Salvage of colon interposition by antethoracic free jejunal transfer

CASE REPORT CARLSON ET AL SALVAGE OF COLON INTERPOSITION

Ann Thorac Surg 1994;58:1523-5

infarction caused by coronary occlusion, or rupture with tamponade.

References 1. Packard M, Wechsler H. Aneurysms of coronary arteries. AMA Arch Intern Med 1929;43:1-14. 2. Scott DH. Aneurysm of the coronary arteries. Am Heart J 1948;36:403-21. 3. Hartnelle GG, Parnell BM, Pridie RB. Coronary artery ectasia. Its prevalence and clinical significance in 4993 patients. Br Heart J 1985;34:392-5. 4. Parkhurst GF, Decker JP. Bacterial aortitis and mycotic aneurysm of the aorta. A report of twelve cases. Am J Pathol 1955;31:821-35. 5. Cliff MM, Soulen RL, Finestone AJ. Mycotic aneurysms-a challenge and a clue: review of ten-year experience. Arch Intern Med 1970;126:977-82. 6. Infante CM, Martinez MS, Horta AM, Amat SJ, Landazuri EO. Enfermedad del seno y aneurismas micoticos coronarios en una enferma con endocarditis bacteriana oculta. Rev Med Univ Navarra 1982;26:245-7. 7. Davidson A, Eshaghpour E, Young N, Mintz GS. Late thrombosis of a coronary mycotic aneurysm. Am Heart J 1991;121: 1549-50. 8. Velazquez T. Aneurisma micotico de la arteria coronaria; presentacion de un caso y revision de la literatura. Arch Inst Cardiol Mex 1952;22:49-53.

Salvage of Colon Interposition by Antethoracic Free Jejunal Transfer Grant W. Carlson, MD, Timothy M. Anderson, MD, John R. Galloway, MD, and Kamal A. Mansour, MD

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longed nasogastric intubation (Fig 1). She had a history of multiple gastric operations and a right colectomy performed to manage the complications of peptic ulcer disease. She also had been on long-term steroid therapy for asthma. On July 29,1992, the patient underwent an esophagectomy and a left colon interposition in the posterior mediastinum using an Ivor Lewis approach. Postoperatively, dehiscence of the esophagocolonic anastomosis developed, necessitating a diverting cervical esophagostomy. The interposed colon was brought out through a subcutaneous tunnel to form a venting colostomy in the midchest at the nipple line. This was done to check its viability and to shorten the gap to be bridged later. In the meantime, it was used for tube feeding purposes. Several days later, the abdominal ileocolonic anastomosis dehisced and a diverting ileostomy was performed. On March 25, 1993, enteric continuity between the cervical esophagus and the interposed colon was reestablished with a free jejunal graft placed in a subcutaneous tunnel. The microvascular anastomosis was performed to the right internal mammary vessels after removal of the third costal cartilage (Fig 2). Postoperatively, a small fistula developed at the jejunocoIonic anastomosis, which subsequently closed in response to conservative treatment (Fig 3). The patient returned to oral alimentation with no functional impairment (Fig 4).

Comment Colon interposition has been associated with high morbidity and mortality rates [1, 2]. Ischemia of the distal colonic segment can result in anastomotic dehiscence, fistulization, and stricture formation. Our case represents an unusual

Divisions of General, Cardiothoracic, and Plastic and Reconstructive Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia

Intrathoracic disruption of an esophagocolonic anastomosis after colon interposition can be a fatal complication. A case is presented in which an antethoracic free jejunal transfer achieved successful salvage. The patient returned to oral alimentation with no functional impairment. (Ann Thorae Surg 1994;58:1523-5)

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olon interposition is an established technique for esophageal reconstruction in the presence of benign disease, especially when the stomach is unavailable for transposition. Intrathoracic disruption of the esophagocoIonic anastomosis can be a fatal complication, however. A patient is described whose disrupted anastomosis was successfully treated by an antethoracic free jejunal transfer to restore the continuity of the upper gastrointestinal tract. A 65-year-old woman presented with an extensive esophageal stricture secondary to reflux esophagitis after proAccepted for publication Feb 18, 1994. Address reprint requests to Dr Mansour, Cardiothoracic Surgery, The Emory Clinic, 1365 Clifton Road, NE, Atlanta, GA 30322.

© 1994 by The Society of Thoracic Surgeons

Fig 1. Long, narrow distal esophageal stricture secondary to long-term nasogastric intubation. 0003-4975/94/$7.00

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CASE REPORT CARLSON ET AL SALVAGE OF COLON INTERPOSITION

Ann Thorac Surg 1994;58: 1523-5

int, mammary artery & vein

Fig 4. Antethoracic jejunal graft is clearly visible as it extends from the neck to the lower chest.

Fig 2. Technique of placing a subcutaneous free jejunal graft between the cervical esophagus and subcutaneous colostomy. Notice the blood supply furnished by the mid-internal mammary vessels.

salvage involving the use of a microvascular free jejunal transfer. In 1980, Chang and associates [3] first described 2 patients in whom free jejunal flaps were used as patch grafts to repair areas of stenosis after colonic interposition. In 1984, Fisher and colleagues [4] used a free jejunal segment to replace a strictured segment of colon interposition; the area was approached by resecting a portion of

the manubrium and clavicle and the microvascular anastomosis was performed in the neck. Theile and Robinson [5] reviewed 3 cases of microvascular jejunal salvage of a failed colonic interposition; access to the retrosternal colon was achieved by median sternotomy in all the patients. Two patients had areas of stricture replaced and a third patient needed a free jejunal interposition after total necrosis of the colon occurred. Gastric transposition was performed and the jejunum used to bridge the gap to the pharynx. The graft was anastomosed to the internal mammary vessels. Jejunal interposition is useful for distal esophageal substitution, but the mesenteric length usually prohibits its use in the upper chest and neck [6]. Gorbunov and associates [7] described lengthening the mesentery in jejunal interposition through the placement of microvascular interpositional vein grafts. If flow through the marginal vessels was insufficient, the proximal small intestine was revascularized by performing a microvascular anastomosis of the mesentery to the internal mammary vessels. They reported 14 patients in whom the jejunum was tunneled to the neck in the subcutaneous plane. There were no cases of graft necrosis or fistula formation. The treatment used in our patient represents a different approach to the management of a failed colon interposition. The anastomotic dehiscence necessitated diversion of the gastrointestinal tract. Placing the colonic segment in the subcutaneous plane permitted an antethoracic reconstruction to be performed with the jejunum anastomosed to the internal mammary vessels. This circumvented the need to reenter the scarred mediastinum and the potential for mediastinal contamination.

References Fig 3. Barium swallow study done 3 months postoperatively shows complete restoration of esophagojejunocolonic continuity.

1. Mansour KA, Hansen HA, Hersh T, et al. Colon interposition

for advanced esophageal stricture. Experience with 40 patients. Ann Thorac Surg 1981;32:584-92.

Ann Thorac Surg 1994;58:1525-7

2. Curet-Scott MJ, Ferguson MK, Little AG, et al. Colon interposition for benign esophageal disease. Surgery 1987;102:568-74. 3. Chang T-S, Hwang O-L, Wang W. Reconstruction of esophageal defects with microsurgically / revascularized jejunal segments: a report of 13 cases. J Microsurg 1980;2:83-94. 4. Fisher J, Payne WS, Irons GB. Salvage of a failed colon interposition in the esophagus with a free jejunal graft. Mayo Clin Proc 1984;59:197-201. 5. Theile DE, Robinson DW. Microvascular salvage for failed colonic interposition. Aust N Z J Surg 1987;57:749-52. 6. Wright C, Cuschieri A. Jejunal interposition for benign esophageal disease. Ann Surg 1987;205:54-60. 7. Gorbunov GN, Marinichev VL, Volkow ON, et al. Microvascular reconstruction of the esophagus with pedicled small intestine. Ann Plastic Surg 1993;31:439-42.

Hemangiopericytoma of the Mediastinum Causing Spontaneous Hemothorax Masatoshi Mori, MD, Norihiko Nakanishi, MD, and Keizo Furuya, MD Departments of Chest Surgery, Internal Medicine, and Pathology, Ehime Prefectural Central Hospital, Ehime, Japan

Mediastinal tumors rarely cause spontaneous hemothorax. We report a case of right-sided hemothorax that occurred in a 37-year-old woman with a hemangiopericytoma in the posterior portion of the superior mediastinum. (Ann Thome Surg 1994;58:1525-7)

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lth ou gh mediastinal tumors present with a variety of clinical signs and symptoms, spontaneous bleeding into the pleural space is extremely rare. On the other hand, many causes for spontaneous hemothorax have been documented, but mediastinal tumors are a rare cause. In this report we describe an unusual case of mediastinal tumor presenting as spontaneous hemothorax. A 37-year-old woman was admitted to our hospital with a chief complaint of dyspnea. Two days before admission, she was seen at another hospital complaining of right chest pain that had persisted for the past 4 months and a roentgenogram and computed tomographic scan of the chest showed a mediastinal mass. The next evening she had several fits of coughing and then fainted. She was brought to another hospital, where a chest roentgenogram showed a mass and an accumulation of fluid in the right pleural space. She was transferred to our hospital on July 17,1993. On admission, physical examination revealed decreased breath sounds in her right chest. Systolic blood pressure Accepted for publication Feb 22, 1994. Address reprint requests to Dr Mori, Department of Chest Surgery, Ehime Prefectural Central Hospital. 83 Kasuga-machi, Matsuyama City, Ehime 790, Japan.

© 1994 by The Society of Thoracic Surgeons

CASE REPORT MORI ET AL HEMANGIOPERICYTOMA CAUSING HEMOTHORAX

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Fig 1. Contrast-enhanced computed tomographic scan of the chest demonstrating a hypervascular mass in the posterior mediastinum.

was 70 mm Hg. Laboratory studies revealed a hemoglobin level of 9.7 g/dL, a white blood cell count of 20AOO/mL, and a platelet count of 583,000/mL. A chest roentgenogram demonstrated an 8 X 6-cm mass in the right upper lobe and an accumulation of fluid in her right pleural space. Thoracentesis revealed right-sided hemothorax and 750 mL of blood was evacuated through a chest tube. Reexpansion of the right lung was sufficient. Results of cytologic examination of the bloody pleural fluid were negative for malignant cells. A computed tomographic scan of the chest showed an 8 X 7-cm mass that was thought to be an intrapulmonary tumor which extensively involved the mediastinum. With contrast enhancement, the mass was found to be hypervascular and there were low-density areas suggesting the presence of necrosis (Fig 1). Transbronchial biopsy specimens of the mass obtained through the superior segmental bronchus of the right lower lobe failed to yield a pathologic diagnosis. Percutaneous biopsy of the mass was terminated after an initial aspiration with a fine needle yielded blood. To eradicate the source of bleeding and to confirm the diagnosis of the mass, an operation was performed on August 19, 1993. Through a right thoracotomy, a dark red, well-circumscribed mass, measuring 8 X 6.5 X 3.5 em and weighing 140 g, was totally excised. The entire surface of the right lung showed fibrous adhesions. The pear-shaped mass, lying along the second to fourth vertebral bodies, was covered with a capsule, but the tight adherence of the mass to the visceral pleura of the superior segment of the lower lobe had caused injury to the lung. A total of 4,000-mL of blood was lost during resection of the richly vascularized tumor, requiring the transfusion of 19 units of blood. Macroscopically, the resected specimen was a smooth, encapsulated mass and the cut surface appeared grayish pink to pale brown, showing foci of cystic degeneration and hemorrhage. Histopathologic examination revealed that the tumor consisted of tightly packed, spindle-shaped cells situated around numerous thin-walled vascular channels. Branching sinusoidal vessels lined with flat endothelium showed an antlerlike configuration. The tumor cells were almost uniform in size and had round to oval nuclei but exhibited no pleomorphism. Occasional areas of necrosis and hemorrhage were seen. The number of mitotic figures in the 0003-4975/94/$7.00