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Giant Hiatal Hernia with Gastric Volvulus Complicating Pneumonectomy
Ann Thorac Surg 2006;81:1491–2
CASE REPORT
BLUM AND SUNDARESAN GIANT HIATAL HERNIA
1491
duct was identified, and it was ligated with complete recovery of the patient. In summary, this is an exceptional and possibly unique case of post-traumatic chylothorax due to the penetrating trauma of the chest.
References
Giant Hiatal Hernia with Gastric Volvulus Complicating Pneumonectomy Matthew G. Blum, MD, and R. Sudhir Sundaresan, MD Division of Cardiothoracic Surgery, Department of Surgery, Northwestern University Medical School, Chicago, and Northwestern Memorial Hospital, Chicago, Illinois; Division of Thoracic Surgery, Department of Surgery, University of Ottawa Medical School, Ottawa, Ontario, Canada
Gastric volvulus is a potentially lethal condition. Pneumonectomy patients have decreased physiologic reserve, and thus they are more susceptible to morbidity and mortality from postoperative complications. We report successful management of a patient with hiatal hernia that resulted in acute gastric volvulus after left pneumonectomy. (Ann Thorac Surg 2006;81:1491–2) © 2006 by The Society of Thoracic Surgeons
P
neumonectomy is a risky operation, but it is generally well tolerated in carefully selected patients. However, altered postoperative physiology gives minor complications potentially lethal implications, particularly in pneumonectomy patients receiving neoadjuvant therapy for loco-regionally advanced lung cancer. We report a
Accepted for publication March 16, 2005. Address correspondence to Dr Sundaresan, Ottawa Hospital, General Campus, Rm 6356, 6NW, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada; e-mail: [email protected].
© 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Preoperative chest roentgenograms (PA and lateral) showing a large hiatal hernia.
case of a giant hiatal hernia resulting in acute gastric volvulus after left pneumonectomy. Judgment, stabilization, and careful timing of reoperation were required to minimize the physiologic insult from this complication. A 54-year-old man with stage IIIa adenocarcinoma of the left upper lobe (T3 N2 M0) was treated on the Northwestern University multimodality therapy protocol (NU9961). The protocol entails induction chemotherapy (carboplatin, gemcitabine) followed by concurrent chemoradiotherapy (vinorelbine, paclitaxel, 4000 cGy), and subsequent pulmonary resection based on the response [1]. His lung function was excellent (forced expiratory volume in 1 second of 113% of predicted). Preoperative chest roentgenogram showed a large hiatal hernia (Fig 1) in addition to his lung cancer. However, he had only mild symptoms of gastroesophageal reflux that were easily controlled with medications, and thus he did not fulfill the criteria for hiatal hernia repair. The patient sustained an excellent clinical and radiologic response to induction therapy; therefore he underwent an elective left thoracotomy. Lobectomy was planned, but pneumonectomy was considered a distinct possibility. At thoracotomy, the large hiatal hernia was noted and decompressed with an orogastric tube. During the attempted lobectomy, the adventitial plane of the pulmonary artery was noted to be obliterated by fibrosis. Dissection was inadvertently carried along the media, effectively removing a large zone of arterial adventitia. Subsequent disruption of the thin arterial media resulted in significant blood loss and necessitated intrapericardial pneumonectomy. With the left hemithorax now empty, the hiatal herniation became more prominent. Because of the relatively large blood loss sustained to this point, it was decided that the large hiatal hernia would be addressed in the future if clinically indicated. A chest tube was placed for postoperative mediastinal balancing. The patient was extubated in the operating room. His overnight intensive care unit course was uneventful. The next morning it was noted that everything he swallowed was regurgitated undigested. His chest roentgenogram showed gastric herniation slightly increased 0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2005.03.065
FEATURE ARTICLES
1. Janzing H, Tonnard P, Van den Brande F, Derom F. Chylothorax after blunt chest trauma. Acta Chir Belg 1992;92:26 –7. 2. Markham KM, Glover JL, Welsh RJ, Lucas RJ, Bendick PJ. Octreotide in the treatment of thoracic duct injuries. Am Surg 2000;66:1165–7. 3. Browse NL, Allen DR, Wilson NM. Management of chylothorax. Br J Surg 1997;84:1711– 6. 4. Mikroulis D, Didilis V, Bitzikas G, Bougioukaws G. Octreotide in the treatment of chylothorax. Chest 2002;121:2079 – 80. 5. Rimensberger PC, Muller-Schenker B, Kalangos A, Beghetti M. Treatment of persistent postoperative chylothorax with somatostatin. Ann Thor Surg 1998;66:253– 4. 6. Patterson GA, Todd TRJ, Delarue NC, Ilves R, Pearson FG, Cooper JD. Supradiapragmatic ligation of the thoracic duct in intractable chylous fistula. Ann Thorac Surg 1981;32:44 –9. 7. Kent RB, Pinson W. Thoracoscopic ligation of the thoracic duct. Surg Endosc 1993;7:52–3. 8. Ohtsuka T, Tanaka M, Nakajima J, Takamoto S. Videoscopic supradiaphragmatic duct division using ultrasonic coagulator. Eur J Cardiothorac Surg 2002;22:828 –30.
1492
CASE REPORT BLUM AND SUNDARESAN GIANT HIATAL HERNIA
FEATURE ARTICLES
Fig 2. Chest roentgenogram showing gastric herniation slightly increased from the immediate postoperative chest roentgenogram.
from his immediate postoperative chest roentgenogram (Fig 2). Satisfactory urine output and absence of tachycardia, acidosis, or pain suggested that he did not have gastric ischemia or necrosis. Urgent endoscopy confirmed gastric viability and facilitated placement of a nasogastric tube (NGT). Endoscopic NGT placement was required because the antrum of the stomach was inverted (cephalad to the fundus). Continuous nasogastric suction and parenteral alimentation were maintained for 7 days to allow physiologic accommodation to his pneumonectomy and stabilization of his fluid status. Then he underwent laparotomy, hernia reduction, and CollisNissen repair. He tolerated this well and was discharged 1 week later. At 14 months follow-up, he is doing well, and he enjoys freedom from his previous reflux symptoms.
Comment Massive hiatal hernia with gastric volvulus is a serious condition that can result in strangulation. Generally, this scenario is a late complication of longstanding hiatal hernia. In our case, left pneumonectomy likely created a vacant space into which the stomach could acutely herniate to a greater degree than preoperatively. The exaggerated herniation then resulted in volvulus with complete gastric obstruction. In a similar case, Simoens and colleagues [2] reported gastric herniation and volvulus occurring 17 days after left upper lobectomy. Gastric herniation and volvulus 1 year after left pneumonectomy has also been reported [3]. In this latter case, the diagnosis was initially unclear because of difficulty judging the contour of the left hemi-diaphragm. At the time of abdominal exploration, a foramen of Bochdalek hernia through a dorso-lateral foramen was found and repaired.
Ann Thorac Surg 2006;81:1491–2
We believe that acute gastric herniation and volvulus after pneumonectomy has not been previously reported. The management of giant hiatal hernia in patients undergoing major pulmonary resection, particularly left pneumonectomy, poses an interesting problem. Concomitant hiatal hernia repair and pneumonectomy is an option, but it seems inadvisable for several reasons. First, the physiologic demands from pneumonectomy alone are substantial, with reported mortality rates near 10%. Giant hiatal hernia repair requires considerable dissection and results in significant fluid shifts that would increase the risk of postpneumonectomy pulmonary edema. Second, the postpneumonectomy space is vulnerable to infection. Giant hiatal hernias are often associated with esophageal shortening and often require an esophageal lengthening procedure such as a Collis gastroplasty. Microbial contamination of the pneumonectomy space from gastroplasty creation would be disastrous. Given the difficulty sustained by our patient, recommending hiatal hernia repair prior to pneumonectomy might have been a consideration, although his paucity of symptoms did not seem to justify this. Our judgment was to avoid hiatal hernia repair concomitant with a difficult pulmonary resection. Gastric decompression was used to minimize the risk of strangulation while allowing the patient time to recover from intraoperative fluid shifts. Had this approach been ineffective, limited surgery with laparotomy and gastropexy alone (Stamm gastrostomy) would have been a reasonable alternative temporizing measure. We do not routinely use the NGT after pulmonary resection, as these have been associated with increased perioperative pulmonary complications [4, 5]. However, one option in this case would have been to position the NGT during the operation for postoperative decompression. The NGT could then be removed after physiologic stabilization and when operative intervention could be safely undertaken. Because an endoscopic-guided NGT achieved satisfactory decompression, we were able to wait 1 week and perform definitive repair with good results.
References 1. Argiris A, Liptay M, LaCombe M. A phase I/II trial of induction chemotherapy with carboplatin and gemcitabine followed by concurrent vinorelbine and paclitaxel with chest radiation in patients with stage III non-small cell lung cancer. Lung Cancer 2004; 45(2):243–53. 2. Simoens C, Verschakelen JA, Ponette E, Baert, AL. Gastric volvulus as a complication of a left superior lobectomy in a patient with pre-existing hiatal hernia. JBR-BTR 1994;77: 164 –5. 3. Simml G. Zwerchfellhernie nach pneumonektomie. Wien Med Wochenschrift 1976;126(15):202– 4. 4. Argov S, Goldstein I, Barzilai A. Is the routine use of the nasogastric tube justified in upper abdominal surgery? Am J Surg 1980;139(6):844 –50. 5. Alessi DM, Berci G. Aspiration and nasogastric intubation. Otolaryngol Head Neck Surg 1986;94(4):486 –9.
CASE REPORT
BLUM AND SUNDARESAN GIANT HIATAL HERNIA
1491
duct was identified, and it was ligated with complete recovery of the patient. In summary, this is an exceptional and possibly unique case of post-traumatic chylothorax due to the penetrating trauma of the chest.
References
Giant Hiatal Hernia with Gastric Volvulus Complicating Pneumonectomy Matthew G. Blum, MD, and R. Sudhir Sundaresan, MD Division of Cardiothoracic Surgery, Department of Surgery, Northwestern University Medical School, Chicago, and Northwestern Memorial Hospital, Chicago, Illinois; Division of Thoracic Surgery, Department of Surgery, University of Ottawa Medical School, Ottawa, Ontario, Canada
Gastric volvulus is a potentially lethal condition. Pneumonectomy patients have decreased physiologic reserve, and thus they are more susceptible to morbidity and mortality from postoperative complications. We report successful management of a patient with hiatal hernia that resulted in acute gastric volvulus after left pneumonectomy. (Ann Thorac Surg 2006;81:1491–2) © 2006 by The Society of Thoracic Surgeons
P
neumonectomy is a risky operation, but it is generally well tolerated in carefully selected patients. However, altered postoperative physiology gives minor complications potentially lethal implications, particularly in pneumonectomy patients receiving neoadjuvant therapy for loco-regionally advanced lung cancer. We report a
Accepted for publication March 16, 2005. Address correspondence to Dr Sundaresan, Ottawa Hospital, General Campus, Rm 6356, 6NW, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada; e-mail: [email protected].
© 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Preoperative chest roentgenograms (PA and lateral) showing a large hiatal hernia.
case of a giant hiatal hernia resulting in acute gastric volvulus after left pneumonectomy. Judgment, stabilization, and careful timing of reoperation were required to minimize the physiologic insult from this complication. A 54-year-old man with stage IIIa adenocarcinoma of the left upper lobe (T3 N2 M0) was treated on the Northwestern University multimodality therapy protocol (NU9961). The protocol entails induction chemotherapy (carboplatin, gemcitabine) followed by concurrent chemoradiotherapy (vinorelbine, paclitaxel, 4000 cGy), and subsequent pulmonary resection based on the response [1]. His lung function was excellent (forced expiratory volume in 1 second of 113% of predicted). Preoperative chest roentgenogram showed a large hiatal hernia (Fig 1) in addition to his lung cancer. However, he had only mild symptoms of gastroesophageal reflux that were easily controlled with medications, and thus he did not fulfill the criteria for hiatal hernia repair. The patient sustained an excellent clinical and radiologic response to induction therapy; therefore he underwent an elective left thoracotomy. Lobectomy was planned, but pneumonectomy was considered a distinct possibility. At thoracotomy, the large hiatal hernia was noted and decompressed with an orogastric tube. During the attempted lobectomy, the adventitial plane of the pulmonary artery was noted to be obliterated by fibrosis. Dissection was inadvertently carried along the media, effectively removing a large zone of arterial adventitia. Subsequent disruption of the thin arterial media resulted in significant blood loss and necessitated intrapericardial pneumonectomy. With the left hemithorax now empty, the hiatal herniation became more prominent. Because of the relatively large blood loss sustained to this point, it was decided that the large hiatal hernia would be addressed in the future if clinically indicated. A chest tube was placed for postoperative mediastinal balancing. The patient was extubated in the operating room. His overnight intensive care unit course was uneventful. The next morning it was noted that everything he swallowed was regurgitated undigested. His chest roentgenogram showed gastric herniation slightly increased 0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2005.03.065
FEATURE ARTICLES
1. Janzing H, Tonnard P, Van den Brande F, Derom F. Chylothorax after blunt chest trauma. Acta Chir Belg 1992;92:26 –7. 2. Markham KM, Glover JL, Welsh RJ, Lucas RJ, Bendick PJ. Octreotide in the treatment of thoracic duct injuries. Am Surg 2000;66:1165–7. 3. Browse NL, Allen DR, Wilson NM. Management of chylothorax. Br J Surg 1997;84:1711– 6. 4. Mikroulis D, Didilis V, Bitzikas G, Bougioukaws G. Octreotide in the treatment of chylothorax. Chest 2002;121:2079 – 80. 5. Rimensberger PC, Muller-Schenker B, Kalangos A, Beghetti M. Treatment of persistent postoperative chylothorax with somatostatin. Ann Thor Surg 1998;66:253– 4. 6. Patterson GA, Todd TRJ, Delarue NC, Ilves R, Pearson FG, Cooper JD. Supradiapragmatic ligation of the thoracic duct in intractable chylous fistula. Ann Thorac Surg 1981;32:44 –9. 7. Kent RB, Pinson W. Thoracoscopic ligation of the thoracic duct. Surg Endosc 1993;7:52–3. 8. Ohtsuka T, Tanaka M, Nakajima J, Takamoto S. Videoscopic supradiaphragmatic duct division using ultrasonic coagulator. Eur J Cardiothorac Surg 2002;22:828 –30.
1492
CASE REPORT BLUM AND SUNDARESAN GIANT HIATAL HERNIA
FEATURE ARTICLES
Fig 2. Chest roentgenogram showing gastric herniation slightly increased from the immediate postoperative chest roentgenogram.
from his immediate postoperative chest roentgenogram (Fig 2). Satisfactory urine output and absence of tachycardia, acidosis, or pain suggested that he did not have gastric ischemia or necrosis. Urgent endoscopy confirmed gastric viability and facilitated placement of a nasogastric tube (NGT). Endoscopic NGT placement was required because the antrum of the stomach was inverted (cephalad to the fundus). Continuous nasogastric suction and parenteral alimentation were maintained for 7 days to allow physiologic accommodation to his pneumonectomy and stabilization of his fluid status. Then he underwent laparotomy, hernia reduction, and CollisNissen repair. He tolerated this well and was discharged 1 week later. At 14 months follow-up, he is doing well, and he enjoys freedom from his previous reflux symptoms.
Comment Massive hiatal hernia with gastric volvulus is a serious condition that can result in strangulation. Generally, this scenario is a late complication of longstanding hiatal hernia. In our case, left pneumonectomy likely created a vacant space into which the stomach could acutely herniate to a greater degree than preoperatively. The exaggerated herniation then resulted in volvulus with complete gastric obstruction. In a similar case, Simoens and colleagues [2] reported gastric herniation and volvulus occurring 17 days after left upper lobectomy. Gastric herniation and volvulus 1 year after left pneumonectomy has also been reported [3]. In this latter case, the diagnosis was initially unclear because of difficulty judging the contour of the left hemi-diaphragm. At the time of abdominal exploration, a foramen of Bochdalek hernia through a dorso-lateral foramen was found and repaired.
Ann Thorac Surg 2006;81:1491–2
We believe that acute gastric herniation and volvulus after pneumonectomy has not been previously reported. The management of giant hiatal hernia in patients undergoing major pulmonary resection, particularly left pneumonectomy, poses an interesting problem. Concomitant hiatal hernia repair and pneumonectomy is an option, but it seems inadvisable for several reasons. First, the physiologic demands from pneumonectomy alone are substantial, with reported mortality rates near 10%. Giant hiatal hernia repair requires considerable dissection and results in significant fluid shifts that would increase the risk of postpneumonectomy pulmonary edema. Second, the postpneumonectomy space is vulnerable to infection. Giant hiatal hernias are often associated with esophageal shortening and often require an esophageal lengthening procedure such as a Collis gastroplasty. Microbial contamination of the pneumonectomy space from gastroplasty creation would be disastrous. Given the difficulty sustained by our patient, recommending hiatal hernia repair prior to pneumonectomy might have been a consideration, although his paucity of symptoms did not seem to justify this. Our judgment was to avoid hiatal hernia repair concomitant with a difficult pulmonary resection. Gastric decompression was used to minimize the risk of strangulation while allowing the patient time to recover from intraoperative fluid shifts. Had this approach been ineffective, limited surgery with laparotomy and gastropexy alone (Stamm gastrostomy) would have been a reasonable alternative temporizing measure. We do not routinely use the NGT after pulmonary resection, as these have been associated with increased perioperative pulmonary complications [4, 5]. However, one option in this case would have been to position the NGT during the operation for postoperative decompression. The NGT could then be removed after physiologic stabilization and when operative intervention could be safely undertaken. Because an endoscopic-guided NGT achieved satisfactory decompression, we were able to wait 1 week and perform definitive repair with good results.
References 1. Argiris A, Liptay M, LaCombe M. A phase I/II trial of induction chemotherapy with carboplatin and gemcitabine followed by concurrent vinorelbine and paclitaxel with chest radiation in patients with stage III non-small cell lung cancer. Lung Cancer 2004; 45(2):243–53. 2. Simoens C, Verschakelen JA, Ponette E, Baert, AL. Gastric volvulus as a complication of a left superior lobectomy in a patient with pre-existing hiatal hernia. JBR-BTR 1994;77: 164 –5. 3. Simml G. Zwerchfellhernie nach pneumonektomie. Wien Med Wochenschrift 1976;126(15):202– 4. 4. Argov S, Goldstein I, Barzilai A. Is the routine use of the nasogastric tube justified in upper abdominal surgery? Am J Surg 1980;139(6):844 –50. 5. Alessi DM, Berci G. Aspiration and nasogastric intubation. Otolaryngol Head Neck Surg 1986;94(4):486 –9.