- Email: [email protected]
Diaphragmatic hernia after right gastroepiploic artery coronary artery bypass grafting
458
CASEREPORT VERHOFSTEAND TAM HERNIA AFTERGEA GRAFTING
day. Over mid-term follow-up (12 months), she has had no further neurologic events. Pathologic examination revealed complex atherosclerotic plaque and thrombus.
Ann Thorac Surg 1995;60:458-9
9. Cohn LH. Thoracic aortic aneurysms and aortic dissection. In: Sabiston DC, Spencer FC, eds. Surgery of the chest. Philadelphia: Saunders, 1990:1182-209.
Comment With the continued i m p r o v e m e n t in imaging technology, localized areas of aortic atherosclerosis will be detected as the only source for prior stroke [3] and therefore raise the question of how best to treat this finding. Nonoperative therapy using anticoagulation has only been effective anecdotally in other instances of aortic embolization [1]. Extrapolating from the experience of others where intraoperative strategies to debride areas of protruding aortic atheromas led to a decrease in perioperative stroke [5, 6], a case can be made for primary surgical intervention w h e n intraluminal abnormalities within the aorta are thought to be responsible for stroke. This has been done in selected cases w h e n there has been evidence for repeated peripheral emboli and a mass in the arch by echocardiography [7, 8]. Surgical treatment for an abnormal aorta consists mainly of replacement insofar as the disease process is generally a diffuse one [9]. Others have reported modification of operative strategy, when significant aortic lesions were encountered intraoperatively by TEE, to include arch d e b r i d e m e n t [5, 6] and aortic arch exploration in the setting of multiple peripheral emboli [7, 8]. This report underscores the importance of careful evaluation of the aortic arch as a source for unexplained stroke and describes a successful treatment strategy. Emphasis on initial arterial cannulation placement with guidance from TEE and epiaortic echocardiography as well as a "notouch" technique using hypothermic circulatory arrest is noteworthy.
References 1. Bansal RC, Pauls GL, Shankel SW. Blue digit syndrome: transesophageal echocardiographic identification of thoracic aortic plaque-related thrombi and successful outcome with warfarin. J Am Soc Echocardiogr 1993;6:319-23. 2. Tunick PA, Kronzon I. Protruding atherosclerotic plaque in the aortic arch of a patient with systemic embolization: a new finding seen by transesophageal echocardiography. Am Heart J 1990;120:658-60. 3. Karalis DG, Chandrasekaran K, Victor MF, Ross JJ, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coil Cardiol 1991;17:73-8. 4. Blanchard DC, Kimura BJ, Dittrich HC, Demaria AN. Transesophageal echocardiography of the aorta. JAMA 1994;272: 546 -51. 5. Katz ES, Tunick PA, Rusinck H, Ribakove G, Spencer RC, Kronzon I. Protruding atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coil Cardiol 1992;20:70-7. 6. Ribakove GH, Katz ES, Galloway AC, et al. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg 1992;53:758-63. 7. Tunick PA, Culliford AT, Lamparello PJ, Kronzon I. Atheromatosis of the aortic arch as an occult source of multiple systemic emboli. Ann Intern Med 1991;114:391-2. 8. Tunick PA, Lackner H, Katz ES, Culliford AT, Giangola G, Kronzon I. Multiple emboli from a large aortic arch thrombus in a patient with thrombotic diathesis. Am Heart J 1992;124: 239-41. © 1995 by The Society of Thoracic Surgeons
Diaphragmatic Hernia After Right Gastroepiploic Artery Coronary Artery Bypass Grafting Marnix A. Verhofste, MD, and Stanley K. C. Tam, MD Cardiac Surgical Unit, Mount Auburn Hospital, Cambridge, Massachusetts
We report a case of a diaphragmatic hernia, with perforated viscus, originating from the diaphragmatic incision that was made to accommodate the right gastroepiploic artery coronary artery bypass graft. Avoidance of an excessively large right gastroepiploic artery pedicle and interrupted sutures placed at the limits of the diaphragmatic incision, perpendicular to the direction of the musculotendinous fibers of the diaphragm, should prevent this potentially lethal complication. Prompt recognition and treatment of this complication when it occurs is lifesaving.
(Ann Thorac Surg 1995;60:458-9) ight gastroepiploic artery (GEA) is a valuable adjunct to internal m a m m a r y arteries as an arterial conduit for coronary artery bypass grafting. Here we report a diaphragmatic hernia originating from the diaphragmatic incisions t h r o u g h which the right GEA was brought into the pericardium.
R
The patient is a 61-year-old m a n with severe peripheral vascular disease who in August 1990 u n d e r w e n t coronary artery, bypass grafting with the left internal m a m m a r y artery, to the left anterior descending artery a n d aortic valve replacement for critical aortic stenosis. Although
See also page 382. the patient had severe three-vessel disease at the time, no further bypass grafts were attempted because the ascending aorta was found to be heavily calcified. He also had u n d e r g o n e ligation a n d stripping of the right greater saphenous vein in 1974, and his left greater saphenous vein was harvested but was not used during his first cardiac operation. Because of recurrent myocardial infarctions a n d unstable angina, despite percutaneous transluminal coronary angioplasty, redo coronary artery bypass grafting was performed using the right internal m a m m a r y artery to the distal right coronary artery a n d the right GEA to an obtuse marginal branch of the circumflex artery posterolaterally. Accepted for publicationApril 5, 1995. Address reprint requests to Dr Tam, 300 Mount Auburn St, Suite 516, Cambridge, MA 02138. 0003-4975/95/$9.50 0003-4975(95)00413-F
A n n Thorac S u r g 1995;60:458-9
The operation was performed with moderate systemic hypothermia and ventricular fibrillation without aortic cross-clamping. The right GEA was brought into the pericardium through a diaphragmatic incision using a retrogastric and retrohepatic route to accommodate the posterolateral location of the obtuse marginal circumflex artery. This transverse diaphragmatic incision, measuring approximately 2 to 3 cm in length, was made in a musculotendinous portion of the diaphragm posteriorly, near the midline but anterior to the esophageal hiatus. The anatomy of the diaphragm and the esophageal hiatus appeared to be normal at the time. The patient had an excellent postoperative course and was discharged home on postoperative day 6 with a normal predischarge chest roentgenogram. On postoperative day 10 transient vague upper abdominal pain developed without nausea and vomiting. Workups at the time included abdominal and chest roentgenograms, which were normal. On postoperative day 13 the patient re-presented with acute onset of shortness of breath without any abdominal symptoms. A chest roentgenogram revealed a hydropneumothorax on the left side. After insertion of a chest tube, the patient's respiratory status improved. Gram stain of the serous drainage from the chest tube revealed gram-negative organisms. An u p p e r gastrointestinal series revealed Gastrografin (Squibb Diagnostic, Princeton, NJ) leakage into the left chest. After broad-spectrum antibiotic coverage and fluid resuscitation, the patient was explored through a left thoracotomy within 12 hours of admission. The fundus of the stomach was found in the left side of the chest. There was a small perforation in the fundus without evidence of ischemic necrosis. The anatomy of the esophageal hiatus appeared to be normal and intact. The hernia through which the fundus passed appeared to have originated from enlargement of the diaphragmatic incision made to accommodate the right GEA pedicle. This hernia measured approximately 6 to 8 cm. After primary closure of the gastric perforation, the fundus was reduced back below the diaphragm. The diaphragmatic defect then was closed primarily with interrupted sutures. Again the patient had an excellent postoperative course. A Gastrografin upper gastrointestinal series revealed only a small sliding hiatal hernia with mild gastroesophageal reflux. A few days later a barium upper gastrointestinal study and a computed tomographic scan of the chest and abdomen with oral contrast demonstrated absence of any diaphragmatic hernias. The patient was discharged 2 weeks after thoracotomy.
Comment Diaphragmatic hernia after right GEA coronary artery bypass grafting was not reported in several large series [1-4]. The hernia appeared to have originated and enlarged from the diaphragmatic incision needed to accommodate the GEA pedicle. Presumably, this enlargement of the diaphragmatic incision resulted from a tear of the diaphragm along the direction of its musculotendinous
CASE REPORT VERHOFSTE AND TAM HERNIA AFTER GEA GRAFTING
459
fibers. Minimizing the length of the diaphragmatic incision needed by keeping the right GEA pedicle small and placing interrupted sutures at the limits of the diaphragmatic incision, perpendicular to the direction of the musculotendinous fibers of the diaphragm, should prevent this complication. This case report demonstrates the potential for occurrence of a diaphragmatic hernia and its associated gastrointestinal complication after right GEA coronary artery bypass grafting, especially if the retrogastric and retrohepatic route are used. Prompt diagnosis and treatment is lifesaving.
References 1. Lytle BW, Cosgrove DM, Ratliff NB, Loop FD. Coronary artery bypass grafting with the right gastroepiploic artery. J Thorac Cardiovasc Surg 1989;97:826-31. 2. Suma H, Wanibuchi Y, Furuta S, Takeuchi A. Does use of gastroepiploic artery graft increase surgical risk? J Thorac Cardiovasc Surg 1991;101:121-5. 3. Suma H, Wanibuchi Y, Terada Y, Fukuda S, Takayama T, Furuta S. The right gastroepiploic artery graft: clinical and angiographic midterm results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615-23. 4. Grandjean JG, Boonstra PW, den Heyer P, Ebels T. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. J Thorac Cardiovasc Surg 1994;107:1309-16.
INVITED COMMENTARY In the past 10 years, the right gastroepiploic artery (GEA) has been accepted as a reliable conduit to bypass the coronary artery in terms of its safety of use and excellent mid-term patency of the graft. Although it has been known that there are few abdominal complications with use of GEA graft, Drs Verhofste and Tam report here a case of diaphragmatic hernia and gastric perforation after GEA grafting. They used the posterior route technique in which the graft is located behind the stomach and the liver and passes the diaphragm at its very posterior part close to the esophagus. As they mentioned, the stomach may slip into the chest cavity when the diaphragmatic hole is too large at the posterior part. In my experience with the GEA graft in 565 patients, I have never found this particular complication, maybe because I always use the anterior route locating the GEA pedicle in front of the liver and making a hole in the diaphragm more anteriorly at the muscle part. Even with the anterior route technique, GEA is long enough to reach the posterior part of the heart. I believe this case report has an important message for those who prefer the posterior route technique for GEA grafting.
Hisayoshi Suma, MD Cattedra di Cardiochirurgia Universita Cattolica del Sacro Cuore Largo F, Vito Rome, Italy 1-00168
CASEREPORT VERHOFSTEAND TAM HERNIA AFTERGEA GRAFTING
day. Over mid-term follow-up (12 months), she has had no further neurologic events. Pathologic examination revealed complex atherosclerotic plaque and thrombus.
Ann Thorac Surg 1995;60:458-9
9. Cohn LH. Thoracic aortic aneurysms and aortic dissection. In: Sabiston DC, Spencer FC, eds. Surgery of the chest. Philadelphia: Saunders, 1990:1182-209.
Comment With the continued i m p r o v e m e n t in imaging technology, localized areas of aortic atherosclerosis will be detected as the only source for prior stroke [3] and therefore raise the question of how best to treat this finding. Nonoperative therapy using anticoagulation has only been effective anecdotally in other instances of aortic embolization [1]. Extrapolating from the experience of others where intraoperative strategies to debride areas of protruding aortic atheromas led to a decrease in perioperative stroke [5, 6], a case can be made for primary surgical intervention w h e n intraluminal abnormalities within the aorta are thought to be responsible for stroke. This has been done in selected cases w h e n there has been evidence for repeated peripheral emboli and a mass in the arch by echocardiography [7, 8]. Surgical treatment for an abnormal aorta consists mainly of replacement insofar as the disease process is generally a diffuse one [9]. Others have reported modification of operative strategy, when significant aortic lesions were encountered intraoperatively by TEE, to include arch d e b r i d e m e n t [5, 6] and aortic arch exploration in the setting of multiple peripheral emboli [7, 8]. This report underscores the importance of careful evaluation of the aortic arch as a source for unexplained stroke and describes a successful treatment strategy. Emphasis on initial arterial cannulation placement with guidance from TEE and epiaortic echocardiography as well as a "notouch" technique using hypothermic circulatory arrest is noteworthy.
References 1. Bansal RC, Pauls GL, Shankel SW. Blue digit syndrome: transesophageal echocardiographic identification of thoracic aortic plaque-related thrombi and successful outcome with warfarin. J Am Soc Echocardiogr 1993;6:319-23. 2. Tunick PA, Kronzon I. Protruding atherosclerotic plaque in the aortic arch of a patient with systemic embolization: a new finding seen by transesophageal echocardiography. Am Heart J 1990;120:658-60. 3. Karalis DG, Chandrasekaran K, Victor MF, Ross JJ, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coil Cardiol 1991;17:73-8. 4. Blanchard DC, Kimura BJ, Dittrich HC, Demaria AN. Transesophageal echocardiography of the aorta. JAMA 1994;272: 546 -51. 5. Katz ES, Tunick PA, Rusinck H, Ribakove G, Spencer RC, Kronzon I. Protruding atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coil Cardiol 1992;20:70-7. 6. Ribakove GH, Katz ES, Galloway AC, et al. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg 1992;53:758-63. 7. Tunick PA, Culliford AT, Lamparello PJ, Kronzon I. Atheromatosis of the aortic arch as an occult source of multiple systemic emboli. Ann Intern Med 1991;114:391-2. 8. Tunick PA, Lackner H, Katz ES, Culliford AT, Giangola G, Kronzon I. Multiple emboli from a large aortic arch thrombus in a patient with thrombotic diathesis. Am Heart J 1992;124: 239-41. © 1995 by The Society of Thoracic Surgeons
Diaphragmatic Hernia After Right Gastroepiploic Artery Coronary Artery Bypass Grafting Marnix A. Verhofste, MD, and Stanley K. C. Tam, MD Cardiac Surgical Unit, Mount Auburn Hospital, Cambridge, Massachusetts
We report a case of a diaphragmatic hernia, with perforated viscus, originating from the diaphragmatic incision that was made to accommodate the right gastroepiploic artery coronary artery bypass graft. Avoidance of an excessively large right gastroepiploic artery pedicle and interrupted sutures placed at the limits of the diaphragmatic incision, perpendicular to the direction of the musculotendinous fibers of the diaphragm, should prevent this potentially lethal complication. Prompt recognition and treatment of this complication when it occurs is lifesaving.
(Ann Thorac Surg 1995;60:458-9) ight gastroepiploic artery (GEA) is a valuable adjunct to internal m a m m a r y arteries as an arterial conduit for coronary artery bypass grafting. Here we report a diaphragmatic hernia originating from the diaphragmatic incisions t h r o u g h which the right GEA was brought into the pericardium.
R
The patient is a 61-year-old m a n with severe peripheral vascular disease who in August 1990 u n d e r w e n t coronary artery, bypass grafting with the left internal m a m m a r y artery, to the left anterior descending artery a n d aortic valve replacement for critical aortic stenosis. Although
See also page 382. the patient had severe three-vessel disease at the time, no further bypass grafts were attempted because the ascending aorta was found to be heavily calcified. He also had u n d e r g o n e ligation a n d stripping of the right greater saphenous vein in 1974, and his left greater saphenous vein was harvested but was not used during his first cardiac operation. Because of recurrent myocardial infarctions a n d unstable angina, despite percutaneous transluminal coronary angioplasty, redo coronary artery bypass grafting was performed using the right internal m a m m a r y artery to the distal right coronary artery a n d the right GEA to an obtuse marginal branch of the circumflex artery posterolaterally. Accepted for publicationApril 5, 1995. Address reprint requests to Dr Tam, 300 Mount Auburn St, Suite 516, Cambridge, MA 02138. 0003-4975/95/$9.50 0003-4975(95)00413-F
A n n Thorac S u r g 1995;60:458-9
The operation was performed with moderate systemic hypothermia and ventricular fibrillation without aortic cross-clamping. The right GEA was brought into the pericardium through a diaphragmatic incision using a retrogastric and retrohepatic route to accommodate the posterolateral location of the obtuse marginal circumflex artery. This transverse diaphragmatic incision, measuring approximately 2 to 3 cm in length, was made in a musculotendinous portion of the diaphragm posteriorly, near the midline but anterior to the esophageal hiatus. The anatomy of the diaphragm and the esophageal hiatus appeared to be normal at the time. The patient had an excellent postoperative course and was discharged home on postoperative day 6 with a normal predischarge chest roentgenogram. On postoperative day 10 transient vague upper abdominal pain developed without nausea and vomiting. Workups at the time included abdominal and chest roentgenograms, which were normal. On postoperative day 13 the patient re-presented with acute onset of shortness of breath without any abdominal symptoms. A chest roentgenogram revealed a hydropneumothorax on the left side. After insertion of a chest tube, the patient's respiratory status improved. Gram stain of the serous drainage from the chest tube revealed gram-negative organisms. An u p p e r gastrointestinal series revealed Gastrografin (Squibb Diagnostic, Princeton, NJ) leakage into the left chest. After broad-spectrum antibiotic coverage and fluid resuscitation, the patient was explored through a left thoracotomy within 12 hours of admission. The fundus of the stomach was found in the left side of the chest. There was a small perforation in the fundus without evidence of ischemic necrosis. The anatomy of the esophageal hiatus appeared to be normal and intact. The hernia through which the fundus passed appeared to have originated from enlargement of the diaphragmatic incision made to accommodate the right GEA pedicle. This hernia measured approximately 6 to 8 cm. After primary closure of the gastric perforation, the fundus was reduced back below the diaphragm. The diaphragmatic defect then was closed primarily with interrupted sutures. Again the patient had an excellent postoperative course. A Gastrografin upper gastrointestinal series revealed only a small sliding hiatal hernia with mild gastroesophageal reflux. A few days later a barium upper gastrointestinal study and a computed tomographic scan of the chest and abdomen with oral contrast demonstrated absence of any diaphragmatic hernias. The patient was discharged 2 weeks after thoracotomy.
Comment Diaphragmatic hernia after right GEA coronary artery bypass grafting was not reported in several large series [1-4]. The hernia appeared to have originated and enlarged from the diaphragmatic incision needed to accommodate the GEA pedicle. Presumably, this enlargement of the diaphragmatic incision resulted from a tear of the diaphragm along the direction of its musculotendinous
CASE REPORT VERHOFSTE AND TAM HERNIA AFTER GEA GRAFTING
459
fibers. Minimizing the length of the diaphragmatic incision needed by keeping the right GEA pedicle small and placing interrupted sutures at the limits of the diaphragmatic incision, perpendicular to the direction of the musculotendinous fibers of the diaphragm, should prevent this complication. This case report demonstrates the potential for occurrence of a diaphragmatic hernia and its associated gastrointestinal complication after right GEA coronary artery bypass grafting, especially if the retrogastric and retrohepatic route are used. Prompt diagnosis and treatment is lifesaving.
References 1. Lytle BW, Cosgrove DM, Ratliff NB, Loop FD. Coronary artery bypass grafting with the right gastroepiploic artery. J Thorac Cardiovasc Surg 1989;97:826-31. 2. Suma H, Wanibuchi Y, Furuta S, Takeuchi A. Does use of gastroepiploic artery graft increase surgical risk? J Thorac Cardiovasc Surg 1991;101:121-5. 3. Suma H, Wanibuchi Y, Terada Y, Fukuda S, Takayama T, Furuta S. The right gastroepiploic artery graft: clinical and angiographic midterm results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615-23. 4. Grandjean JG, Boonstra PW, den Heyer P, Ebels T. Arterial revascularization with the right gastroepiploic artery and internal mammary arteries in 300 patients. J Thorac Cardiovasc Surg 1994;107:1309-16.
INVITED COMMENTARY In the past 10 years, the right gastroepiploic artery (GEA) has been accepted as a reliable conduit to bypass the coronary artery in terms of its safety of use and excellent mid-term patency of the graft. Although it has been known that there are few abdominal complications with use of GEA graft, Drs Verhofste and Tam report here a case of diaphragmatic hernia and gastric perforation after GEA grafting. They used the posterior route technique in which the graft is located behind the stomach and the liver and passes the diaphragm at its very posterior part close to the esophagus. As they mentioned, the stomach may slip into the chest cavity when the diaphragmatic hole is too large at the posterior part. In my experience with the GEA graft in 565 patients, I have never found this particular complication, maybe because I always use the anterior route locating the GEA pedicle in front of the liver and making a hole in the diaphragm more anteriorly at the muscle part. Even with the anterior route technique, GEA is long enough to reach the posterior part of the heart. I believe this case report has an important message for those who prefer the posterior route technique for GEA grafting.
Hisayoshi Suma, MD Cattedra di Cardiochirurgia Universita Cattolica del Sacro Cuore Largo F, Vito Rome, Italy 1-00168