Ann Thorac Surg 2009;88:667-669. doi:10.1016/j.athoracsur.2008.12.077
© 2009 The Society of Thoracic Surgeons
Case Reports
Coronary Revascularization Through a Median Sternotomy After Pre-sternal Jejunum Reconstruction for Esophageal Carcinoma
Hiroyuki Nishi, MD,
Masataka Mitsuno, MD,
Hiroe Tanaka, MD,
Masaaki Ryomoto, MD,
Shinya Fukui, MD,
Yuji Miyamoto, MD*
Department of Cardiovascular Surgery, Hyogo College of Medicine, Hyogo, Japan
Accepted for publication December 23, 2008.
* Address correspondence to Dr Miyamoto, Department of Cardiovascular Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo, 663-8501, Japan (Email: y-miyamo{at}hyo-med.ac.jp).
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Abstract
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Cardiac surgery after an operation for esophageal carcinoma is technically challenging. Herein, we report a case of a 77-year-old man with unstable angina after esophagectomy with jejunum reconstruction through a pre-sternal route. The patient was successfully treated by coronary artery bypass grafting through a median sternotomy. In this difficult and rare situation, a median sternotomy was still possible by a careful preoperative examination and intraoperative strategy.
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Introduction
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A median sternotomy is considered to be almost impossible when the patient has undergone esophagectomy with reconstruction through a pre-sternal or retrosternal route [1–5]. Herein, we report a case of a patient who underwent esophagoplasty using the jejunum through a pre-sternal route after a resected esophageal carcinoma, followed by successful revascularization of the left anterior descending coronary artery and the right coronary artery performed through a median sternotomy 10 years later.
Unstable angina developed in a 77-year-old man, which was associated with S-T segment depression on the anterior and lateral leads of an electrocardiogram. He had a history of multiple percutaneous catheter intervention. The patient also had a complicated history of esophageal carcinoma 10 years before admission. At that time, he initially underwent an esophagectomy through a right thoracotomy with a retrosternal gastric bypass. However, he had an infection and leakage of his anastomosis at the neck develop, which resulted in removal of the gastric tube and a re-reconstruction of the jejunum through a pre-sternal route. At admission to our facility, the route of his jejunum could be seen from the outside (Fig 1A), and preoperative computed tomographic scans demonstrated the jejunum underlying just above the sternum (Fig 1B).
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Fig 1. (A) The route of the patient's jejunum can be seen from the outside. (B) Preoperative computed tomographic scans demonstrating the jejunum lying just above the sternum. The patient's feeding artery of the jejunum was detected on the left side of the jejunum.
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Coronary angiography revealed occlusion of the left anterior descending coronary artery due to a previous stent, and significant stenosis on the origin of the posterior descending artery and the posterolateral branch. The patient had a right dominant coronary system, and multiple stents had already been placed at the bifurcation between the posterior descending artery and the posterolateral branch. Due to ineffective medical therapy, the patient was placed on intra-aortic balloon pumping. As percutaneous catheter intervention was not indicated because of impossible access and repeat intervention due to previous stents, we opted for urgent surgical intervention. Although dissection around the jejunum is hazardous due to its thin wall, the only approach that could access both the left anterior descending coronary artery and the right coronary artery was a median sternotomy.
During surgery, the skin incision was made slightly right of the previous incision because a feeding artery of his jejunum, which should not be damaged, was detected on the left side by enhanced computed tomography. Careful dissection around the jejunum was performed and the adhesion between the jejunum and the sternum was separated (Fig 2). It was difficult to dissect around the neck and subxiphoid lesion as we could not determine the relationship between the jejunum and the surrounding tissue. In particular, the jejunum ran toward the right side around the subxiphoid. A usual median sternotomy was performed with an oscillating saw. The left internal thoracic artery could not be identified due to severe adhesion around the trail of the previously removed gastric tube. Thus, we decided to use a saphenous vein graft as a conduit. Although the jejunum was mobilized to the left side, it was impossible to open the chest wide enough because of the restriction of the jejunum. After cardiopulmonary bypass was performed in a routine manner, distal anastomosis of the saphenous vein graft was performed (ie, saphenous vein graft to posterior descending artery-posterolateral branch and saphenous vein graft to left anterior descending coronary artery). The patient was weaned from bypass without problems and his postoperative course was uneventful. A postoperative computed tomographic angiography demonstrated patent grafts.
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Fig 2. Intraoperative pictures showing the jejunum tube after careful dissection was performed and the adhesion between the jejunum and the sternum was separated.
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Comment
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With recent advances in surgical techniques and postoperative management, more cardiac surgeons are expected to experience the requirement for open heart surgery in a patient who has previously undergone esophagectomy and reconstruction through a pre-sternal or retrosternal route [1–4, 5]. Most previous reports suggest that routine median sternotomy should be avoided due to risk of injury to the reconstructed gastrointestinal tract. A left thoracotomy [1–3] and a right parasternal approach [4] were described as alternatives. In coronary artery bypass grafting, a left thoracotomy is usually applied, as it is an established technique of revascularization for the left coronary system. A right thoracotomy was also reported for a tracheotomy patient who required bypass surgery to the right coronary artery system [6]. In the present case, a right thoracotomy was considered to be an ineffective approach due to the previous right thoracotomy. Although coronary artery bypass grafting to the right coronary system through a left thoracotomy was previously reported [3], we considered this unsafe in our unstable patient with intra-aortic balloon pumping. As it was impossible to choose percutaneous catheter intervention for the patient, coronary artery bypass grafting by using a conventional approach was the only option. Although one report suggested the potential of a median sternotomy for this kind of patient [5], we believe that there is no published case report demonstrating a successful sternotomy, particularly in a patient with pre-sternal reconstruction of the jejunum.
Although we were able to perform a successful median sternotomy in this patient, the technique was technically demanding. First, it is important to detect and not to touch the feeding artery of the jejunum, potentially using enhanced computed tomography or angiography for assessing its location. Second, careful dissection around the jejunum is required. Although it was previously reported that a retrosternal gastric tube could be easily bluntly dissected [5], the situation in the jejunum is quite different due to its thin wall and serosa. In the present case, successful mobilization was achieved with comprehensive preoperative evaluation and careful and meticulous dissection. Third, due to restricted, right-side only mobilization, the surgical field exposure was relatively limited. When the chest opening width is limited, it is challenging to perform off-pump coronary artery bypass grafting. Thus, it is important to consider the risks and benefits of this approach and decide an appropriate plan before operation.
The present case demonstrated that a median sternotomy can be performed even after esophagectomy with pre-sternal reconstruction with jejunum. Although an alternative approach, such as a left thoracotomy would be ideal after esophagectomy to avoid injuring the reconstructed gastrointestinal tract, surgeons may consider a median sternotomy as a possible approach for open heart surgery.
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References
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- Safi HJ, Barnett MG, Turner W. Coronary artery bypass after substernal colon interposition for carcinoma of the esophagus Cardiovasc Surg 1994;2:415-417.[Medline]
- Hirose H, Amano A, Yoshida S, Takahashi A. Coronary artery bypass graft after esophagectomy Eur J Cardiothorac Surg 1999;15:729-731.[Abstract/Free Full Text]
- Iemura J, Oku H, Ohtaki M, Inoue T. Coronary artery bypass grafting following substernal gastric interposition Jpn Circ J 2000;64:404-405.[Medline]
- Mazzitelli D, Bedda W, Petrova D, Lange R. Gastropexy Eur J Cardiothorac Surg 2004;25:290-292.[Abstract/Free Full Text]
- Takami H, Doki Y, Yachiku K, Takeuchi D, Arisawa J, Kobayashi T. Aortic valve replacement for a patient with porcelain aorta and retrosternal gastric tube reconstruction after esophageal resection Jpn J Thorac Cardiovasc Surg 2003;51:685-687.[Medline]
- Marshall W, Meng R, Ehrenhaft J. Coronary artery bypass grafting in patients with tracheostoma Ann Thorac Surg 1988;46:465-466.[Abstract/Free Full Text]
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Abstract
Introduction
