Ann Thorac Surg 2008;86:316. doi:10.1016/j.athoracsur.2007.09.006
© 2008 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Axillary Stomach: An Unusual Postpneumonectomy Complication
Sudhakar N.J. Pipavath, MDa,*,
Michael S. Mulligan, MDb
a Department of Radiology, University of Washington Medical Center, Seattle, Washington
b Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, Washington
* Address correspondence to Dr Pipavath, Department of Radiology, University of Washington Medical Center, Box 357115, 1959 NE Pacific St, Seattle, WA 98195 (Email: snjp{at}u.washington.edu).
A 39-year-old man with left upper lobe lung cancer had undergone pneumonectomy 2 years before and had a complicated postoperative course with bronchopleural fistula and empyema that was treated with an open window thoracostomy with persistent purulent drainage. Then he underwent repeat thoracotomy with an omental flap brought into the chest through an anterior incision in the diaphragm. The omentum was tacked to the diaphragm in eight separate locations. Then the chest was closed, but a rib had been resected at his initial operation. Four months later he was noted to have a left lateral chest wall defect that progressively enlarged and contained a reducible hernia. The scout view at computed tomography demonstrates stomach containing air ("S," Fig 1). Coronal reformats of the multidetector computed tomographic images demonstrate the contiguous diaphragmatic (arrows, Fig 2) and left lateral chest wall defects (arrows, Fig 3) and the herniated contents of the stomach, small bowel, left colon, and the omentum.
The herniated abdominal contents were reduced surgically below the diaphragm, and the defects in the diaphragm and the chest wall were reconstructed with thick Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ). A roentgenogram of the chest obtained after the repair demonstrates complete reduction of the hernia (Fig 4).
The unique properties render the omentum an excellent choice of vascularized pedicle in the management of the most complex cardiothoracic surgical problems [1]. However, the technique involves mobilization through a diaphragmatic defect with a potential for diaphragmatic or intercostodiaphragmatic herniation of intrabdominal contents. Intercostodiaphragmatic herniation of intrabdominal contents is a rare postpneumonectomy complication. In a large series of 85 patients who underwent omental transposition to the chest, none of them had herniation of intrabdominal contents into the chest, either through a diaphragmatic defect or through the substernal route [1]. It has been reported as a complication of penetrating trauma, such as a bull gore injury [2].
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References
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- Shrager JB, Wain JC, Wright CD, et al. Omentum is highly effective in the management of complex cardiothoracic surgical problems J Thorac Cardiovasc Surg 2003;125:526-532.[Abstract/Free Full Text]
- Nabi G, Seenu V, Misra MC. Intercostodiaphragmatic hernia secondary to a bull gore injury: a delayed detection Indian J Chest Dis Allied Sci 2002;44:187-189.[Medline]
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