Ann Thorac Surg 2006;82:717-719
© 2006 The Society of Thoracic Surgeons
Case report
Perforated Diverticulum: Rare Complication of Interposed Substernal Colon
Yu-Jen Cheng, MD*,
Hsien-Pin Li, MD,
Eing-Long Kao, MD
Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
Accepted for publication October 6, 2005.
* Address correspondence to Dr Cheng, Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Rd, Kaohsiung, 80708 Taiwan (Email: yujen.cheng{at}msa.hinet.net).
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Abstract
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Substernal colon interposition is a good reconstruction option after salvage surgery for caustic ingestion injury. Although redundancy and reflux sometimes complicate these cases, there have been no reports in the English literature of perforated diverticula in interposed colon segments. We report a 23-year-old man who underwent substernal colon flap reconstruction after caustic ingestion injury. He had perforated colon diverticulitis develop, which led to a lung abscess 7 years later, followed by resection of the necrotic lung parenchyma and colon repair. This rare case illuminates the importance of including perforated diverticula in interposed colon in the differential diagnosis for such patients.
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Introduction
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The clinical presentations of patients with caustic ingestion vary, and even experienced clinicians can misjudge them. In serious cases, emergent salvage surgery is a key consideration during the acute stage [1]. After recovering from the acute stage these patients have the option of esophageal reconstruction, usually through colon interposition. Although redundancy and reflux are known potential complications of reconstruction [2], the English literature contains no reports of a perforated diverticulum in an interposed colon, which is a serious late complication. Herein we present such a rare case.
A 23-year-old man accidentally ingested acetic acid in 1998 and underwent salvage surgery consisting of esophagectomy and total gastrectomy at that time. He then underwent esophageal reconstruction with interposition of the ascending colon through the substernal tract 4 months after salvage surgery. Recovery went smoothly (Fig 1A) with intermittent bolus intake until March 2005,when he had a fever develop with abdominal pain, vomiting, and dysphagia. At admission, a chest roentgenogram showed an abnormal right pericardial shadow. Roentgenograms taken after a barium swallow showed barium stasis in the lower portion of the colon flap, and a chest computed tomographic scan showed fluid accumulation in the right pericardial area (Figs 1B–1D). Given the impression of partial outlet obstruction of the colon flap, the patient recovered uneventfully with conservative treatment. Discharge instructions included refraining from taking in large boluses of food, but these instructions were not heeded. After 3 months, the patient returned to the hospital with another episode of dysphagia and abdominal pain. The hospital admitted him and advised him to undergo exploratory surgery, but he left the hospital without further treatment due to personal reasons. After 2 weeks he returned to the hospital, which again admitted him due to a lung abscess and sepsis (Fig 2A). He underwent chest tube placement on the right for right-sided pneumothorax that occurred after airway intubation (Fig 2B). Under the indication of perforated lung abscess, he then underwent a right exploratory thoracotomy. The right middle lobe and the anterior segment of the right upper lobe were necrotic and adherent to a cystic lesion that extended from the colon flap; the cystic lesion turned out to be a perforated diverticulum. Under the impression of colon diverticulitis with perforation into the lung parenchyma, the patient underwent pleural decortication, right middle lobectomy, and resection of the anterior segment of the right upper lobe with resection of the ruptured diverticulum and primary repair of the colon flap. In an additional laparotomy, a feeding jejunostomy was created after checking the patency of the colon flap outlet.
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Fig 1. (A) Normal chest roentgenogram at follow-up in June 2000. (B) Chest roentgenogram showing a right pericardial shadow in March 2005. (C) Chest roentgenogram with contrast showing barium stasis in the lower portion of the colon flap in March 2005. (D) Chest computed tomographic scan showing fluid accumulation in the right pericardial area.
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Fig 2. (A) Chest roentgenogram showing a right lung abscess in July 2005 with clinical evidence of sepsis. (B) Chest roentgenogram taken post airway intubation showing right pneumothorax with severe air leak.
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Comment
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This is the first case in the English literature of an unrecognized diverticulum in a mediastinal colon flap that became infected, and that subsequently ruptured into the adjacent lung parenchyma. Caustic ingestion injury, which usually occurs because of a suicide attempt, is not rare in Taiwan. In serious cases, emergent salvage surgery is the best option [1]. Transhiatal esophagectomy combined with total gastrectomy is the standard procedure for caustic ingestion injury in operable patients [3, 4]. If patients survive the initial insult, the colon is the first choice for reconstruction through the substernal route [5]. The choice of which colon segment to use has been fully discussed in the literature [6]. When choosing the right colon, the ileocecal valve can serve as an antireflux mechanism; isoperistalsis and reduced fecal content are further benefits of using the right colon. Nonetheless, the choice depends on surgical preference. In the present case, we used a segment of the right ascending colon to substitute for the damaged region, and no diverticulum was visible in the initial colon segment. As this case makes it clear, it is crucial to make sure there are no visible diverticula in the chosen segment.
A recent report, stating that disordered colonic electrical activity is responsible for the development of diverticula, represents a new concept that requires further study [7]. However the pathogenesis in this case was likely the result of high intraluminal pressure caused by an intermittent and violent intake of food. A roentgenogram with contrast in March 2005 showed contrast stasis in the area of the diverticulum, but we initially overlooked it due to its rarity. We discovered the diverticulum when it became infected and subsequently ruptured into the lung parenchyma. We thus present this rare case to notify the medical community that perforated diverticula in the interposed colon should be included in the differential diagnosis for patients with similar clinical presentations.
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References
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- Domreis JS, Jobe BA, Aye RW, Deveney KE, Sheppard BC, Deveney CW. Management of long-term failure after colon interposition for benign disease Am J Surg 2002;183:544-546.[Medline]
- Gossot D, Sarfati E, Celerier M. Early blunt esophagectomy in severe caustic burns of the upper digestive tractreport of 29 cases. J Thorac Cardiovasc Surg 1987;94:188-191.[Abstract]
- Estrera A, Taylor W, Mills LJ, Platt MR. Corrosive burns of the esophagus and stomacha recommendation for an aggressive surgical approach. Ann Thorac Surg 1986;41:276-283.[Abstract]
- Bassiouny IE, Al-Ramadan SA, Al-Nady A. Long-term functional results of transhiatal oesophagectomy and colonic interposition for caustic oesophageal stricture Eur J Pediatr Surg 2002;12:243-247.[Medline]
- Popovici Z. A new philosophy in esophageal reconstruction with colonthirty-years experience. Dis Esophagus 2003;16:323-327.[Medline]
- Shafik A, Ahmed I, Shafik AA, El Sibai O. Diverticular diseaseelectrophysiologic study and a new concept of pathogenesis. World J Surg 2004;28:411-415.[Medline]
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Abstract
Introduction
