Hydropneumothorax Due to Esophageal Rupture.

BACKGROUND: A brief review of the historical aspects of esophageal rupture is presented along with a case and current recommendations for diagnostic evaluation and treatment. CASE REPORT: A 97-year-old woman complained of acute dyspnea without prior vomiting. Chest x-ray study showed a large right pneumothorax with associated effusion. A thoracostomy tube was placed with return of > 1 L turbid fluid with polymicrobial culture and elevated pleural fluid amylase level. Chest computed tomography (CT) scan demonstrated overt leakage of oral contrast into the right pleural space. She was treated with ongoing pleural evacuation, antibiotics, antifungals, and total parenteral nutrition. The patient and family declined surgical resection as well as endoscopic stent placement. In 1724, Boerhaave described spontaneous rupture of the esophagus postmortem; Boerhaave syndrome remains the name for complete disruption of the esophageal wall in the absence of pre-existing pathology typically occurring after vomiting. It most commonly occurs in the distal left posterolateral thoracic esophagus. Contrast esophagram is considered the "gold standard" for diagnosing esophageal rupture although CT esophagography also shows good diagnostic performance. Treatment includes nil per os status, broad-spectrum antibiotics, and drainage of the pleural space. Surgical repair of the esophageal perforation should be done early if the patient is deemed a good candidate, and esophageal stenting is also an option. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Esophageal perforation should be suspected in patients with new pleural effusion, often with overt pneumothorax, that is polymicrobial with elevated amylase.

The tale of spring water cysts: a historical outline of surgery for congenital pericardial diverticula and cysts.

Congenital pericardial diverticula and cysts are extremely uncommon lesions within the anterior mediastinum. Both lesions derive from the pericardial celom and represent different stages of a common embryogenesis. Initial reports date from the 19th century. Surgical pioneers were Otto Pickhardt, who removed a pericardial cyst at Lenox Hill Hospital in New York in 1931, and Richard Sweet, who accomplished the first resection of a pericardial diverticulum at Massachusetts General Hospital in Boston in 1943. These lesions were also called spring water cysts because they usually contain watery, crystal-clear fluid. This history outlines the milestones of evolving surgical management, from the first report in 1837 up to the present time.