Asian Cardiovasc Thorac Ann 2007;15:515-517
© 2007 Asia Publishing EXchange Ltd
Perforation of a Substernal Interposed Ileocolon Caused by Right Thoracic Herniation
Va-Kei Kok, MD
Department of Surgery, Taipei County Hospital, Taipei, Taiwan
For reprint information contact: Va-Kei Kok, MD, Tel: 886 2 2351 1176, Fax: 886 2 2395 5097, Email: kokvakei{at}ms29.hinet.net, Department of Surgery, Taipei County Hospital, 5th Floor, No.17, Lane 12, Qing Tian Street, Taipei 106, Taiwan.
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ABSTRACT
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Perforation of a retrosternal interposed ileocolon is rare. We present a case of perforation of the interposed colon on the ninth postoperative day, which subsequently herniated to the right pleural space. We suggest that the dilated haustral trapping and the associated "waterfall" effect may have resulted in incarceration of the colon. Careful dissection of the pleura in order to create a retrosternal tunnel, and the use of a suitable length of an esophageal substitute could prevent this complication.
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INTRODUCTION
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Esophagectomy for benign disease is performed infrequently,1 reconstruction of a resected esophagus with colonic interposition gaining variable acceptance since first being reported in 1911.2,3 Colonic interposition can typically be accomplished with low mortality (0% to 5%) and high patient acceptance of morbidity (20% to 60%).1–3 In 1985, Larson et al reported that anastomotic leaks arose only at the proximal anastomosis, with an incidence of 31.8%.3 For the period from 1974 to 1986 inclusive, Curet-Scott et al reviewed 53 consecutive (benign-disease) patients who underwent esophageal resection followed by colonic interposition,2 all experiencing colonic perforation perioperatively, with one patient featuring a redundant colon. Acute peri-surgical perforation of a colonic substitute appears to be a rare complication.
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CASE REPORT
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A 48-year-old woman had undergone transhiatal esophagogastrectomy due to severe caustic injury with hydrochloric acid (HCl) six months previously. On admission, she was advised to undergo right colonic interposition with esophageal reconstruction. The surgical procedure involved an iso-peristaltic right colon segmental interposition and terminal ileum segmentation using re-established upper-enteric continuity. The colonic segment was passed into the patient’s neck through a retrosternal tunnel with the creation of a cervical anastomosis.
The patient’s postoperative care included nasogastric tube decompression, which was performed uneventfully. The patient underwent an upper gastrointestinal tract (UGI) examination with 100mL of Gastrografin® (Diatrizoate) on the eighth postoperative day as part of an overall UGI study (Figure 1
), all of which revealed essentially normal esophageal function without any evidence of leakage of Gastrografin®. The patient was afebrile and was allowed a small amount of water on the ninth postoperative day, three hours subsequent to which she complained of chest discomfort and dyspnea. Upon examination, the patient’s breathing sounds appeared to be somewhat subdued in her right chest. Following a posteroanterior chest radiograph (Figure 2) it was apparent that the patient had suffered a hydropneumothorax in the right chest. Chest tube decompression was performed and pyothorax was noted. Under the clinical impression of colonic substitute perforation, sternotomy was immediately carried out.
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Figure 1. Upper gastrointestinal tract study revealing a normal post-surgery outcome without any evidence of leakage.
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The sternotomy was commenced at the subxiphoid process, revealing redundancy of colonic substitute with substantial dilatation present, and herniation to the right chest through the punctured pleura. The wall of the cecum was found to be quite densely adhered to the anterior chest wall. A section of colonic substitute tissue featuring necrosis and measuring 4 x 3 cm with perforation was also detected at the anterior wall of the cecum when the colonic substitute was dissected free from the chest wall. The vascular pedicle and cervical anastomatic sites appeared to be patent and demonstrated good healing. In order to avoid any further mediastinitis and sepsis breakdown, the patient’s colonic substitute was removed immediately. The patient remained free of mediastinitis and was discharged home with a feeding jejunostomy, approximately three weeks after initial admission.
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DISCUSSION
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It is likely that contribution to the complication by either ischemia or a congestive problem of the colonic segment occurred, as the perforation that developed was proximate to the distal end of the inserted segment. Local factors such as the presence of inflammatory bowel disease may also have played a role. We have some doubts as to whether colon interposition infarction is able to cause bowel perforation or not. In 1985, Larson and colleagues reported a case of colonic ulceration featuring perforation, and concluded that such an event occurred presumably due to the relative inadequacy of blood flow in the middle colonic artery or one of its major branches.3 The authors discussed the potential for rapid-onset postoperative interposed-colon perforation and its potential to arise spontaneously or secondary to rapid ischemic ulceration.
Medical opinion varies as to whether the right colon or the left colon should be used as the surrogate conduit, with an anti-peristaltically positioned left colon potentially predisposing to reflux, and the right colon possibly revealing a poorer vascular supply than its alternative.3 The right colon may also feature relatively poorer venous drainage than the left.3,4 Moreover, in 1980 Wilkins documented a five-times greater incidence of colon necrosis in right colon segments than in left-colon interpositions,5 the most frequent cause of postoperative death being colon necrosis; a technical complication that can usually be avoided. The typical cause of interposition infarct is venous obstruction,4 although the application of a meticulous surgical technique helps to decrease the incidence of this complication and its sometimes fatal outcome.2 The question of concern here, and that warranting discussion, is how to search for and/or clearly define these lethal complications prior to the patient developing associated signs and symptoms.
The radiographical findings of this case were discussed postoperatively. Herniation was shown in the UGI study to have already occurred (Figure 3), and subsequently deteriorated with the commencement of oral intake and/or the removal of the patient’s decompression tube. In addition, a lateral view X-Ray film may have shown the situation more clearly. Although the UGI study with water-soluble contrast medium revealed no anastomotic leak, no redundancy of the interposed ileocolonic segment was apparent and use of the water-soluble contrast medium did not reveal any pathological changes indicative of a mucosal problem. Such gas-associated problems may be indicative of lethal pathological alterations which occur postoperatively, although water-soluble contrast medium is typically not able to present the fine mucosal detail necessary for appropriate diagnosis.3
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Figure 3. The dilated haustral trapping of the bowel and the "waterfall" effect may represent rather ominous signs for bowel-loop incarceration.
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From the findings of the follow-up surgical procedure, it would appear that the perforation of the interposed colon was caused by necrosis of the wall of the dilated bowel. Regional ischemia of the bowel wall combined with local inflammation was suspected in our patient. DeMeester et al suggested that redundancy of an interposed colonic segment can be a problem with esophageal reconstruction, and that proper anchoring of the transplant can reduce the problem of redundancy.6 Following this, the herniation of the redundant colonic segment could have caused its incarceration, which could then have led to subsequent perforation of the colonic segment.
Reviewing our case, it would seem likely that three factors were critical to its lack of success: 1) redundancy of the interposed colon, 2) the negative pressure existing within the chest cavity, and 3) the emergence of a defect of the right pleura. The negative pressure within the thoracic cavity may have acted as a suction mechanism causing bowel-loop incarceration at the site of the pleural defect. The replaced colonic substitute adhering to the chest wall and the development of regional ischemia of the bowel wall are probably the leading causes of the failure of such a surgical procedure.
It is most likely that the problem described in this case was technical as the conduit was too long and naturally herniated to the right. The second-look operative finding confirmed that the substitute had incarcerated to the defect in the pleura. The perforation was secondary to kinking of the vascular arcade and compression of the venous drainage. What signs or symptoms can alert the attentive physician to the possible development of a complication such as that reported in our patient? The long redundant colonic substitute may itself constitute a risk factor in such a surgical procedure. The combined dilated haustral trapping of the bowel and the "waterfall" effect may elicit abnormal gas filling within the lumen which may represent a rather ominous sign of bowel-loop incarceration (Figure 3
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In conclusion, in order to prevent this rare complication; extreme care must be taken by the surgeon when dissecting the pleura to avoid breaking the pleura at the time of reconstruction of the retrosternal tunnel. A suitable length of colonic material should be used as an esophageal substitute and appropriate end anchoring of the conduit conducted. Conducting a single contrast barium examination following colonic reconstruction is appropriate unless gross extravasation is suspected. Finallly, the left hemicolon may be a better choice of colonic section for esophageal reconstruction purposes than the right hemicolon.
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REFERENCES
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- Young MM, Deschamps C, Trastek VF, Allen MS, Miller DL, Schleck CD, et al. Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results. Ann Thorac Surg 2000;70:1651–5.[Abstract/Free Full Text]
- Curet-Scott MJ, Ferguson MK, Little AG, Skinner DB. Colon interposition for benign esophageal disease. Surg 1987;102:568–74.
- Larson TC 3rd, Shuman LS, Libshitz HI, McMurtrey MJ. Complications of colonic interposition. Cancer 1985;56:681–90.[Medline]
- Postlethwait RW. Colonic interposition for esophageal substitution. Surg Gynecol Obstet 1983;156:377–83.[Medline]
- Wilkins EW Jr. Long-segment colon substitution for the esophagus. Ann Surg 1980;192:722–5.[Medline]
- DeMeester TR, Johansson KE, Franze I, Eypasch E, Lu CT, McGill JE, et al. Indications, surgical technique, and long-term functional results of colon interposition or bypass. Ann Surg 1988;208:460–74.[Medline]
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ABSTRACT
INTRODUCTION
