Esophageal reconstruction with pyopneumothorax: double air-fluid level lesions.

A 52-year-old man presented with progressive dysphagia and body weight loss for one month. Esophageal cancer with squamous cell carcinoma was diagnosed via esophagoscopy. Then he received subtotal esophagectomy with reconstruction. After the operation, follow-up chest radiograph showed two air-fluid level lesions over both lungs (Picture 1A, B). We performed thoracocentesis and tube drainage to the right lesion (black arrows), which was diagnosed as pyopneumothorax. The left lesion (white arrows) was due to anterior esophageal reconstruction, which was compatible with computed tomography and esophagography (Picture 2). Pyopneumothorax is a possible complication following reconstruction in patients with esophageal cancer (1). It may be due to anastomotic leakage, benign fistula or empyema with gas-producing bacteria (2). Clinical images of pyopneumothorax can mimic reconstruction with presentation of airfluid level lesions. Differential diagnosis can be easily done by recognizing the anastomotic site of reconstruction, chest sonography or computed tomography with esophagography. Tube drainage of a reconstruction lesion which is misdiag-