- Email: [email protected]
Giant Esophageal Diverticula After Laparoscopic Band Placement
1330
CASE REPORT SUHAIL ET AL ESOPHAGEAL DIVERTICULUM
Ann Thorac Surg 2012;94:1330 –32
combination of muscle flaps and various prostheses allows for application of this limb-sparing procedure in an extended group of patients with extended shoulder girdle neoplasms. Considering the superior functional and oncologic outcomes and comparable morbidity in comparison with more disabling surgical procedures [1, 6], the Tikhoff–Linberg procedure should be included in the repertoire of procedures considered in the treatment of these patients.
References
FEATURE ARTICLES
Fig 3. Three-dimensional reconstruction of the computed tomography scan demonstrating the partially resected right scapula and the prosthetic chest wall reconstruction.
ability to use either the thoracodorsal or the subscapular arterial pedicle, with or without the skin flap. Marlex mesh reconstruction is highly effective in the reconstruction of large chest wall defects. Over time, the ingrowth of fibroblasts into the material further assists in the stabilization of the thoracic cage. In general, chest wall defects exceeding the size of the patient’s palm require mesh reconstruction. Bony reconstruction with methyl methacrylate gained popularity because of its ability to be customized to an individual defect, which provides optimal cosmetic and functional results. The use of a sandwiched prosthesis—methyl methacrylate between two layers of Marlex mesh—is highly effective in the replacement of the rigid chest wall. A multimodality approach is required in these patients, with significant preoperative planning involving both surgical specialties and radiologists. Some have described a need for prolonged postoperative ventilation because of the lengthy operative procedure and altered chest wall mechanics. Respiratory complications are the major cause of mortality in this patient population [4, 5]. Postoperative pneumonia may mandate prolonged ventilatory support and tracheostomy or may result in an infected prosthesis if associated with respiratory failure and septicemia, respectively. We planned a two-stage operative approach in our patient in an attempt to avoid pulmonary complications, and to allow for thorough pathologic analysis of the surgical margins before placement of the muscle graft. The availability and ease of a vacuum wound dressing facilitates this approach, eliminating the need for multiple dressing changes, which can be quite painful. Certainly, chest wall reconstruction is simpler after a forequarter amputation; however, the functional result of this procedure is not equivalent. The ability to reconstruct the resected chest wall with a © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Sandy G, Shores J, Reeves M. Tikhoff-Linberg procedure and chest wall resection for recurrent sarcoma of the shoulder girdle involving the chest wall. J Surg Oncol 2005;89:91– 4. 2. Lardinois D, Muller M, Furrer M, et al. Functional assessment of chest wall integrity after methylmethacrylate reconstruction. Ann Thorac Surg 2000;69:919 –23. 3. Villa MT, Chang DW. Muscle and omental flaps for chest wall reconstruction. Thorac Surg Clin 2010;20:543–50. 4. Chapelier A, Missana MC, Couturaud B, et al. Sternal resection and reconstruction for primary tumors. Ann Thorac Surg 2004;77: 1001–7. 5. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279 – 85. 6. Voggenreiter G, Assenmacher S, Schmit-Neuerburg KP. Tikhoff-Linberg procedure for bone and soft tissue tumors of the shoulder girdle. Arch Surg 1999;134:252–7.
Giant Esophageal Diverticula After Laparoscopic Band Placement Mohammed Suhail, BS, Adam Smith, DO, Albert H. Olivencia-Yurvati, DO, and Jay Patel, DO Texas College of Osteopathic Medicine, Department of Surgery, and Plaza Medical Center of Fort Worth, University of North Texas Health Science Center, Fort Worth, Texas
An esophageal diverticulum is seen in a variety of gastroesophageal conditions, with most having an underlying motility disorder. The diverticulum is diagnosed by combining the patient’s history, physical examination, computed tomographic chest scan, and barium radiography. We present an unusual case of a 43-year-old patient with a history of leiomyoma resection of the esophagus and an ensuing placement of a laparoscopic band for weight loss. One year after banding, persistent dysphagia led to the diagnosis of a large esophageal diverticulum. We believe that this esophageal diverticulum is the largest reported secondary to a laparoscopic band. (Ann Thorac Surg 2012;94:1330 –32) © 2012 by The Society of Thoracic Surgeons Accepted for publication Feb 14, 2012. Address correspondence to Dr Olivencia-Yurvati, University of North Texas Health Science Center, Department of Surgery, 855 Montgomery St, Fort Worth, TX 76107; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.02.082
Ann Thorac Surg 2012;94:1330 –32
CASE REPORT SUHAIL ET AL ESOPHAGEAL DIVERTICULUM
1331
L
aparoscopic adjustable gastric banding (LAGB) has become an adjunct bariatric procedure in helping to control obesity. In effect it helps to decrease weight and lower morbidity and mortality associated with obesity. However, postoperatively LAGB also increases lower esophageal sphincter pressures and causes significant motility disturbances [1, 2]. These changes in lower esophageal pressure can cause deleterious effects to the more proximal esophagus triggering esophageal widening and dilations [2]. We present a patient with a history of leiomyoma resection of the esophagus, and an ensuing placement of a laparoscopic band led to the formation of a largest esophageal diverticulum.
Fig 1. Patient’s current computed tomographic scan of the abdomen showing the lap band (arrow) in proper anatomical position.
Fig 2. Chest computed tomographic scan with oral contrast showing a large intrathoracic diverticulum (arrow) with dimensions of 8.3 cm craniocaudally by 7.7 cm anteroposteriorly by 4.0 cm transversely.
ticulum itself. Extensive adhesiolysis was performed, freeing the proximal and distal esophagus and the diverticulum. A number 52 bougie was placed by anesthesiology and used as a guide for the esophageal diverticulectomy. The diverticulum was excised using a TA-90 stapler (Ethicon, Cincinnati, OH). The diverticulum was removed and the area was reinforced and oversewn in a modified-Lembert manner using a 3-0 silk suture. One pleural tube was placed, and the chest was closed in the usual manner. Postoperatively, his vital signs were stable and his pain was controlled. His chest tube output was 240 mL on postoperative day 1. Day 2 chest tube output was 160 mL over the night shift. He was continued on nil per os status
Fig 3. Esophagogram (arrow) showing delayed transition of contrast within the esophagus.
FEATURE ARTICLES
A 43-year-old white man presented for surgical management of his laparoscopic band adjustment. The patient lost approximately 170 pounds after his initial laparoscopic band placement. He later experienced dysphagia and significant upper esophageal discomfort. The patient began to experience occasional reflux, and a fluoroscopy during a laparoscopic band adjustment led to the discovery of an esophageal diverticulum. This finding was interesting because he had a resection of a leiomyoma at the midlevel of the esophagus 2 years before the lapband placement. His current computed tomographic (CT) scan of the abdomen showed the lap band in proper anatomic position (Fig 1). A chest CT scan with oral contrast showed a large intrathoracic diverticulum with dimensions of 8.3 cm craniocaudal by 7.7 cm anteroposterior by 4.0 cm transversely (Fig 2). Other imaging included an esophagogram showing delayed transition of contrast within the esophagus (Fig 3). We believe that the diverticulum developed in the area of the previous myotomy. The patient underwent laparoscopic band deflation and removal of the laparoscopic band. He was then sterilely prepared again and draped with Betadine solution after positioning for thoracotomy. A right posterolateral thoracotomy incision was made to excise the previous scar tissue. Dense adhesions of the lung were noted from the visceral and parietal pleura to the diver-
1332
CASE REPORT KIM ET AL TUBERCULOUS STERNAL OSTEOMYELITIS
and maintained on intravenous fluids. On postoperative day 5, the patient underwent a barium esophagram that showed no extravasation of contrast and a complete resolution of the diverticulum. At this point, the patient was administered a clear liquid diet and advanced to a full liquid diet the next day. The pleural tube was removed on day 7, and the patient was discharged on day 8. At the 3-week postoperative follow-up, the patient was asymptomatic and continued to progress well, tolerating a full liquid diet. Six weeks postoperatively, he had recovered fully without any symptoms of achalasia or reflux. Six months after resection, she remains asymptomatic and continues to tolerate a normal diet.
Comment
FEATURE ARTICLES
Postoperatively, LAGB increases lower esophageal sphincter pressure from 12.1 to 13.3 mm Hg [1, 3]. Nausea, vomiting, and alterations in esophageal motility can occur after LAGB placement [4]. Such an outcome would require band deflation and in severe cases band removal [2]. The obstruction caused by gastric banding can result in esophageal dilation and dysmotility through weakening of the esophageal musculature [1]. Esophageal diverticulum frequently arises from an increased intraesophageal pressure and is associated with a motility disorder [5, 6]. The prevalence of esophageal diverticulum remains unknown because of its high frequency of asymptomatic behavior. There is no correlation between the size of diverticulum and the severity of symptoms [7]. Streitz et al [7] advocates performing a myotomy only in the area of the motor abnormality and sparing the lower esophageal sphincter unless it is hypertensive. Similarly, Nehra et al [8] recommends myotomy across the entire sphincter zone and including the length of the motor abnormality, as determined on preoperative studies. In a study by Varghese and colleagues [5], of the 34 patients with an epiphrenic diverticulum, 82% experienced a disorder in esophageal motility demonstrated either by manometry or the finding of a tertiary contraction on barium swallow, whereas the remaining suffered from a hiatal hernia. Patients with motility disorders undergoing diverticulectomy and esophagomyotomy have a 2% to 12% chance of developing an esophageal leak; however, most are contained and are asymptomatic with spontaneous resolution. Recurrent diverticulum has not reported, although dysphagia with an associated motility disorder may persist. No prior studies on myotomy specifically address motility disorders caused by an external distal end obstruction such as a lap band placement because of its rarity. The current literature recommends performing an esophagomyotomy at the site of motor abnormality in correcting primary motility disorders, but band deflation and removal was sufficient to correct the dysmotility because the symptoms for the patient arose after LAGB. Diverticula of the esophageal body are rare and range from 2 to 9 cm, with an average of 5 cm at the level of the mid to distal esophagus [5]. However, this report presents a unique case of a diverticulum located in the proximal to mid esophagus ex© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2012;94:1332–5
tending 25 cm from incisors, with dimensions of 8.3 ⫻ 7.7 ⫻ 4.0 cm. This case report demonstrates a rare and unique etiology for the development of an esophageal diverticulum in the setting of a laparoscopic band placement. Weakness of the muscular wall caused by resection of a leiomyoma contributed to this patient’s diverticulum formation, secondary to the increased chronic back pressure from the distal band.
References 1. Suter M, Dorta G, Giusti V, et al. Gastric banding interferes with esophageal motility and gastroesophageal reflux. Arch Surg 2005;140:639 – 43. 2. Wiesner W, Hauser M, Schob O, et al. Pseudo-achalasia following laparoscopically placed adjustable gastric banding. Obes Surg 2001;11:513– 8. 3. Korenkov M, Köhler L, Yücel N, et al. Esophageal motility and reflux symptoms after bariatric surgery. Obes Surg 2002;12: 72– 6. 4. Dargent J. Esophageal dilatation after laparoscopic adjustable gastric banding: definition and strategy. Obes Surg 2005;15: 843– 8. 5. Varghese TK Jr, Marshall B, Chang AC, et al. Surgical treatment of epiphrenic diverticula: a 30-year experience. Ann Thorac Surg 2007;84:1801–9. 6. Conrad C, Nissen F. Giant epiphrenic diverticula. Eur J Radiol 1982;2:48 –9. 7. Streitz JM, Glick ME, Ellis H. Selective use of myotomy for treatment of epiphrenic diverticula manometric and clinical analysis. Arch Surg 1992;127:585– 8. 8. Nehra D, Lord RV, Demeester TR, et al. Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg 2002;235:346 –54.
Chronic Sternum Wound Infection Caused by Mycobacterium tuberculosis After Cardiac Surgery Ho Jin Kim, MD, Joon Bum Kim, MD, and Cheol Hyun Chung, MD Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
The sternum wound infection, caused by Mycobacterium tuberculosis after a cardiac surgery, is an extremely rare postoperative complication. It requires a high degree of suspicion for a correct diagnosis. Often a successful treatment is impeded by the insidious nature of tuberculosis infection and the time-consuming diagnosis process. We report two cases in which we successfully treated this infection with sternum resection, wound debridement, and antituberculosis medication. (Ann Thorac Surg 2012;94:1332–5) © 2012 by The Society of Thoracic Surgeons Accepted for publication Feb 2, 2012. Address correspondence to Dr J.B. Kim, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea; e-mail: jbkim1975@amc. seoul.kr.
0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.02.028
CASE REPORT SUHAIL ET AL ESOPHAGEAL DIVERTICULUM
Ann Thorac Surg 2012;94:1330 –32
combination of muscle flaps and various prostheses allows for application of this limb-sparing procedure in an extended group of patients with extended shoulder girdle neoplasms. Considering the superior functional and oncologic outcomes and comparable morbidity in comparison with more disabling surgical procedures [1, 6], the Tikhoff–Linberg procedure should be included in the repertoire of procedures considered in the treatment of these patients.
References
FEATURE ARTICLES
Fig 3. Three-dimensional reconstruction of the computed tomography scan demonstrating the partially resected right scapula and the prosthetic chest wall reconstruction.
ability to use either the thoracodorsal or the subscapular arterial pedicle, with or without the skin flap. Marlex mesh reconstruction is highly effective in the reconstruction of large chest wall defects. Over time, the ingrowth of fibroblasts into the material further assists in the stabilization of the thoracic cage. In general, chest wall defects exceeding the size of the patient’s palm require mesh reconstruction. Bony reconstruction with methyl methacrylate gained popularity because of its ability to be customized to an individual defect, which provides optimal cosmetic and functional results. The use of a sandwiched prosthesis—methyl methacrylate between two layers of Marlex mesh—is highly effective in the replacement of the rigid chest wall. A multimodality approach is required in these patients, with significant preoperative planning involving both surgical specialties and radiologists. Some have described a need for prolonged postoperative ventilation because of the lengthy operative procedure and altered chest wall mechanics. Respiratory complications are the major cause of mortality in this patient population [4, 5]. Postoperative pneumonia may mandate prolonged ventilatory support and tracheostomy or may result in an infected prosthesis if associated with respiratory failure and septicemia, respectively. We planned a two-stage operative approach in our patient in an attempt to avoid pulmonary complications, and to allow for thorough pathologic analysis of the surgical margins before placement of the muscle graft. The availability and ease of a vacuum wound dressing facilitates this approach, eliminating the need for multiple dressing changes, which can be quite painful. Certainly, chest wall reconstruction is simpler after a forequarter amputation; however, the functional result of this procedure is not equivalent. The ability to reconstruct the resected chest wall with a © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Sandy G, Shores J, Reeves M. Tikhoff-Linberg procedure and chest wall resection for recurrent sarcoma of the shoulder girdle involving the chest wall. J Surg Oncol 2005;89:91– 4. 2. Lardinois D, Muller M, Furrer M, et al. Functional assessment of chest wall integrity after methylmethacrylate reconstruction. Ann Thorac Surg 2000;69:919 –23. 3. Villa MT, Chang DW. Muscle and omental flaps for chest wall reconstruction. Thorac Surg Clin 2010;20:543–50. 4. Chapelier A, Missana MC, Couturaud B, et al. Sternal resection and reconstruction for primary tumors. Ann Thorac Surg 2004;77: 1001–7. 5. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279 – 85. 6. Voggenreiter G, Assenmacher S, Schmit-Neuerburg KP. Tikhoff-Linberg procedure for bone and soft tissue tumors of the shoulder girdle. Arch Surg 1999;134:252–7.
Giant Esophageal Diverticula After Laparoscopic Band Placement Mohammed Suhail, BS, Adam Smith, DO, Albert H. Olivencia-Yurvati, DO, and Jay Patel, DO Texas College of Osteopathic Medicine, Department of Surgery, and Plaza Medical Center of Fort Worth, University of North Texas Health Science Center, Fort Worth, Texas
An esophageal diverticulum is seen in a variety of gastroesophageal conditions, with most having an underlying motility disorder. The diverticulum is diagnosed by combining the patient’s history, physical examination, computed tomographic chest scan, and barium radiography. We present an unusual case of a 43-year-old patient with a history of leiomyoma resection of the esophagus and an ensuing placement of a laparoscopic band for weight loss. One year after banding, persistent dysphagia led to the diagnosis of a large esophageal diverticulum. We believe that this esophageal diverticulum is the largest reported secondary to a laparoscopic band. (Ann Thorac Surg 2012;94:1330 –32) © 2012 by The Society of Thoracic Surgeons Accepted for publication Feb 14, 2012. Address correspondence to Dr Olivencia-Yurvati, University of North Texas Health Science Center, Department of Surgery, 855 Montgomery St, Fort Worth, TX 76107; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.02.082
Ann Thorac Surg 2012;94:1330 –32
CASE REPORT SUHAIL ET AL ESOPHAGEAL DIVERTICULUM
1331
L
aparoscopic adjustable gastric banding (LAGB) has become an adjunct bariatric procedure in helping to control obesity. In effect it helps to decrease weight and lower morbidity and mortality associated with obesity. However, postoperatively LAGB also increases lower esophageal sphincter pressures and causes significant motility disturbances [1, 2]. These changes in lower esophageal pressure can cause deleterious effects to the more proximal esophagus triggering esophageal widening and dilations [2]. We present a patient with a history of leiomyoma resection of the esophagus, and an ensuing placement of a laparoscopic band led to the formation of a largest esophageal diverticulum.
Fig 1. Patient’s current computed tomographic scan of the abdomen showing the lap band (arrow) in proper anatomical position.
Fig 2. Chest computed tomographic scan with oral contrast showing a large intrathoracic diverticulum (arrow) with dimensions of 8.3 cm craniocaudally by 7.7 cm anteroposteriorly by 4.0 cm transversely.
ticulum itself. Extensive adhesiolysis was performed, freeing the proximal and distal esophagus and the diverticulum. A number 52 bougie was placed by anesthesiology and used as a guide for the esophageal diverticulectomy. The diverticulum was excised using a TA-90 stapler (Ethicon, Cincinnati, OH). The diverticulum was removed and the area was reinforced and oversewn in a modified-Lembert manner using a 3-0 silk suture. One pleural tube was placed, and the chest was closed in the usual manner. Postoperatively, his vital signs were stable and his pain was controlled. His chest tube output was 240 mL on postoperative day 1. Day 2 chest tube output was 160 mL over the night shift. He was continued on nil per os status
Fig 3. Esophagogram (arrow) showing delayed transition of contrast within the esophagus.
FEATURE ARTICLES
A 43-year-old white man presented for surgical management of his laparoscopic band adjustment. The patient lost approximately 170 pounds after his initial laparoscopic band placement. He later experienced dysphagia and significant upper esophageal discomfort. The patient began to experience occasional reflux, and a fluoroscopy during a laparoscopic band adjustment led to the discovery of an esophageal diverticulum. This finding was interesting because he had a resection of a leiomyoma at the midlevel of the esophagus 2 years before the lapband placement. His current computed tomographic (CT) scan of the abdomen showed the lap band in proper anatomic position (Fig 1). A chest CT scan with oral contrast showed a large intrathoracic diverticulum with dimensions of 8.3 cm craniocaudal by 7.7 cm anteroposterior by 4.0 cm transversely (Fig 2). Other imaging included an esophagogram showing delayed transition of contrast within the esophagus (Fig 3). We believe that the diverticulum developed in the area of the previous myotomy. The patient underwent laparoscopic band deflation and removal of the laparoscopic band. He was then sterilely prepared again and draped with Betadine solution after positioning for thoracotomy. A right posterolateral thoracotomy incision was made to excise the previous scar tissue. Dense adhesions of the lung were noted from the visceral and parietal pleura to the diver-
1332
CASE REPORT KIM ET AL TUBERCULOUS STERNAL OSTEOMYELITIS
and maintained on intravenous fluids. On postoperative day 5, the patient underwent a barium esophagram that showed no extravasation of contrast and a complete resolution of the diverticulum. At this point, the patient was administered a clear liquid diet and advanced to a full liquid diet the next day. The pleural tube was removed on day 7, and the patient was discharged on day 8. At the 3-week postoperative follow-up, the patient was asymptomatic and continued to progress well, tolerating a full liquid diet. Six weeks postoperatively, he had recovered fully without any symptoms of achalasia or reflux. Six months after resection, she remains asymptomatic and continues to tolerate a normal diet.
Comment
FEATURE ARTICLES
Postoperatively, LAGB increases lower esophageal sphincter pressure from 12.1 to 13.3 mm Hg [1, 3]. Nausea, vomiting, and alterations in esophageal motility can occur after LAGB placement [4]. Such an outcome would require band deflation and in severe cases band removal [2]. The obstruction caused by gastric banding can result in esophageal dilation and dysmotility through weakening of the esophageal musculature [1]. Esophageal diverticulum frequently arises from an increased intraesophageal pressure and is associated with a motility disorder [5, 6]. The prevalence of esophageal diverticulum remains unknown because of its high frequency of asymptomatic behavior. There is no correlation between the size of diverticulum and the severity of symptoms [7]. Streitz et al [7] advocates performing a myotomy only in the area of the motor abnormality and sparing the lower esophageal sphincter unless it is hypertensive. Similarly, Nehra et al [8] recommends myotomy across the entire sphincter zone and including the length of the motor abnormality, as determined on preoperative studies. In a study by Varghese and colleagues [5], of the 34 patients with an epiphrenic diverticulum, 82% experienced a disorder in esophageal motility demonstrated either by manometry or the finding of a tertiary contraction on barium swallow, whereas the remaining suffered from a hiatal hernia. Patients with motility disorders undergoing diverticulectomy and esophagomyotomy have a 2% to 12% chance of developing an esophageal leak; however, most are contained and are asymptomatic with spontaneous resolution. Recurrent diverticulum has not reported, although dysphagia with an associated motility disorder may persist. No prior studies on myotomy specifically address motility disorders caused by an external distal end obstruction such as a lap band placement because of its rarity. The current literature recommends performing an esophagomyotomy at the site of motor abnormality in correcting primary motility disorders, but band deflation and removal was sufficient to correct the dysmotility because the symptoms for the patient arose after LAGB. Diverticula of the esophageal body are rare and range from 2 to 9 cm, with an average of 5 cm at the level of the mid to distal esophagus [5]. However, this report presents a unique case of a diverticulum located in the proximal to mid esophagus ex© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2012;94:1332–5
tending 25 cm from incisors, with dimensions of 8.3 ⫻ 7.7 ⫻ 4.0 cm. This case report demonstrates a rare and unique etiology for the development of an esophageal diverticulum in the setting of a laparoscopic band placement. Weakness of the muscular wall caused by resection of a leiomyoma contributed to this patient’s diverticulum formation, secondary to the increased chronic back pressure from the distal band.
References 1. Suter M, Dorta G, Giusti V, et al. Gastric banding interferes with esophageal motility and gastroesophageal reflux. Arch Surg 2005;140:639 – 43. 2. Wiesner W, Hauser M, Schob O, et al. Pseudo-achalasia following laparoscopically placed adjustable gastric banding. Obes Surg 2001;11:513– 8. 3. Korenkov M, Köhler L, Yücel N, et al. Esophageal motility and reflux symptoms after bariatric surgery. Obes Surg 2002;12: 72– 6. 4. Dargent J. Esophageal dilatation after laparoscopic adjustable gastric banding: definition and strategy. Obes Surg 2005;15: 843– 8. 5. Varghese TK Jr, Marshall B, Chang AC, et al. Surgical treatment of epiphrenic diverticula: a 30-year experience. Ann Thorac Surg 2007;84:1801–9. 6. Conrad C, Nissen F. Giant epiphrenic diverticula. Eur J Radiol 1982;2:48 –9. 7. Streitz JM, Glick ME, Ellis H. Selective use of myotomy for treatment of epiphrenic diverticula manometric and clinical analysis. Arch Surg 1992;127:585– 8. 8. Nehra D, Lord RV, Demeester TR, et al. Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg 2002;235:346 –54.
Chronic Sternum Wound Infection Caused by Mycobacterium tuberculosis After Cardiac Surgery Ho Jin Kim, MD, Joon Bum Kim, MD, and Cheol Hyun Chung, MD Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
The sternum wound infection, caused by Mycobacterium tuberculosis after a cardiac surgery, is an extremely rare postoperative complication. It requires a high degree of suspicion for a correct diagnosis. Often a successful treatment is impeded by the insidious nature of tuberculosis infection and the time-consuming diagnosis process. We report two cases in which we successfully treated this infection with sternum resection, wound debridement, and antituberculosis medication. (Ann Thorac Surg 2012;94:1332–5) © 2012 by The Society of Thoracic Surgeons Accepted for publication Feb 2, 2012. Address correspondence to Dr J.B. Kim, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, Republic of Korea; e-mail: jbkim1975@amc. seoul.kr.
0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.02.028