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Ann Thorac Surg 2006;82:e8-e10
© 2006 The Society of Thoracic Surgeons

Case report

Strangulation of the Reconstructive Gastric Tube by the Azygos Arch

Frank Cheau-Feng Lin, MDa, Hyde Russell, MDb, Mark K. Ferguson, MDb,*

a Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taiwan, Republic of China
b Department of Surgery, The University of Chicago, Chicago, Illinois

Accepted for publication May 2, 2006.

* Address correspondence to Dr Ferguson, The University of Chicago, 5841 S Maryland Ave, MC5035, Chicago, IL 60637. (Email: mferguso{at}surgery.bsd.uchicago.edu).


   Abstract
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 Abstract
Introduction
 Case Reports
 Comment
 References
 
Graft necrosis after esophageal reconstruction is a rare but disastrous complication associated with a high mortality rate. Azygos arch strangulation of the graft is an unusual cause of graft necrosis. We report two cases of postesophagectomy gastric tube reconstruction complicated by azygos arch strangulation and graft ischemia. In one patient, graft necrosis resulted and a reconstruction was performed later with a colon interposition. In the other patient, the azygos arch was divided and the graft was preserved. We recommend dividing the azygos arch routinely during transthoracic or thoracoscopic esophagectomy if the reconstruction graft is to be brought up through the posterior mediastinal route to help avoid this problem.


   Introduction
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 Abstract
 Introduction
Case Reports
 Comment
 References
 
Esophagectomy with reconstruction is a challenging operation with high attendant morbidity and mortality. Graft necrosis is a dreaded complication of esophageal reconstruction, and the consequent mortality rate has been reported to exceed 50% [1]. This entity is rare, and as a result, its causes have not been thoroughly analyzed. Causes of graft necrosis other than intrinsic vascular insufficiency have rarely been reported.

The azygos vein arches across the esophagus and the trachea at the level of fourth thoracic vertebra, merging with the superior vena cava. During esophageal reconstruction, the gastric tube is brought up through the esophageal bed (the posterior mediastinal route), and some surgeons leave the azygos arch intact so that it helps contain the conduit in the mediastinum. The azygos arch potentially can constrict the conduit, however, and might cause strangulation of the interposition in some cases. We report 2 patients in whom the azygos arch strangulated the gastric tube used for esophageal reconstruction, a condition that has seldom been reported.


   Case Reports
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 Case Reports
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Patient 1
A 75-year-old man underwent a McKeown modification of an Ivor Lewis esophagectomy for squamous cell carcinoma of the middle third of the thoracic esophagus. This was reconstructed with a gastric tube placed in the posterior mediastinum, and a hand-sewn esophagogastrostomy was performed in the neck. The pathologic staging was T3N1M0 stage III. The postoperative chest roentgenogram showed a distended gastric tube above the level of the azygos arch. The nasogastric tube output was about 100 mL per day.

The postoperative course was uneventful until postoperative day 8, when 750 mL of cloudy, foul-smelling fluid suddenly drained through the patient's right chest tube. The pleural fluid analysis was compatible with an empyema; fluid amylase was not measured. The peripheral white blood cell count was 18,500/mm3. The patient was tachycardic but was afebrile.

A computed tomography scan of the chest revealed gastric tube distension above the azygos arch and pleural fluid in the right chest. An urgent right thoracotomy was performed. The gastric tube was strangulated by the azygos vein, with alimentary tract contents leaking from the staple line of the distended portion of the stomach superior to the azygos vein, unrelated to the anastomosis. The azygos vein was twisted several times, and no blood flow was observed through it.

We divided the azygos arch and decompressed the distended gastric tube. The region of the gastric tube that had been tethered by the azygos arch had hyperemic serosa. Once the gastric tube returned to its normal tension-free size, there was no further evidence of leakage. No reinforcing sutures were placed to help avoid creating additional ischemia. The pleural cavity was decorticated and irrigated. The patient was extubated 26 days after the event and subsequently tolerated oral intake well. He was discharged to home 45 days after the event.

Patient 2
A 77-year-old man underwent thoracoscopic mobilization of the esophagus for management of a gastroesophageal junction adenocarcinoma. Of note, the arch of the azygos vein was left intact. This was followed by laparotomy for gastric mobilization and jejunostomy tube placement. Reconstruction was performed with a gastric tube positioned in the posterior mediastinum, and a cervical esophagostomy was accomplished using a linear stapled technique. The final pathology demonstrated a T3N0M0 stage IIA adenosquamous carcinoma.

The patient's postoperative recovery was uneventful, and he was discharged from the hospital on postoperative day 6. A chest roentgenogram late during the initial hospitalization demonstrated a distended gastric pull-up with a clear indentation at the level of the azygos vein (Figure 1). The patient presented to the emergency department 8 days later complaining of a fever and a cough. A chest roentgenogram revealed a dilated gastric tube above the azygos arch level and right lower lobe pneumonia. A barium esophagram revealed a fistulous connection between the gastric pull-up and the trachea at the level of the carina.


Figure 1
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  		Fig 1. The postoperative chest roentgenogram revealed a dilated gastric tube with a clearly evident constriction at the level of the azygos vein arch.

 
The patient underwent a right thoracotomy. The azygos vein was found to be tightly compressing the gastric tube medial to it, and this appeared to have resulted in ischemic necrosis of the portion of the stomach tube superior to the vein. A fistula was found between the necrotic stomach and the adjacent trachea. The fistula was divided and débrided, and the airway was repaired with a flap of parietal pleura. The necrotic portion of the gastric tube was excised, the stomach remnant was returned to the abdomen, and the proximal esophagus was brought out as a cervical esophagostomy.

His postoperative course was complicated by a mediastinal abscess that required a drainage procedure, but the patient was ultimately discharged home on jejunal tube feedings. He underwent reconstruction 6 months later with a right colon interposition and recovered completely.


   Comment
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 Abstract
 Introduction
 Case Reports
 Comment
References
 
Necrosis of an esophageal reconstructive organ is a rare but catastrophic complication. The incidence is estimated to be 1% to 5% [2–5], and the mortality rate is reported to be as high as 50% to 97% [1, 2]. Ischemia with partial thickness necrosis, with loss of the mucosa only, occurs twice as often as does full thickness necrosis [2, 6]. The necrosis usually occurs in the superior portion of the graft near the anastomosis, which can be adequately explained by the distance of this portion from the origin of the gastric blood supply [3]. The time frame during which necrosis is detected ranges from 2 days to 1 month postoperatively [3, 7]. There may be initial ischemia rather than actual necrosis, and only a portion of these patients progress to necrosis. Graft failure is usually discovered only as a result of recognizing an anastomotic leak. The consequences of delayed recognition are prolonged hospital stay, the need for intensive care, multiple reoperations, loss of the graft, and even loss of life [2].

Knowledge of the causes of ischemia and necrosis enables surgeons to detect problems early, which may prevent graft necrosis. The factors that cause graft necrosis are similar to those that cause anastomotic leaks. Most scholars classify them as local, systemic, and surgical factors [1]. Arterial insufficiency, venous insufficiency, anastomotic tension, adjacent infection, gastric distension, and extrinsic compression (usually at the thoracic inlet for the substernal route) are the local factors leading to necrosis. Malnutrition, hypotension, and hypoxia are the systemic etiologies of necrosis. A technical error such as torsion of the conduit is an important but uncommon factor.

The esophagus is normally compressed by the aortic arch, left mainstem bronchus, and diaphragm; the azygos vein does not compress the esophagus under normal conditions. However, in certain diseases in which esophageal dilatation occurs, such as achalasia and Chagas disease with megaesophagus, tethering of the esophagus by the azygos vein may cause obstruction [8]. The reconstructive gastric tube is usually wider than the native esophagus. Our patients had an atypical pattern of ischemia/necrosis delineated by the azygos arch, in which the azygos arch appeared to have strangulated the gastric tube. Ischemia and necrosis of the gastric tubes ensued. Collard and colleagues [4] reported a similar experience.

It is interesting to note that the resections for both patients were performed through an open thoracotomy. For many years, one of the authors (MKF) routinely left the azygos vein intact during such resections to help maintain the reconstructive gastric tube in the mediastinum. The combination of this and redundancy of the tube, permitting it to balloon into the right pleural cavity, likely resulted in ischemic compression by the azygos vein in the cases presented here. The azygos vein is always left intact during transhiatal esophagectomy, but no such complication has been reported related to this technique. It is possible that the type of dissection performed during this procedure creates a wider mediastinal route while at the same time leaving the pleura intact, helping to avoid azygos arch strangulation. We suggest routine transection of the azygos arch during open or thoracoscopic resections if the graft is to be passed through the posterior mediastinal route.

Reconstruction graft necrosis is a catastrophic complication after esophagectomy. Early detection and prevention is very important for the survival of patients so affected. Detection is not always easy. If the diagnosis is considered, endoscopic examination is helpful in the early diagnosis and in the follow-up of the condition of the conduit [3]. The graft may just be ischemic without necrosis [3, 7]. The ischemia may resolve after a period of recovery or will progress to necrosis. If the ischemia progresses or necrosis is noted, early surgical intervention may be lifesaving. Routine division of the azygos vein during esophagectomy performed by thoracotomy or thoracoscopy may prevent graft necrosis caused by the azygos vein.


   References
Top
 Abstract
 Introduction
 Case Reports
 Comment
 References
 

  1. Urschel JD. Esophagogastrostomy anastomosis leaks complicating esophagectomya review. Am J Surg 1995;169:634-640.[Medline]
  2. Moorehead RJ, Wong J. Gangrene in esophageal substitutes after resection and bypass procedures for carcinoma of esophagus Hepatogastroenterol 1990;37:364-367.
  3. Maish MS, DeMeester SR, Choustoulakis JW, et al. The safety and usefulness of endoscopy for evaluation of the graft and anastomosis early after esophagectomy and reconstruction Surg Endosc 2005;19:1093-1102.[Medline]
  4. Collard J, Tinton N, Malaise J, Romagnoli R, Otte JB, Kestens PJ. Esophageal replacementgastric tube or whole stomach?. Ann Thorac Surg 1995;60:261-267.[Abstract/Free Full Text]
  5. Orringer MB, Marshall B, Iannettoni, MD. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease World J Surg 2001;25:196-203.[Medline]
  6. Okazaki M, Asato H, Takushima A, Nakatsuka T, Ueda K, Harii K. Secondary reconstruction of failed esophageal reconstruction Ann Plast Surg 2005;54:530-537.[Medline]
  7. Cheng W, Heitmiller F, Jones B. Subacute ischemia of the colon esophageal interposition Ann Thorac Surg 1994;57:899-903.[Abstract/Free Full Text]
  8. Sachdev AK, Negi SS, Kumar N. Vascular tethering of the megaoesophagus by the azygos arch masquerading as a malignancy Trop Gastroenterol 2003;24:129-130.[Medline]



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