3sSZv3wAAAABJRU5ErkJggg==","orcid":"","institution":"The Affiliated Hospital of Yunnan University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yong-jun","middleName":"","lastName":"Deng","suffix":""},{"id":140842069,"identity":"ab104003-7819-4ad0-8a17-4934f46ddccd","order_by":1,"name":"Huan-peng Liu","email":"","orcid":"","institution":"The Affiliated Hospital of Yunnan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Huan-peng","middleName":"","lastName":"Liu","suffix":""},{"id":140842070,"identity":"6a470514-6f85-4142-a66f-3315e8f41c79","order_by":2,"name":"Jian-bin Zou","email":"","orcid":"","institution":"The Affiliated Hospital of Yunnan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jian-bin","middleName":"","lastName":"Zou","suffix":""}],"badges":[],"createdAt":"2022-09-29 09:14:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2115780/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2115780/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-023-02208-2","type":"published","date":"2023-06-13T21:13:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":27379378,"identity":"4228c48a-dbc4-4a3b-8943-d5fb39c3b40d","added_by":"auto","created_at":"2022-10-05 15:09:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":274877,"visible":true,"origin":"","legend":"\u003cp\u003eCT scan of the chest revealed subcutaneous and mediastinal emphysema in the chest and left Encapsulated Effusion. a: Lung window, Arrow: subcutaneous and mediastinal emphysemas. b: Mediastinal window, Arrow: encapsulated effusion.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2115780/v1/9fc53090d5937044983b1f3d.png"},{"id":27380050,"identity":"52b557d2-2df6-469e-b089-44ea9ca23c47","added_by":"auto","created_at":"2022-10-05 15:14:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":648758,"visible":true,"origin":"","legend":"\u003cp\u003eEsophagography showed an extensive tear on the left side of the middle and lower portions of thoracic esophagus. a: postero-anterior position, b: left lateral position, c: right lateral position. Arrow: contrast agent entered into left thoracic cavity through the ruptured esophagus.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2115780/v1/9c1a0eb4f14843bc6023e970.png"},{"id":27379376,"identity":"12a8462d-592b-47b2-9449-476622ee50d5","added_by":"auto","created_at":"2022-10-05 15:09:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":903666,"visible":true,"origin":"","legend":"\u003cp\u003eView of pleural fiberboard. (a), middle and lower portion of ruptured thoracic esophagus (b), and resected entire thoracic esophagus (c) through left-sided thoracotomy.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2115780/v1/2b7e8362fac06b94bb5d69fb.png"},{"id":27380051,"identity":"d96a0089-8591-4f76-8604-7ab5500fda15","added_by":"auto","created_at":"2022-10-05 15:14:10","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":511036,"visible":true,"origin":"","legend":"\u003cp\u003eA postoperative esophagography showed no evidence of anastomotic leak. a: postero-anterior position, b: left lateral position, c: right lateral position.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-2115780/v1/5bd43fae5058c6682b52edd2.png"},{"id":44733158,"identity":"9217accc-3e67-493e-897f-3c7461d39b1e","added_by":"auto","created_at":"2023-10-16 22:04:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2248902,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2115780/v1/9323f4a6-07c1-4e1d-9a0b-3ed50ecbe740.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eUnconventional surgery for thoracic esophageal rupture with empyema and mediastinitis: A case report and literature review\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpontaneous esophageal rupture is a rare but serious disease with a high mortality rate\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The etiology of esophageal rupture can be divided into iatrogenic instrument operation, spontaneous esophageal perforation, foreign body swallowing injury, chest injury, surgical accidental injury, esophageal chemical burns, tumor causes and others. Surgical treatment is the preferred surgical treatment, which can thoroughly remove pleural and mediastinal pollutants, avoid the formation of empyema, repair rupture and promote healing. Esophagus rupture caused by high pressure gas is rare, which is easily to be misdiagnosed at first time, leading to treatment delay; therefore the life-saving rate is still low. Empyema refers to bacteria invading the pleural cavity, producing purulent exudate and accumulating in the pleural cavity, which is a clinical disease with high morbidity and mortality and often treated by surgical. Mediastinitis is mainly a downward necrotizing mediastinitis caused by deep sternal wound infection, esophageal perforation or ENT infection \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Researchers had reported the treatment of thoracic esophageal rupture and with concomitant empyema and mediastinitis\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e, but esophagus rupture caused by high pressure gas with concomitant empyema and mediastinitis had never reported.\u003c/p\u003e \u003cp\u003eWe report a case injured by high pressure gas of a running air compressor, who had a long size of longitudinal rupture of thoracic esophagus and concomitant empyema treated with left thoracic and left neck approach esophagogastrostomy in the same period. Expecting to provide some effective treatment references for esophagus rupture caused by high pressure gas with concomitant empyema and mediastinitis.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eThe patient was a 41-year-old male worker with a main complaint of left s empyema and fever without special history. Five days ago, when he was operating an air compressor, the gas pipe of the running air compressor fell off and intubated his mouth accidentally. The patient suddenly developed acute chest pain and shortness of breath, and he was sent to the local municipal hospital on the same day. Thoracic subcutaneous and mediastinal emphysemas as well as left encapsulated effusion were observed on computed tomography scan, and then closed drainage of his left pleural cavity was performed via the 7th intercostal space on the same day. Although the left lung was dilated after placing the thoracic catheter 2 days later, bubbles and thick pleural effusion were still be observed in the closed thoracic drainage device, and the patient began to fever. Then the patient was transferred to the department of thoracic surgery of our hospital on the 5 th day.\u003c/p\u003e\n\u003cp\u003eAfter admission, the physical examination, Blood testing and biochemical examination were performed and the results were shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe results of physical examination, Blood testing and biochemical examination\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIndexes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003enumerical value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e170 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWeight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72 kg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e120/72 mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e106/min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erespiratory rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25/min\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpO2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.3\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 mg/L\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eserum total protein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eserum albumin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 mg/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eEsophagography showed an extensive tear on the left side of the middle and lower part of thoracic esophagus, and chest CT displayed pleural effusion (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Then the patient was diagnosed as a rupture of the thoracic esophagus and empyema. Surgery should be emergently performed in consideration of concomitant serious infection in the left thoracic cavity.\u003c/p\u003e\n\u003cp\u003eInitially, the patient was intubated with a double-lumen tube and then lying in a full right supine position. The left lung was deflated and one-lung ventilation was started. An 18cm left posterolateral incision was made between the 6 th ribs. Pleural fibreboard thickening leads to chest wall adhesion.\u003c/p\u003e\n\u003cp\u003eA large amount of necrotic tissue, pus and residual food were found in the left thoracic cavity and mediastinum, which were surrounded by thickened viscera and parietal pleural fibreboard. A rupture site of about 7 cm was found in the middle and lower left side of the thoracic esophagus, and the rupture edge showed signs of necrosis. Then total thoracic esophagectomy and left cervical esophagogastrostomy were attempted simultaneously. Next, the necrotized substances were removed, empyema debridement and decortication were performed, followed by a large amount of massive irrigation. To facilitate operation and avoid pollution, the ruptured side of esophagus was sutured intermittently. Mobilization of the entire thoracic esophagus was performed from the level of diaphragmatic reflection to the thoracic inlet, and then the whole thoracic esophagus was resected, followed by massive irrigation with normal saline and poseidon iodine repeatedly. Then the diaphragm was cut open and entered the abdominal cavity until the upper abdomen reached the best exposure state. Generally, the stomach was fully active at the small and large curvature of the cardia and stomach. A tubular stomach was constructed by resecting the lesser curvature of the stomach and cardia along a line about 4\u0026ndash;5 cm from the edge of the greater curvature using a linear cutting stapler (Covidien, America), while a left cervical incision was made on the anterior edge of the sternocleidomastoid muscle and the cervical esophagus was moved. The tubular stomach was pulled up to the left neck along the esophageal bed, then a left cervical anastomosis was subsequently carried out in an end-to-side fashion close to the greater curvature of the tubular stomach using a 25mm circular stapler (Covidien, America). The diaphragm was sutured and a 32F chest tube was placed via the 7th intercostal space.\u003c/p\u003e\n\u003cp\u003eThe overall postoperative performance of the patients was good. An esophagography using meglumine diatrizoate was performed on the 7th postoperative day, which showed no evidence of anastomotic leak. The patient was discharged home on the 11th day after operation. Three months after the operation, the patient developed a symptom of dysphagia, and an anastomotic stenosis was confirmed which was relieved by endoscopic esophageal dilatation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIt has been reported that the most common cause of esophageal rupture or perforation is severe vomiting, accounting for 64%, followed by other mechanical factors, such as trauma, overeating and cough, accounting for 19% \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Traumatic esophageal ruptures accounted for 4\u0026ndash;14% of all esophageal perforations \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Both traumatic esophageal rupture and spontaneous esophageal perforation had a low incidence and were associated with significant mortality. Early diagnosis and appropriate intervention were needed to reduce incidence rate and mortality \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe awareness of this disease and doctor's experience can make the early diagnosis of this disease. Actually, only about 30% of cases were diagnosed as rupture of the esophagus at their first visit to hospital. In case of doubt, esophagography should be performed with an aqueous contrast agent (such as meglumine diatrizoate). When mediastinal or thoracic leakage is observed, the disease can be diagnosed. CT may also be useful in the diagnosis of diseases, especially in these critically ill patients. Endoscopic examination seems to be a relative contraindication owing to need to inject air into the esophagus.\u003c/p\u003e \u003cp\u003eFor treatment, primary repair can be performed in patients with esophageal perforation or rupture within 24 hours. However, the treatment of late esophagus perforation or rupture remains controversial \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. At present there is no consensus on the optimal treatment strategy to handle these patients due to the lack of many randomized controlled trials. Surgery and conservative treatment including thoracic cavity drainage are feasible options, but surgical treatment is safer and better than conservative procedures, and may achieve better results than conservative treatment \u003csup\u003e[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Fukushima et al., reported that the mortality rates after surgery and conservative treatment were 7.7% and 50.0%, respectively, indicating that the prognosis of the surgical treatment group was good \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. If surgical treatment is indicated, what is the choice of primary repair or esophagectomy with or without immediate reconstruction? In fact, it is generally accepted that the treatment of this disease must be individualized according to the location, cause and clinical characteristics of the rupture or perforation (such as the length of time between onset and treatment, the degree of mediastinitis or chest infection, the extent of esophageal injury, concurrent medical conditions and hemodynamic stability) \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe patient not only had a large esophageal rupture, but also had a time interval of more than 24 hours between the occurrence and diagnosis of the rupture. Was it reasonable for the patient to perform thoracic esophagectomy and cervical esophagogastrostomy at the same period under the condition of serious pleural infection? It has been recommended that esophagectomy should be conducted if extensive esophageal rupture occurs \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, and the length of esophageal rupture was considered as an indicator of esophagectomy\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Okonta KE suggested that esophagectomy was superior to conservative treatment for delayed benign esophageal perforation (defined as a perforation diagnosed after 24h) \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Although the left thorax of the patient was seriously infected, his nutritional status was good and his hemodynamics was relatively stable. After thoracotomy, the pus and necrotic tissue in the thorax could be completely removed. After repeated large-scale washing with normal saline and Poseidon iodine, the thorax was very clean, almost reaching the level of wound cleaning. So we performed an entire thoracic portion esophagectomy with an immediate reconstruction with left neck approach esophagogastrostomy according to our experience, furthermore the tubular stomach was pulled up to the left neck trans-esophageal bed way, rather than trans-substernal pathway. Because of the simultaneous anastomosis, the patient avoided esophageal rejection and staged surgery, and achieved good results.\u003c/p\u003e \u003cp\u003eIn conclusion, esophageal rupture caused by high-pressure gas is rare, and surgery is an effective treatment option for such disease. It was safe and technically feasible for our treatment strategy to undertake an esophagectomy with an immediate reconstruction with left neck approach esophagogastrostomy for the patient with an extensive thoracic esophageal rupture and concomitant empyema and mediastinitis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputerized tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eENT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eear-nose-throat\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethnic Committee of the Affiliated Hospital of Yunnan University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYong-jun Deng：the acquisition, analysis, interpretation of data and have drafted the work or substantively revised it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHuan-peng Liu and Jian-bin Zou：the acquisition, analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eHayakawa S, Mitsui A, Kato Y, et al. Laparoscopic transhiatal suture closure for spontaneous esophageal rupture: a case report. Surg Case Rep. 2019;5(1):149.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBrisset J, Daix T. Spontaneous community-acquired PVL-producing Staphylococcus aureus mediastinitis in an immunocompetent adult-a case report. 20(1), 354 (2020).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKarpitskiĭ AS, Shestiuk AM, Boufalik RI, et al. [A case of successful surgical treatment of spontaneous rupture of the esophagus, complicated by mediastinitis and empyema of the pleura]. Vestn Khir Im I I Grek. 2011;170(1):82\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDivisi D, Di Tommaso S, Garramone M, et al. Necrotizing mediastinitis linked to Boerhaave\u0026apos;s syndrome: a surgical approach. Thorac Cardiovasc Surg. 2009;57(1):57\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKijima MAT, Nagao F. Experiences in the diagnosis and treatment of spontaneous rapture of the esophagus. A case of rapture concomitant with a gastric cancer -with a review of preexisting proemetic factors reported in Japan. Jikeikai Med J. 1987;102:1483\u0026ndash;987.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBernard AW, Ben-David K, Pritts T. Delayed presentation of thoracic esophageal perforation after blunt trauma. J Emerg Med. 2008;34(1):49\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBhatia P, Fortin D, Inculet RI, et al. Current concepts in the management of esophageal perforations: a twenty-seven year Canadian experience. Ann Thorac Surg. 2011;92(1):209\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKhan AZ, Strauss D, Mason RC. Boerhaave\u0026apos;s syndrome: diagnosis and surgical management. Surgeon. 2007;5(1):39\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAltorjay A, Kiss J, V\u0026ouml;r\u0026ouml;s A, et al. The role of esophagectomy in the management of esophageal perforations. Ann Thorac Surg. 1998;65(5):1433\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOkonta KE, Kesieme EB. Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option? Interact Cardiovasc Thorac Surg. 2012;15(3):509\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKarstens KF, Bellon E, Tachezy M, et al. Surgical Management of Non-Malignant Esophageal Perforations: A Single-Center Analysis Over a 15-Year Period. Dig Surg. 2020;37(4):302\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFukushima JNK, Hanaoka T, et al. Hozontekikaryou de tiryoushita tokuhatuseisyokudouharetsu no 1rei (in Japanese). Kyurin I kaishi. 1988;19:455\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKeeling WB, Miller DL, Lam GT, et al Low mortality after treatment for esophageal perforation: a single-center experience. \u003cem\u003eAnn Thorac Surg\u003c/em\u003e. 90(5), 1669\u0026ndash;1673; discussion 1673 (2010).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOchiai T, Hiranuma S, Takiguchi N, et al. Treatment strategy for Boerhaave\u0026apos;s syndrome. Dis Esophagus. 2004;17(1):98\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Esophageal rupture, Surgical treatment, High pressure gas, Esophagogastrostomy","lastPublishedDoi":"10.21203/rs.3.rs-2115780/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2115780/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Treatment of esophageal perforation or rupture is complicated and controversial, especially in advanced cases. In fact, it is generally accepted that thisdisease must be treated individually according to the location, causes and clinical features of rupture or perforation (such as the length timebetween onset and treatment, the degree of mediastinitis or chest infection, the extent of esophageal injury, concurrent medical conditions and hemodynamic stability).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e A very rare case was admitted to our department, who was injured 5 days ago by high-pressure gas of a running air compressor and resulted in a long-term longitudinal rupture of the thoracic esophagus. Although the patient suffered from empyema and mediastinitis at the same time, and his condition was very serious, the debridement and desquamation of empyema were still implemented, followed by left thoracic esophagectomy and left neck approach esophagogastrostomy in the same period successfully. The patient got a good result finally.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion and Conclusions：\u003c/strong\u003eEsophageal rupture caused by high- pressure gas is rare, and surgery is an effective treatment option for such disease. It was safe and technically feasible for our treatment strategy to undertake an esophagectomy with an immediate reconstruction with left neck approach esophagogastrostomy for the patient with an extensive thoracic esophageal rupture and concomitant empyema and mediastinitis.\u003c/p\u003e","manuscriptTitle":"Unconventional surgery for thoracic esophageal rupture with empyema and mediastinitis: A case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-10-05 15:09:08","doi":"10.21203/rs.3.rs-2115780/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-01-09T19:05:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-11-23T12:15:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"527df9fb-08f3-49cd-8575-4a38c3e71451","date":"2022-11-22T14:43:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6f5f4572-af8e-42ea-8d7e-2bfcad44e1f7","date":"2022-11-20T15:17:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-11-20T08:52:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-09-30T10:11:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-09-30T10:11:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2022-09-29T09:04:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c4b48e0-1099-4893-bf15-ea64fd648b0b","owner":[],"postedDate":"October 5th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T21:47:47+00:00","versionOfRecord":{"articleIdentity":"rs-2115780","link":"https://doi.org/10.1186/s13019-023-02208-2","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2023-06-13 21:13:56","publishedOnDateReadable":"June 13th, 2023"},"versionCreatedAt":"2022-10-05 15:09:08","video":"","vorDoi":"10.1186/s13019-023-02208-2","vorDoiUrl":"https://doi.org/10.1186/s13019-023-02208-2","workflowStages":[]},"version":"v1","identity":"rs-2115780","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2115780","identity":"rs-2115780","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}