Ann Thorac Surg 2000;69:286-288
© 2000 The Society of Thoracic Surgeons
Case Reports
Esophagectomy after pneumonectomy: a surgical challenge
Michael J. Reardon, MDa,
Anthony L. Estrera, MDa,
Lori D. Conklin, MDa,
Patrick R. Reardon, MDa,
F. Charles Brunicardi, MDa,
Arthur C. Beall, MDa
a Michael E. DeBakey Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA
Address reprint requests to Dr Reardon, 6550 Fannin, Suite 1619, Houston, TX 77030
e-mail: reardonm{at}bcm.tmc.edu
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Abstract
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Esophagectomy after pneumonectomy has been reported rarely, and the surgical approach presents a challenge. We report a case of a transthoracic esophagectomy in a 54-year-old man who had undergone right pneumonectomy for non–small cell lung cancer 16 years previously.
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Introduction
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The incidence of esophageal cancer in patients with a previous history of lung cancer is low, ranging from 0.05% to 0.5% [1, 2]. Even lower is the incidence of patients who have undergone esophagectomy with a previous history of pneumonectomy. There have been only two cases reported in the literature [1]. These case reports, however, do not outline the surgical approach to esophagectomy or the postpneumonectomy space. Transhiatal esophagectomy is theoretically appealing in avoiding the postpneumonectomy space, but may not be technically feasible due to anatomic changes and adhesions after pneumonectomy and nodal dissection. Transthoracic esophagectomy through the postpneumonectomy space will provide a challenge due to the anatomic changes associated with pneumonectomy and the risks of reentering this space. We report a patient who had previously undergone a right pneumonectomy for non–small cell cancer of the lung, who presented with early-stage esophageal cancer. Transhiatal dissection was prevented by dense adhesions, and transthoracic esophagogastrectomy was performed through the right postpneumonectomy space. The anatomic and physiologic changes associated with the pneumonectomy, and the general considerations of performing esophagectomy after pneumonectomy are reviewed.
A 54-year-old man with a 60 pack/year history of smoking and heavy alcohol intake was admitted to our institution for evaluation of dysphagia. His medical history was significant for non–small cell carcinoma of the right lung treated by pneumonectomy 16 years previously. Barium swallow and esophagogastroduodenoscopy demonstrated a distal esophageal mass. The biopsies performed revealed adenocarcinoma, arising from Barrett’s mucosa. Further evaluation included chest x-rays, the films of which demonstrated an opacified right hemithorax and a clear left lung field. Computed tomography (CT) of the chest and abdomen demonstrated no evidence of metastasis or adenopathy. In addition, a previous right pneumonectomy with shift of the mediastinum and heart to the right, and an anterior herniation of the left lung into the right hemithorax were noted. Pulmonary function tests revealed a forced expiratory volume (FEV1) of 1.71 L (48% predicted), forced vital capacity (FVC) of 2.46 L (51% predicted), and diffusion lung capacity of oxygen (DLCO) of 14.5 mL · min-1 · mm Hg-1 (48% predicted). Based on the clinical data indicating surgical resectability, the decision was made to proceed with esophageal resection.
The patient underwent laparoscopic mobilization of the proximal duodenum, stomach, and distal esophagus. On dissection of the distal esophagus at the hiatus, dense adhesions extending into the right hemithorax were encountered, and transhiatal esophagectomy was therefore considered technically hazardous. Upon completion of the abdominal dissection, the patient was placed in the left lateral decubitus position and a right posterolateral thoracotomy was performed through the previous incision. The right thorax was entered through the fourth intercostal space. Substantial fibrosis was encountered. Because of the posterolateral shift of the mediastinum, the pericardium and heart were adjacent to the right lateral chest wall. Thickened pleura was encountered with no evidence of a loculated air or fluid cavity. The esophagus was identified in the posterior mediastinum. Extensive sharp dissection was required to mobilize the esophagus, confirming our initial impression that blunt mobilization would not be possible. The mobilized stomach was brought through the hiatus, and the esophagus and proximal stomach were resected. The esophagogastrostomy was performed using an end-to-end anastomosis stapler 3 cm above the level of the azygous vein. A single soft, closed suction drain was used for the right hemithorax.
The patient’s postoperative course was complicated by an Acinetobacter left lower lobe pneumonia. He recovered well with imipenem antibiotic treatment, and was discharged home doing well on postoperative day 12. Pathology revealed a 3.2 cm moderately differentiated adenocarcinoma of the distal esophagus arising from Barrett’s esophagus confined to the submucosa, with margins and nine lymph nodes free of tumor. At 6-month follow-up he is doing well.
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Comment
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Anatomic changes in the postpneumonectomy space have been evaluated by autopsy and radiologic studies [3, 4]. These studies have demonstrated that after pneumonectomy a mediastinal shift toward the operated side, elevation of the ipsilateral hemidiaphragm, narrowing of the intercostal spaces, and hyperexpansion of the remaining lung are evident [3–5]. The degree of mediastinal shift depends on the extent of hyperexpansion of the remaining lung which is directly related to the level of pulmonary herniation [3]. As reported by Spirn and coworkers [5], a varying degree of anterior pulmonary herniation is observed with either right or left pneumonectomy, but posterior herniation is seen in only 50% of left pneumonectomies and not with right pneumonectomy. This is thought to be related to the presence and position of the aorta.
Following pneumonectomy, the ipsilateral hemithorax rapidly accumulates pleural fluid. The pleural fluid gradually reabsorbs as the hemithorax contracts. The rate and amount of fluid that reabsorbs are variable, and patients have been reported to have small loculations as long as 188 months after pneumonectomy [3]. Suarez and associates [3] found in an autopsy report that only 10 of 37 (27%) patients postpneumonectomy had complete obliteration of the space. Biondetti and colleagues [4] reported in a CT study that complete obliteration of the space occurred only in 9 of 22 (41%) cases even as long out as 99 months. These anatomic as well as physiologic changes after pneumonectomy have been reviewed extensively by Kopec and coworkers [6].
As the mediastinum gradually shifts toward the operated side, the heart shifts posterolaterally depending on the degree of pulmonary herniation. To a lesser degree, the esophagus and trachea and great vessels shift posterolaterally. Complete obliteration of the postpneumonectomy space is associated with significant anatomic distortion. For this reason, a preoperative CT scan is useful for delineating these anatomic alterations. Right pneumonectomy in this patient also involved violation of the pleura and paraesophageal mediastinal tissues, due to takedown of the inferior pulmonary ligament, dissection and transection of the right main stem bronchus flush with the carina, and lymphadenectomy of level 4, 7, and 9 lymph nodes. This resulted in dense adhesions around the esophagus. Combined with the associated anatomic distortion, there appeared to be a high risk of complications such as injury to the membranous portion of the left main stem bronchus or carina, and azygous vein injury with transhiatal esophagectomy. A left-sided transthoracic approach would avoid the postpneumonectomy space but require retraction of the ventilated left lung, risking retractor injury. The esophagus was also displaced to the right, making a left-sided approach difficult. Transthoracic esophagogastrectomy through the right chest would carry the challenge of operating in the postpneumonectomy space, as well as the potential risks of operating with the remaining lung dependent, the potential contamination of the pleural space, the potential for leak if the anastomosis were performed within the chest, and the physiologic insult of the thoracotomy incision. In this case, despite these drawbacks, it seemed to be the safer option.
The intercostal space entered is directly dependent on the degree of obliteration of the space and elevation of the hemidiaphragm. Suarez and associates [3] noted that in all cases with complete obliteration, the hemidiaphragm was above the level of the fourth rib, and in 93% of the cases involving complete obliteration, the diaphragm was located above the fifth rib. Thus, entering the thorax above the fifth rib may be necessary.
Careful dissection is necessary when entering the thoracotomy space because the pericardium, great vessels, or esophagus may be adherent to the lateral wall. In the thorax, a thick fibrous pleura is encountered. This fibrous pleura, which is derived from the rind around the mediastinal contents, requires careful separation from the lateral and posterior chest walls. After mobilization of the mediastinal contents, identification of the esophagus is aided by palpating the nasogastric tube within the esophagus. Sharp dissection was necessary to mobilize the esophagus. After completion of the anastomosis, drainage of the space was accomplished with a soft, flat, closed suction drain.
In conclusion, reexploration of the postpneumonectomy space occurs rarely. Indications include esophagectomy, trauma, and cardiac procedures. If indicated, knowledge of the anatomic and physiologic changes that occur with pneumonectomy is required. For esophagectomy after pneumonectomy, a preoperative CT scan is useful not only for oncologic staging, but for delineating the anatomic changes that can occur. These anatomic changes include a posterolateral shift of the mediastinal structures toward the operated side, and elevation of the diaphragm to the level of the fourth or fifth rib.
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References
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Fekete F., Sauvanet A., Kaisserian G., et al. Associated primary esophageal and lung carcinoma. Ann Thorac Surg 1994;58:837-842.[Abstract/Free Full Text]
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Barbone G., Longo G., Fiore T. The treatment of the patient undergoing thoracotomy after pneumonectomy. Minerva Chir 1991;46:1183-1185.[Medline]
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Suarez J., Clagett O.T., Brown A.L., Jr The postpneumonectomy space. J Thorac Cardiovasc Surg 1967;57:539-542.[Medline]
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Biondetti P.R., Fiore D., Sartori F., et al. Evaluation of the post-pneumonectomy space by computed tomography. J Comput Assist Tomogr 1982;6:238-242.[Medline]
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Spirn P.W., Gross G.W., Wechler R.J., Steiner R.M. Radiology of the chest after thoracic surgery. Semin Roentgenol 1988;23:9-31.[Medline]
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Kopec S.E., Irwin R.S., Umali-Torres C.B., Balikian J.P., Conlan A.A. The postpneumonectomy state. Chest 1998;114:1158-1184.[Free Full Text]
Accepted for publication June 5, 1999.
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Abstract
Introduction
