Ann Thorac Surg 1999;68:250-252
© 1999 The Society of Thoracic Surgeons
Case Reports
Pleural incarceration of the gastric graft after trans-hiatal esophagectomy
Adam Frank, MDa,
Richard C. Montgomery, MDa,
Thomas E. LeVoyer, MDa,
Melvyn Goldberg, MDa
a Department of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
Address reprint requests to Dr Goldberg, Department of Thoracic Surgical Oncology, Fox Chase Cancer Center, 7701 Burholme Ave, Philadelphia, PA 19111
e-mail: m_goldberg{at}fccc.edu
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Abstract
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We report on a 73-year-old man who underwent a trans-hiatal esophagectomy for a T2N1M0 adenocarcinoma of the distal esophagus and developed an incarcerated herniation of the gastric graft through a defect in the right mediastinal pleura. The patient experienced delayed gastric emptying postoperatively, which was initially suggested by barium swallow. The gastric herniation was unidentified by early postoperative swallowing studies and endoscopies. After diagnosis by a later computed tomographic scan and barium study, the herniation was reduced by incising the mediastinal pleura from the diaphragm to the apex of the chest and by plication of the stomach longitudinally in order to reduce its intrathoracic diameter.
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Introduction
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Since the first trans-hiatal esophagectomy performed in 1933, several authors have suggested that it is an effective treatment for adenocarcinoma of the esophagus and is associated with optimal postoperative function and minimal morbidity. Long-term survival does not seem to be adversely influenced by the limited lymphadenectomy, and several reports have examined the complications and long-term outcome of these patients with encouraging results. The most common complications associated with trans-hiatal esophagectomy include pneumothorax, anastomotic leak, anastomotic stricture, postoperative bleeding, arrhythmias, and vocal cord paralysis [1, 2]. To date, an incarcerated herniation of the gastric graft through a defect in the mediastinal pleura has not been reported.
A 73-year-old man with a history of alcohol and tobacco abuse presented with progressive dysphagia to solid foods. Initial investigations included an upper gastrointestinal (GI) series that demonstrated a lesion at the gastroesophageal junction. Upper esophagogastroscopy identified a fungating tumor involving the distal 5 cm of esophagus. Endoscopic biopsy confirmed the diagnosis of a well-differentiated adenocarcinoma. Computed tomography of the chest and esophageal ultrasound suggested transmural disease without nodal or periesophageal involvement. The patient refused neoadjuvant chemoradiation therapy, and a trans-hiatal esophagectomy was performed with a single-layer, cervical anastomosis. Pyloroplasty was not performed because the pylorus was widely patent at operation. Final pathology demonstrated a T2N1 lesion with negative margins of resection.
Several days postoperatively, the patient’s recovery was complicated by severe hypertension, a cerebral vascular accident, documented aspiration, respiratory failure, and prolonged ventilatory support. After successful extubation, the patient initiated oral feeding and complained of early satiety with eructation of gastric contents. The initial postoperative upper GI series identified a trans-pyloric delay with retention of gastric contents. A large opaque configuration representing the fundus of the stomach extending into the right pleural space was identified on chest roentgenogram. Follow-up esophagogastroscopy revealed a normally positioned gastric graft with no evidence of torsion, and balloon dilatation of the pylorus was easily performed. After these maneuvers, a liquid diet was instituted, advanced without difficulty, and the patient was discharged from the hospital.
At a routine follow-up visit 2 weeks later, the patient was found to be lethargic with slurred speech. He was immediately admitted, and a second cerebral vascular accident was ruled out. A chest roentgenogram revealed that the gastric graft occupied most of the right chest (Fig 1) and an upper GI series demonstrated that the gastric graft had herniated through a small defect in the right mediastinal pleura (Fig 2). At thoracotomy, the herniated stomach was found to be incarcerated through a defect in the mediastinal right pleura. The stomach was draped over the inferior edge of the pleural margin with dependent redundancy into the right hemithorax. The gastric graft was viable and the herniation was reduced by fully opening the pleura from the diaphragm to the apex of the chest. The redundant stomach was plicated longitudinally with interrupted sutures and then fixed to the adjacent anterior and posterior pleural margin, from the apex of the chest to the diaphragm. Postoperatively, the patient’s repeat upper GI showed free flow of barium from the cervical esophagus into the duodenum.
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Fig 1. Chest roentgenogram obtained after readmission demonstrating gastric herniation into the right thorax.
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Comment
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Before the routine use of trans-hiatal esophagectomy, postoperative pneumonia and anastomotic leak were the most frequent complications of esophagectomy [3]. Trans-hiatal esophagectomy reduces the incidence of significant respiratory complications after esophagectomy. However, the incidence of anastomotic leak using this technique has not been as dramatically reduced [4]. This benefit may be theoretical, however, as one study reported a near equal incidence and mortality rate between patients with anastomotic leaks in the neck and chest [5].
The blunt and occasionally blind dissection of the thoracic esophagus may result in specific complications, such as vocal cord paresis, atheroembolism, tracheal injury, or severe hemorrhage from disruption of bronchial arteries, branches of the aorta, or the azygos vein [5, 6]. Each of these complications may require conversion to thoracotomy for repair.
Herniation of the gastric graft after trans-hiatal esophagectomy has yet to be reported. The limited exposure of the mediastinum during the dissection makes recognizing pleural defects difficult. Widely incising the pleura at the initial procedure would have prevented this complication (had it been identified and recognized as a potential problem).
Early satiety and significant reflux were the only symptoms of the graft herniation in this case. The initial chest roentgenogram and swallowing studies were not diagnostic, but in retrospect, suspicious. Unfortunately, hard signs were not identified until later studies (Figs 1, 2) identified obvious herniation and incarceration of the gastric graft. A knowledge of this complication and a high index of suspicion are required so that the correct diagnosis can be made.
We have reviewed the postoperative morbidity of trans-hiatal esophagectomy. In addition, a new complication related to the inability to directly visualize the thoracic portion to the dissection has been recognized. Although pleural tears are common with the trans-hiatal esophagectomy, to date, clinically significant herniation or incarceration of the gastric graft through these defects has not been reported. In this patient, an unidentified intraoperative tear in the right mediastinal pleural permitted the redundant portion of the gastric interposition to herniate and incarcerate through this defect. This complication may have been avoided using a transthoracic approach allowing full visualization of the operative bed. This complication was easily corrected by thoracotomy, complete opening of the mediastinal pleura, and reduction and the herniation with plication of the stomach.
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References
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Bolton J.S., Sardi A., Bowen J.C., Ellis J.K. Transhiatal and transthoracic esophagectomy. A comparative study. J Surg Onc 1992;51:249-253.[Medline]
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Orringer M.B., Marshall B., Stirling M.C. Transhiatal esophagectomy for benign and malignant disease. J Thorac Cardiovasc Surg 1993;105:265-277.[Abstract]
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Postlethwait R.W. Complications and deaths after operations for esophageal carcinoma. J Thorac Cardiovasc Surg 1983;85:827-831.[Abstract]
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Iannettoni M.D., Whyte R.I., Orringer M.B. Catastrophic complications of the cervical esophagogastric anastamosis. J Thorac Cardiovasc Surg 1995;110:1493-1501.[Abstract/Free Full Text]
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Lam T.C.F., Fok M., Cheng S.W.K., Wong J. Anastomotic complications after esophagectomy for cancer. J Thorac Cardiovasc Surg 1992;104:395-400.[Abstract]
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Katariya K., Harvey J.C., Pina E., Beattie E.J. Complications of transhiatal esophagectomy. J Surg Onc 1994;57:157-163.[Medline]
Accepted for publication December 20, 1998.
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Abstract
Introduction
