title: Early severe mediastinal bleeding after esophagectomy: a potentially lethal complication.
abstract: BACKGROUND
  Anastomotic leakage after cervical oesophagogastrostomy is a common and difficult problem. Mediastinal manifestation of anastomotic leakage may lead to mediastinitis with dramatic and potentially lethal outcome. Contamination of the mediastinum can be controlled by endoscopic placement of an expandable metal stent. We present two cases of severe haemorrhage after mediastinal manifestation of anastomotic leakage in patients with and without expandable metal stent (EMS).
  
  
  METHODS
  This case report describes two cases of severe haemorrhage after thoracolaparoscopic esophagectomy with cervical oesophagogastrostomy. The recovery of both patients was complicated by anastomotic leakage with mediastinal manifestation. In one case, 11 days after placement of an EMS for anastomotic leakage a bleeding occurred in the cervical wound. Angiography during surgery showed contrast leakage in the aortic arch. Despite sternotomy and endovascular catheterization, there were no surgical options to treat this condition and the patient died of exsanguination. In the other case the patient presented with severe hematemesis 11 days after surgery. Shortly after this hematemesis the patient became hemodynamic instable. The patient was taken to the operation theatre, but before any intervention could take place resuscitation was needed and the patient died of exsanguination.
  
  
  CONCLUSIONS
  Severe haemorrhage is a rare and potentially lethal complication after esophagectomy. This condition is related to anastomotic leakage with mediastinal manifestation. Awareness of this potentially lethal complication is important for early recognition and treatment of this condition. The role of endoscopic stenting of the cervical anastomosis is controversial and potentially dangerous.
authors.affiliation: Department of Surgery, Catharina Hospital Eindhoven, the Netherlands;
authors.forename: Jeroen E H
authors.initials: JE
authors.lastname: Ponten
authors.forename: Sylvia
authors.initials: S
authors.lastname: van der Horst
authors.forename: Grard A P
authors.initials: GA
authors.lastname: Nieuwenhuijzen
authors.forename: Ted W O
authors.initials: TW
authors.lastname: Elenbaas
authors.forename: Richard
authors.initials: R
authors.lastname: van Hillegersberg
authors.forename: Misha D P
authors.initials: MD
authors.lastname: Luyer
keywords: Severe haemorrhage; anastomotic leakage; expandable metal stent; mediastinitis