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Successful Management of a Perforated Interposed Substernal Ileocolon Caused by Right Pleural Hernia
Successful Management of a Perforated Interposed Substernal Ileocolon Caused by Right Pleural Hernia Atsushi Shiozaki, MD, Hitoshi Fujiwara, MD, Hirotaka Konishi, MD, Tomohiro Arita, MD, Toshiyuki Kosuga, MD, Ryo Morimura, MD, Yasutoshi Murayama, MD, Shuhei Komatsu, MD, Yoshiaki Kuriu, MD, Hisashi Ikoma, MD, Masayoshi Nakanishi, MD, Daisuke Ichikawa, MD, Kazuma Okamoto, MD, and Eigo Otsuji, MD Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
A 73-year-old man underwent esophagectomy and reconstruction with interposition of the ileocolon through the substernal tract. Ten months later he presented with sudden pain in the right side of his chest that developed after vomiting. Emergency surgical intervention revealed a right pleural hernia of the esophageal substitute and a 3-cm perforation in the cecum. After suturing the perforation directly, we made the redundant ileum straight and pulled down the repaired cecum into the abdominal cavity to prevent intrathoracic leakage, successfully preserving the reconstructed organ. This rare case emphasizes the importance of careful dissection of the pleura and the use of a suitable length of ileocolon for reconstruction. (Ann Thorac Surg 2016;101:e5–7) Ó 2016 by The Society of Thoracic Surgeons
I
leocolonic interposition has been widely used to reconstruct the esophagus after resection for malignant and benign diseases [1–3]. Perforation of an ileocolonic interposition graft is a rare but serious complication that requires early diagnosis and treatment [4–7]. We describe a case of a perforated interposed substernal ileocolon 10 months after esophagectomy and reconstruction. This perforation was caused by a right pleural hernia, and surgical management was successfully achieved, with preservation of the reconstructed organ. The patient was a 73-year-old man with T1N0M0 thoracic esophageal squamous cell carcinoma who underwent esophagectomy and reconstruction with interposition of the ileocolon through the substernal tract. Although a postoperative roentgenogram of the chest revealed a visible right pleural hernia of the esophageal substitute (Fig 1A), on examination the patient was systemically well with no initial evidence of ischemia. His oral intake was sufficient, without severe symptoms, and he was finally
Accepted for publication Aug 28, 2015. Address correspondence to Dr Shiozaki, Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan; email: shiozaki@koto. kpu-m.ac.jp.
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
discharged 46 days after the operation. The patient returned to the hospital 9 months after being discharged with sudden pain in the right side of his chest that developed when he vomited after a meal. Thoracoabdominal computed tomography revealed bilateral pleural effusions and air with a right pleural hernia of the esophageal substitute (Fig 1B). Chest tubes were inserted bilaterally, and a large amount of saburra was drained, which indicated perforation of the interposed ileocolon. Because the patient was exhibiting shock, he was transferred to the operating room for emergency intervention 18 hours after the acute event. Right thoracotomy was performed in the left lateral decubitus position. We found large amounts of pus and saburra, and the right thoracic cavity was irrigated with saline. A right pleural hernia of the redundant ileocolon and a 3-cm perforation in the wall of the cecum without ischemia were detected (Figs 2A, 3A). We sutured the perforation directly (Fig 2B). Omentum was not available for repair because of a previous history of a distal gastrectomy. To avoid any further postoperative leakage into the thoracic cavity, we pulled down the sutured portion into the abdominal cavity. After an upper midline laparotomy, the interposed ileocolon was carefully freed from the surrounding tissue through right thoracic and abdominal approaches without damaging its supplying vessels. We then made the redundant interposed ileum straight, and the repaired cecum was carefully pulled out of the pleural space (Figs 2C, 2D, 3B). The wall of the straightened ileocolon was fixed to the right diaphragm to avoid a postoperative pleural hernia. A left thoracotomy was performed with the patient in the right lateral decubitus position. Because large amounts of pus and saburra were also found in the left thoracic cavity, irrigation with saline was performed. Bilateral thoracic and abdominal drains were inserted. The operative time was 409 minutes, and 350 mL of intraoperative bleeding occurred. The patient recovered from shock by postoperative day (POD) 1. A tracheostomy was performed on POD 17 because of pneumonia, which was controlled by antibiotics. Oral intake was resumed on POD 48, and the tracheostomy tube was removed on POD 63. He was discharged from the hospital on POD 126.
Comment Perforation of a reconstructed organ is a rare but lifethreatening complication after esophagectomy. Although there have been several reports on gastric tube perforation, mainly resulting from ulcer formation, perforation of a colonic interposition graft is extremely rare [4–8]. Previous studies have reported various causes of perforation of an interposed colon, such as colonic ulceration [4], diverticulum [5], and Boerhaave’s syndrome [6]. Kok [7] described a case of perforation of a substernal interposed ileocolon caused by a right thoracic hernia that occurred as an acute perisurgical complication on the ninth postoperative day, with a relative inadequacy of blood flow. Although the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.08.081
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CASE REPORT SHIOZAKI ET AL COLONIC INTERPOSITION GRAFT PERFORATION
Ann Thorac Surg 2016;101:e5–7
Fig 1. (A) Postoperative roentgenogram of the chest (after esophagectomy) revealed visible right pleural hernia of esophageal substitute and visible shadowing of lower right lung (arrow). (B) Thoracoabdominal computed tomography (in emergency situation) showed bilateral pleural effusion and air with right pleural hernia of esophageal substitute.
present case was also caused by a right pleural hernia, there have been no reports that this occurred as a late complication without ischemia. One of the main causes of pleural hernia is a small injury to the mediastinal pleura at the stage of preparing the retrosternal canal. The anterior border of the right pleura runs behind the sternum, reaches the midline, and even passes it on the left; therefore the pleura is more frequently injured on the right side [2]. Another important cause of pleural hernia is redundancy of the interposed colon [7]. The length of the interposed ileocolon in our patient appeared to be excessive; therefore the use of a suitable length of an esophageal substitute may prevent Fig 2. Operative findings. (A) Right thoracotomy revealed 3-cm perforation in cecum (arrow). (B) Perforation was sutured directly. (C) We made redundant ileum straight in thoracic cavity. (D) Repaired cecum was pulled down into abdominal cavity. Arrow shows suture line of cecum.
this complication. In this regard, we consider that a similar interposition using the redundant left colon would also be at risk. Regarding the pathogenesis of a perforation of an interposed colon caused by a pleural hernia, Kok [7] proposed incarceration and necrosis of the wall of the dilated bowel. Conversely, neither ischemia nor a congestive problem was observed in the interposed ileocolon in the present case. The pathogenesis of Boerhaave’s syndrome has been attributed to high intraluminal pressure leading to perforation caused by vomiting [6], and although there is currently no conclusive evidence, it may have accounted for perforation in the interposed ileocolon in the present case.
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Fig 3. (A) Right thoracotomy revealed 3-cm perforation in cecum and right pleural hernia of redundant ileocolon. (B) After suturing perforation directly, we made redundant ileum straight and pulled down repaired cecum into abdominal cavity.
In a case report by Kok [7] on perforation of a substernal interposed ileocolon caused by right thoracic herniation, the patient’s colonic substitute was immediately removed through a sternotomy without reconstruction being performed. Although we also considered removing the interposed ileocolon in the preoperative phase, resection of the colonic substitute makes oral intake impossible. Furthermore, subsequent reconstruction operations may become technically difficult. Fortunately, we preserved the interposed ileocolon by directly closing the perforation and performing gentle dissection, which was very beneficial for the patient. Careful dissection of the interposed ileocolon is necessary in this procedure, with particular attention being paid to severe adhesions resulting from the previous operation, and it is important to avoid damage to the supplying vessels. However, the possibility of postoperative leakage from the directly closed cecum represents a cause for concern. If this portion exists in the thoracic cavity, leakage may cause empyema or mediastinitis, which is potentially fatal. Conversely, leakage in the abdominal cavity is easier to control than it is in the thoracic cavity. Therefore we pulled down the sutured portion into the abdominal cavity by making the redundant ileum straight, and the patient was successfully treated without fatal postoperative complications. To the best of our knowledge, a surgical method preserving the reconstructed organ after perforation of an interposed
substernal ileocolon caused by pleural hernia has not yet been described in the literature. In conclusion, we describe a case of perforation of an interposed substernal ileocolon caused by right thoracic herniation that was successfully treated without removing the colonic substitute. Pleural injury needs to be avoided at the time of reconstruction of the retrosternal tunnel to prevent this complication, and a suitable length of the ileocolon is recommended as an esophageal substitute.
References 1. Wilkins EW Jr. Long-segment colon substitution for the esophagus. Ann Surg 1980;192:722–5. 2. Strutynska-Karpinska M, Grabowski K. Esophageal reconstruction. Rijeka, Croatia: InTech Open Access Books; 2012. 3. Young MM, Deschamps C, Trastek VF, et al. Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results. Ann Thorac Surg 2000;70:1651–5. 4. Larson TC 3rd, Shuman LS, Libshitz HI, McMurtrey MJ. Complications of colonic interposition. Cancer 1985;56:681–90. 5. Cheng YJ, Li HP, Kao EL. Perforated diverticulum: rare complication of interposed substernal colon. Ann Thorac Surg 2006;82:717–9. 6. Attia R, Rohatgi A, Scarci M, Hamouda A, Botha AJ. Boerhaave’s syndrome secondary to colonic interposition graft perforation. Int J Colorectal Dis 2010;25:1147–8. 7. Kok VK. Perforation of a substernal interposed ileocolon caused by right thoracic herniation. Asian Cardiovasc Thorac Ann 2007;15:515–7. 8. Ubukata H, Nakachi T, Tabuchi T, et al. Gastric tube perforation after esophagectomy for esophageal cancer. Surg Today 2011;41:612–9.
A 73-year-old man underwent esophagectomy and reconstruction with interposition of the ileocolon through the substernal tract. Ten months later he presented with sudden pain in the right side of his chest that developed after vomiting. Emergency surgical intervention revealed a right pleural hernia of the esophageal substitute and a 3-cm perforation in the cecum. After suturing the perforation directly, we made the redundant ileum straight and pulled down the repaired cecum into the abdominal cavity to prevent intrathoracic leakage, successfully preserving the reconstructed organ. This rare case emphasizes the importance of careful dissection of the pleura and the use of a suitable length of ileocolon for reconstruction. (Ann Thorac Surg 2016;101:e5–7) Ó 2016 by The Society of Thoracic Surgeons
I
leocolonic interposition has been widely used to reconstruct the esophagus after resection for malignant and benign diseases [1–3]. Perforation of an ileocolonic interposition graft is a rare but serious complication that requires early diagnosis and treatment [4–7]. We describe a case of a perforated interposed substernal ileocolon 10 months after esophagectomy and reconstruction. This perforation was caused by a right pleural hernia, and surgical management was successfully achieved, with preservation of the reconstructed organ. The patient was a 73-year-old man with T1N0M0 thoracic esophageal squamous cell carcinoma who underwent esophagectomy and reconstruction with interposition of the ileocolon through the substernal tract. Although a postoperative roentgenogram of the chest revealed a visible right pleural hernia of the esophageal substitute (Fig 1A), on examination the patient was systemically well with no initial evidence of ischemia. His oral intake was sufficient, without severe symptoms, and he was finally
Accepted for publication Aug 28, 2015. Address correspondence to Dr Shiozaki, Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan; email: shiozaki@koto. kpu-m.ac.jp.
Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
discharged 46 days after the operation. The patient returned to the hospital 9 months after being discharged with sudden pain in the right side of his chest that developed when he vomited after a meal. Thoracoabdominal computed tomography revealed bilateral pleural effusions and air with a right pleural hernia of the esophageal substitute (Fig 1B). Chest tubes were inserted bilaterally, and a large amount of saburra was drained, which indicated perforation of the interposed ileocolon. Because the patient was exhibiting shock, he was transferred to the operating room for emergency intervention 18 hours after the acute event. Right thoracotomy was performed in the left lateral decubitus position. We found large amounts of pus and saburra, and the right thoracic cavity was irrigated with saline. A right pleural hernia of the redundant ileocolon and a 3-cm perforation in the wall of the cecum without ischemia were detected (Figs 2A, 3A). We sutured the perforation directly (Fig 2B). Omentum was not available for repair because of a previous history of a distal gastrectomy. To avoid any further postoperative leakage into the thoracic cavity, we pulled down the sutured portion into the abdominal cavity. After an upper midline laparotomy, the interposed ileocolon was carefully freed from the surrounding tissue through right thoracic and abdominal approaches without damaging its supplying vessels. We then made the redundant interposed ileum straight, and the repaired cecum was carefully pulled out of the pleural space (Figs 2C, 2D, 3B). The wall of the straightened ileocolon was fixed to the right diaphragm to avoid a postoperative pleural hernia. A left thoracotomy was performed with the patient in the right lateral decubitus position. Because large amounts of pus and saburra were also found in the left thoracic cavity, irrigation with saline was performed. Bilateral thoracic and abdominal drains were inserted. The operative time was 409 minutes, and 350 mL of intraoperative bleeding occurred. The patient recovered from shock by postoperative day (POD) 1. A tracheostomy was performed on POD 17 because of pneumonia, which was controlled by antibiotics. Oral intake was resumed on POD 48, and the tracheostomy tube was removed on POD 63. He was discharged from the hospital on POD 126.
Comment Perforation of a reconstructed organ is a rare but lifethreatening complication after esophagectomy. Although there have been several reports on gastric tube perforation, mainly resulting from ulcer formation, perforation of a colonic interposition graft is extremely rare [4–8]. Previous studies have reported various causes of perforation of an interposed colon, such as colonic ulceration [4], diverticulum [5], and Boerhaave’s syndrome [6]. Kok [7] described a case of perforation of a substernal interposed ileocolon caused by a right thoracic hernia that occurred as an acute perisurgical complication on the ninth postoperative day, with a relative inadequacy of blood flow. Although the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.08.081
e6
CASE REPORT SHIOZAKI ET AL COLONIC INTERPOSITION GRAFT PERFORATION
Ann Thorac Surg 2016;101:e5–7
Fig 1. (A) Postoperative roentgenogram of the chest (after esophagectomy) revealed visible right pleural hernia of esophageal substitute and visible shadowing of lower right lung (arrow). (B) Thoracoabdominal computed tomography (in emergency situation) showed bilateral pleural effusion and air with right pleural hernia of esophageal substitute.
present case was also caused by a right pleural hernia, there have been no reports that this occurred as a late complication without ischemia. One of the main causes of pleural hernia is a small injury to the mediastinal pleura at the stage of preparing the retrosternal canal. The anterior border of the right pleura runs behind the sternum, reaches the midline, and even passes it on the left; therefore the pleura is more frequently injured on the right side [2]. Another important cause of pleural hernia is redundancy of the interposed colon [7]. The length of the interposed ileocolon in our patient appeared to be excessive; therefore the use of a suitable length of an esophageal substitute may prevent Fig 2. Operative findings. (A) Right thoracotomy revealed 3-cm perforation in cecum (arrow). (B) Perforation was sutured directly. (C) We made redundant ileum straight in thoracic cavity. (D) Repaired cecum was pulled down into abdominal cavity. Arrow shows suture line of cecum.
this complication. In this regard, we consider that a similar interposition using the redundant left colon would also be at risk. Regarding the pathogenesis of a perforation of an interposed colon caused by a pleural hernia, Kok [7] proposed incarceration and necrosis of the wall of the dilated bowel. Conversely, neither ischemia nor a congestive problem was observed in the interposed ileocolon in the present case. The pathogenesis of Boerhaave’s syndrome has been attributed to high intraluminal pressure leading to perforation caused by vomiting [6], and although there is currently no conclusive evidence, it may have accounted for perforation in the interposed ileocolon in the present case.
Ann Thorac Surg 2016;101:e5–7
CASE REPORT SHIOZAKI ET AL COLONIC INTERPOSITION GRAFT PERFORATION
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Fig 3. (A) Right thoracotomy revealed 3-cm perforation in cecum and right pleural hernia of redundant ileocolon. (B) After suturing perforation directly, we made redundant ileum straight and pulled down repaired cecum into abdominal cavity.
In a case report by Kok [7] on perforation of a substernal interposed ileocolon caused by right thoracic herniation, the patient’s colonic substitute was immediately removed through a sternotomy without reconstruction being performed. Although we also considered removing the interposed ileocolon in the preoperative phase, resection of the colonic substitute makes oral intake impossible. Furthermore, subsequent reconstruction operations may become technically difficult. Fortunately, we preserved the interposed ileocolon by directly closing the perforation and performing gentle dissection, which was very beneficial for the patient. Careful dissection of the interposed ileocolon is necessary in this procedure, with particular attention being paid to severe adhesions resulting from the previous operation, and it is important to avoid damage to the supplying vessels. However, the possibility of postoperative leakage from the directly closed cecum represents a cause for concern. If this portion exists in the thoracic cavity, leakage may cause empyema or mediastinitis, which is potentially fatal. Conversely, leakage in the abdominal cavity is easier to control than it is in the thoracic cavity. Therefore we pulled down the sutured portion into the abdominal cavity by making the redundant ileum straight, and the patient was successfully treated without fatal postoperative complications. To the best of our knowledge, a surgical method preserving the reconstructed organ after perforation of an interposed
substernal ileocolon caused by pleural hernia has not yet been described in the literature. In conclusion, we describe a case of perforation of an interposed substernal ileocolon caused by right thoracic herniation that was successfully treated without removing the colonic substitute. Pleural injury needs to be avoided at the time of reconstruction of the retrosternal tunnel to prevent this complication, and a suitable length of the ileocolon is recommended as an esophageal substitute.
References 1. Wilkins EW Jr. Long-segment colon substitution for the esophagus. Ann Surg 1980;192:722–5. 2. Strutynska-Karpinska M, Grabowski K. Esophageal reconstruction. Rijeka, Croatia: InTech Open Access Books; 2012. 3. Young MM, Deschamps C, Trastek VF, et al. Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results. Ann Thorac Surg 2000;70:1651–5. 4. Larson TC 3rd, Shuman LS, Libshitz HI, McMurtrey MJ. Complications of colonic interposition. Cancer 1985;56:681–90. 5. Cheng YJ, Li HP, Kao EL. Perforated diverticulum: rare complication of interposed substernal colon. Ann Thorac Surg 2006;82:717–9. 6. Attia R, Rohatgi A, Scarci M, Hamouda A, Botha AJ. Boerhaave’s syndrome secondary to colonic interposition graft perforation. Int J Colorectal Dis 2010;25:1147–8. 7. Kok VK. Perforation of a substernal interposed ileocolon caused by right thoracic herniation. Asian Cardiovasc Thorac Ann 2007;15:515–7. 8. Ubukata H, Nakachi T, Tabuchi T, et al. Gastric tube perforation after esophagectomy for esophageal cancer. Surg Today 2011;41:612–9.