s/p Gastric Pullthrough for Esophageal CA

Lucencies in the soft tissues suggest subcutaneous air collections. The situation is more complex.
- Air in the supraclavicular region is localized.
- Air in the right axilla appears to dissect tissue planes (muscle).
Note resected Rt. clavicle.
Does the following x-ray help you?

Discussion:

The facts are as follows:

Sub-cutaneous (subQ) air in the right supraclavicular region is close to the site of anastomosis of the stomach and the origin of the esophagus.
Most of the esophagus was resected because of carcinoma at the level of the carina.
The trachea was either involved with the carcinoma or damaged at the time of surgery.
- Although this history was withheld, knowledge of it should not change the differential diagnosis (DDx).

The DDx for subQ air in the anastomotic region would include:

In this regard, the second x-ray is helpful because:

It clearly demonstrates a nasogastric tube entering the air collection, indicating a connection with the the esophageal remnant.
The outline of the air collection, which actually can be seen to be quite large, has a structure resembling bowel in the GI tract.

The most reasonable study to perform in this setting is an esophagram.

This study demonstrates that the air collection in the right supraclavicular region is the stomach.

What about the curvilinear air in the right axilla?

This subQ air which dissects tissue planes is similar to air in soft tissues seen with pneumothorax or pneumomediastinum, neither of which are present.
The curvilinear air leads to the air- containing structure and is most likely a leak at the anastomotic site.
- This subQ air resorbed over a period of a few days.

Ref: Armstrong, P., et. al., Imaging of Diseases of the Chest, 2nd ed, Mosby, St. Louis, MO, 1995, pp. 681-685. excellent discussion!