636 Internal Dislocation of Scapula Following Ivor Lewis Oesophagectomy - a Case Report

Abstract

Internal dislocation of scapula is a known but rare complication following traumatic thoracic injury and lung resection. We report a case and the management in a 69-year-old Caucasian man who underwent a stage two Ivor Lewis oesophagectomy for a T3N1M0 oesophageal adenocarcinoma. Post-operatively, the patient required an FiO2 of 60% and two days later placing on Optiflow to maintain adequate oxygen saturations. A CT thorax on day 5 post-op demonstrated a marked chest well deformity with intrathoracic dislocation of the scapula on the site of thoracotomy, 4th rib displacement downwards into the pleural cavity, left basal atelectasis and a pneumothorax; there was no evidence of anastomotic leak or perforation. Following an unsuccessful trial of conservative management using chest drains, a decision was made for surgical exploration and repair. Intra-operatively, the redo thoracotomy from pervious surgical excision revealed that the initial suture had given way allowing the scapula to dislocate into the thoracic cavity; this was subsequently released, adhesions to the lung dissected and pleural effusion drained. The defect in the posterior section of the 4th rib, was closed using a double-layered 15 x 15 cm prolene mesh, which was further secured to the ribs above and below. Post-operative care with pain management and ionotropic support was required in the intensive care unit, and later ongoing chest physiotherapy for basal atelectasis. This case demonstrated the importance of considering rare thoracic complications after oesophagectomy and early decision for re-operation, with the placement of an inlay mesh shown to be effective.