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Cardiac compression secondary to a massively dilated substernal colon conduit
Journal of Pediatric Surgery (2012) 47, 2126–2128
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Cardiac compression secondary to a massively dilated substernal colon conduit Babar A. Khan a,⁎, Ruxandra C. Ionescu a , Ahmed M. Halal b , Kenneth A. Kesler b a
Department of Medicine, Division of Pulmonary/ Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA b Department of Surgery, Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
Key words: Esophageal atresia; Colon conduit; Cardiac compression
Abstract With the growing success of surgical repairs of congenital defects previously incompatible with life, it is expected of these patients to live longer and experience the complications of these corrective procedures. Esophageal atresia is a congenital defect that occurs in 1 out of 4000 births and is oftentimes a surgical emergency in which colonic conduits are routinely used for esophageal reconstruction. Colonic conduit redundancy and dilatation are well-recognized late complications of colon conduit surgeries for esophageal reconstructions. We report a rare case of symptomatic cardiac compression secondary to a massively dilated substernal colon conduit occurring 44 years after the initial childhood surgery in 1964 with rapid reversal of hemodynamic compromise after conduit removal. © 2012 Elsevier Inc. All rights reserved.
Colonic conduit redundancy and dilatation are wellrecognized late complications of colonic conduit for esophageal reconstruction. We report a rare case of symptomatic cardiac compression secondary to a massively dilated substernal colon conduit occurring 44 years after the initial childhood surgery.
1. Case report Our patient was a 49-year-old male who underwent substernal colon conduit interposition at 5 years of age in 1964 for congenital esophageal atresia. The patient gave written informed consent for the report and a copy of the consent was provided to him. ⁎ Corresponding author. E-mail address: [email protected] (B.A. Khan). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.09.045
He presented in 2008 with a 24 hour history of inability to swallow, shortness of breath, and a left-sided non-reducible supraclavicular mass. He reported transient episodes of similar symptoms over several months prior to the current presentation, but compared to the current event, his symptoms had previously resolved after “pushing the left neck mass into the chest”. Physical examination disclosed an apprehensive patient with a systolic blood pressure of 96/62 mm Hg, heart rate of 120 beats per minute and respiratory rate of 30 breaths per minute. Neck exam revealed jugular venous distention and a large tender supraclavicular mass (Fig. 1) just inferior to the estimated level of the esophagocolonic anastomosis, which was not reducible. Laboratory data was remarkable for a white blood cell count of 16,300 cells/mm3 and a mild acidosis with an arterial pH of 7.28. Computed tomography imaging showed massive distention of the substernal colon interposition filled with liquid and particulate matter, with secondary compression of the heart, ascending aorta, and right pulmonary artery (Fig. 2).
Cardiac compression and dilated substernal colon conduit
2127 The patient was emergently taken to the operating room for conduit removal. An extended sternotomy incision from the left neck superiorly to the umbilicus inferiorly was utilized for exposure. The conduit appeared ischemic and massively dilated with liquid and particulate matter. The gastrocolic anastomosis though widely patent was substantially smaller in diameter than the conduit itself. The conduit was removed expeditiously. Immediately after conduit removal, the central venous pressure dropped from 23 mm Hg to 12 mm Hg. Simultaneously, the systolic blood pressure increased by 20 to 30 mm Hg with subsequent decrease in heart rate. A cervical end-esophagostomy and tube gastrostomy for feeding were established. The patient made an uneventful postoperative recovery and was discharged in improved condition. He underwent a substernal gastric advancement for esophageal reconstruction 6 months after the emergency colectomy and was well 2 years following reconstruction.
2. Discussion Fig. 1 Photograph of the supraclavicular mass caused by a dilated colon conduit (arrow).
Fig. 2
Colon conduit redundancy and dilatation following interposition for esophageal reconstruction ultimately
Montage of CT scan cuts showing the massively dilated colon conduit with secondary compression of the heart and great vessels.
2128 requires surgical intervention in an estimated 8–22% of cases [1,2]. Commonly reported symptoms include dysphagia, regurgitation, and aspiration [3]. Redundancy with dilatation of colonic conduits in the substernal position may additionally result in retrosternal pain and neck swelling [3]. Based on our patient's chronic symptoms leading up to an acute event, we speculate that a progressive cycle of increased retention of liquid and particulate matter and low-grade ischemia ultimately lead to massive conduit dilatation and secondary cardiac compression. A contributory factor to heart and great vessel compression in this case may have included a relative lack of redundancy into either pleural space as the conduit remained in the substernal position over time. Although a component of sepsis may have contributed to this patient's overall presentation, the immediate improvement in cardiac hemodynamics following conduit removal is highly suggestive of cardiac compression as the primary pathophysiology. A MEDLINE search of the English speaking literature found only one previous report of cardiac compression attributed to a dilated substernal colon conduit [4]. Cardiovascular complications can also occur after substernal gastric transposition, secondary to gastric dilation and compression of cardiac structures including sinus node tachycardia or other arrhythmias [5,6]. In addition, if cardiac surgery is needed for valve or coronary artery disease in the future, a different surgical approach such as a thoracotomy may have to be considered [7]. We report a rare case of a patient who underwent substernal colonic conduit surgery over 40 years ago, presenting
B.A. Khan et al. with cardiac compression. We speculate this complication may be seen with increasing frequency, as patients who have undergone substernal colon interposition for benign processes, are now surviving into four decades. Early recognition of symptoms with surgical intervention for cases of impending cardiac compression is worthy of consideration. Finally, this case would also support utilization of an orthotopic posterior mediastinal route for pediatric patients requiring large bowel for esophageal reconstruction when possible.
References [1] Bonavina L, Chella B, Segalin A, et al. Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty. Ann Thorac Surg 1998;65:1446-8. [2] Kelly JP, Shackelfor GD, Roper CL. Esophageal replacement with colon in children: functional results and long-term growth. Ann Thorac Surg 1983;36:634-43. [3] Domreis JS, Jobe BA, Aye RW, et al. Management of long-term failure after colon interposition for benign disease. Am J Surg 2002;183:544-6. [4] Canivet JL, Pret S, Hick G, et al. Cardiac tamponade and pulmonary compression due to volvulus of oesophageal coloplasty. Acta Anesthesiol Belg 2004;55(2):125-7. [5] Spitz L. Gastric transposition for esophageal substitution in children. J Pediatr Surg 1992;27(2):252-9. [6] Choudhury SR, Sharma A, Kohli V. Inappropriate sinus node tachycardia following gastric transposition surgery in children. Pediatr Surg Int 2005;21(2):127-8. [7] Gillinov AM, Casselman FP, Cosgrove III DM. Aortic valve replacement after substernal colon interposition. Ann Thorac Surg 1999;67:838-9.
www.elsevier.com/locate/jpedsurg
Cardiac compression secondary to a massively dilated substernal colon conduit Babar A. Khan a,⁎, Ruxandra C. Ionescu a , Ahmed M. Halal b , Kenneth A. Kesler b a
Department of Medicine, Division of Pulmonary/ Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA b Department of Surgery, Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
Key words: Esophageal atresia; Colon conduit; Cardiac compression
Abstract With the growing success of surgical repairs of congenital defects previously incompatible with life, it is expected of these patients to live longer and experience the complications of these corrective procedures. Esophageal atresia is a congenital defect that occurs in 1 out of 4000 births and is oftentimes a surgical emergency in which colonic conduits are routinely used for esophageal reconstruction. Colonic conduit redundancy and dilatation are well-recognized late complications of colon conduit surgeries for esophageal reconstructions. We report a rare case of symptomatic cardiac compression secondary to a massively dilated substernal colon conduit occurring 44 years after the initial childhood surgery in 1964 with rapid reversal of hemodynamic compromise after conduit removal. © 2012 Elsevier Inc. All rights reserved.
Colonic conduit redundancy and dilatation are wellrecognized late complications of colonic conduit for esophageal reconstruction. We report a rare case of symptomatic cardiac compression secondary to a massively dilated substernal colon conduit occurring 44 years after the initial childhood surgery.
1. Case report Our patient was a 49-year-old male who underwent substernal colon conduit interposition at 5 years of age in 1964 for congenital esophageal atresia. The patient gave written informed consent for the report and a copy of the consent was provided to him. ⁎ Corresponding author. E-mail address: [email protected] (B.A. Khan). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2012.09.045
He presented in 2008 with a 24 hour history of inability to swallow, shortness of breath, and a left-sided non-reducible supraclavicular mass. He reported transient episodes of similar symptoms over several months prior to the current presentation, but compared to the current event, his symptoms had previously resolved after “pushing the left neck mass into the chest”. Physical examination disclosed an apprehensive patient with a systolic blood pressure of 96/62 mm Hg, heart rate of 120 beats per minute and respiratory rate of 30 breaths per minute. Neck exam revealed jugular venous distention and a large tender supraclavicular mass (Fig. 1) just inferior to the estimated level of the esophagocolonic anastomosis, which was not reducible. Laboratory data was remarkable for a white blood cell count of 16,300 cells/mm3 and a mild acidosis with an arterial pH of 7.28. Computed tomography imaging showed massive distention of the substernal colon interposition filled with liquid and particulate matter, with secondary compression of the heart, ascending aorta, and right pulmonary artery (Fig. 2).
Cardiac compression and dilated substernal colon conduit
2127 The patient was emergently taken to the operating room for conduit removal. An extended sternotomy incision from the left neck superiorly to the umbilicus inferiorly was utilized for exposure. The conduit appeared ischemic and massively dilated with liquid and particulate matter. The gastrocolic anastomosis though widely patent was substantially smaller in diameter than the conduit itself. The conduit was removed expeditiously. Immediately after conduit removal, the central venous pressure dropped from 23 mm Hg to 12 mm Hg. Simultaneously, the systolic blood pressure increased by 20 to 30 mm Hg with subsequent decrease in heart rate. A cervical end-esophagostomy and tube gastrostomy for feeding were established. The patient made an uneventful postoperative recovery and was discharged in improved condition. He underwent a substernal gastric advancement for esophageal reconstruction 6 months after the emergency colectomy and was well 2 years following reconstruction.
2. Discussion Fig. 1 Photograph of the supraclavicular mass caused by a dilated colon conduit (arrow).
Fig. 2
Colon conduit redundancy and dilatation following interposition for esophageal reconstruction ultimately
Montage of CT scan cuts showing the massively dilated colon conduit with secondary compression of the heart and great vessels.
2128 requires surgical intervention in an estimated 8–22% of cases [1,2]. Commonly reported symptoms include dysphagia, regurgitation, and aspiration [3]. Redundancy with dilatation of colonic conduits in the substernal position may additionally result in retrosternal pain and neck swelling [3]. Based on our patient's chronic symptoms leading up to an acute event, we speculate that a progressive cycle of increased retention of liquid and particulate matter and low-grade ischemia ultimately lead to massive conduit dilatation and secondary cardiac compression. A contributory factor to heart and great vessel compression in this case may have included a relative lack of redundancy into either pleural space as the conduit remained in the substernal position over time. Although a component of sepsis may have contributed to this patient's overall presentation, the immediate improvement in cardiac hemodynamics following conduit removal is highly suggestive of cardiac compression as the primary pathophysiology. A MEDLINE search of the English speaking literature found only one previous report of cardiac compression attributed to a dilated substernal colon conduit [4]. Cardiovascular complications can also occur after substernal gastric transposition, secondary to gastric dilation and compression of cardiac structures including sinus node tachycardia or other arrhythmias [5,6]. In addition, if cardiac surgery is needed for valve or coronary artery disease in the future, a different surgical approach such as a thoracotomy may have to be considered [7]. We report a rare case of a patient who underwent substernal colonic conduit surgery over 40 years ago, presenting
B.A. Khan et al. with cardiac compression. We speculate this complication may be seen with increasing frequency, as patients who have undergone substernal colon interposition for benign processes, are now surviving into four decades. Early recognition of symptoms with surgical intervention for cases of impending cardiac compression is worthy of consideration. Finally, this case would also support utilization of an orthotopic posterior mediastinal route for pediatric patients requiring large bowel for esophageal reconstruction when possible.
References [1] Bonavina L, Chella B, Segalin A, et al. Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty. Ann Thorac Surg 1998;65:1446-8. [2] Kelly JP, Shackelfor GD, Roper CL. Esophageal replacement with colon in children: functional results and long-term growth. Ann Thorac Surg 1983;36:634-43. [3] Domreis JS, Jobe BA, Aye RW, et al. Management of long-term failure after colon interposition for benign disease. Am J Surg 2002;183:544-6. [4] Canivet JL, Pret S, Hick G, et al. Cardiac tamponade and pulmonary compression due to volvulus of oesophageal coloplasty. Acta Anesthesiol Belg 2004;55(2):125-7. [5] Spitz L. Gastric transposition for esophageal substitution in children. J Pediatr Surg 1992;27(2):252-9. [6] Choudhury SR, Sharma A, Kohli V. Inappropriate sinus node tachycardia following gastric transposition surgery in children. Pediatr Surg Int 2005;21(2):127-8. [7] Gillinov AM, Casselman FP, Cosgrove III DM. Aortic valve replacement after substernal colon interposition. Ann Thorac Surg 1999;67:838-9.