Asian Cardiovasc Thorac Ann 2007;15:518-520
© 2007 Asia Publishing EXchange Ltd
A Rare Complication of Pneumonectomy: Hiatal Hernia Associated with Gastric Volvulus
James AC Thorpe, MD,
Christophoros N Foroulis, MD,
Samir Shah, FRCS(C-Th)
Thoracic Unit, The General Infirmary at Leeds, Leeds, United Kingdom
For reprint information contact: James AC Thorpe, MD Tel: 44 113 281 9349 Fax: 44 113 392 8436 Email: THORPYAT{at}aol.com, St. James’s University Hospital, Becket Street, Leeds LS9 7TF, United Kingdom.
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ABSTRACT
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A rare case of intrathoracic gastric herniation resulting in intermittent gastric volvulus was observed in a 69-year-old female patient five months after left pneumonectomy for lung cancer. The mechanism of post-pneumonectomy intermittent gastric volvulus and the techniques of surgical repair are discussed.
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INTRODUCTION
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Herniation of the stomach through the diaphragmatic hiatus followed by symptoms of gastric volvulus is a very rare late complication after pulmonary resection. Only a few cases of intra-abdominal gastric volvulus have been published in the medical literature, mainly after left sided thoracic procedures.1–4 Post-pulmonary resection gastric volvulus can be either intra-abdominal or intrathoracic.4 A propos of a recent case of para-esophageal hernia and intermittent gastric volvulus, that complicated a left pneumonectomy 5 months postoperatively, the possible mechanisms of post-pneumonectomy gastric herniation and volvulus are discussed.
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CASE REPORT
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A 69-year-old woman, heavy smoker, with a history of hypertension and a myocardial infarction 20 years ago, underwent a left pneumonectomy for a cavitating (8 x 8 cm) squamous cell lung carcinoma of the left lower lobe that was adhered to, but did not invade, the diaphragm. Pneumonectomy was uneventful and the patient was discharged on the 6th postoperative day. Five months after pneumonectomy she was admitted to the gastroenterology department with intermittent upper abdominal and left lower chest pain, and vomiting. Chest X-Ray at admission showed an air fluid level in the base of the left hemithorax, while the trachea, esophagus, and heart were deviated to the left hemithorax (Figure 1a
). After a 7-day period of conservative management, during which the patient had repeated intermittent episodes of chest pain and vomiting, she underwent further diagnostic studies. Fiberoptic gastroscopy raised the suspicion of gastric volvulus, as the scope could not reach the pylorus because of "gastric twisting". Barium swallow confirmed the diagnosis of a mixed (type III) hiatal hernia (Figure 2a, 2b) and chest X-Ray showed a huge air fluid level within the left hemithorax, while the mediastinum had moved to the midline (Figure 1b).
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Figure 1a. Chest X-Ray at admission showing deviation of the mediastinum to the pneumonectomy side, and the air fluid level at the base of the left hemithorax; 1b. Preoperative chest X-Ray after barium swallow, showing huge air fluid in the left hemithorax. The mediastinum has returned back to the midline.
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Figure 2a. Barium swallow showing herniation of the stomach within left hemithorax/type III diaphragmatic hernia; 2b. The herniated fundus of the stomach after reduction, ischemic changes are well shown (darker areas).
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The patient was referred to the thoracic surgery department and underwent urgent surgery via a bilateral subcostal laparotomy incision. The fundus of the stomach was found to be herniated through the hiatus into the left hemithorax together with part of the greater omentum. After reduction of the hernia, the hiatus was found dilated up to 3 fingers width. The herniated stomach had ischemic changes that were reversed within a short period. A trans-mesocolic gastrojejunostomy was then performed to permanently fix the herniated stomach in an abdominal position. The crura of the diaphragm were approximated with interrupted 0 nylon sutures. A chest drain was inserted in the left hemithorax and the abdomen was closed according to the standard fashion.
The patient had a complicated postoperative course. Progressive distention of the abdomen, a fall in urine output, and hypoxemia were observed on the 2nd postoperative day. The patient was intubated and a chest X-Ray showed multiple bilateral pulmonary infiltrations. An urgent exploratory re-laparotomy was performed on the 3rd postoperative day because of aggravated paralytic ileus and a clinical suspicion of development of abdominal compartment syndrome.
Re-laparotomy findings were that of small bowel edema and ischemia, involving the first post-gastrojejunostomy small bowel loop. No evidence of internal hernia formation was detected at re-laparotomy. The ischemic small bowel changes were irreversible so the ischemic bowel loop was resected. The bowel continuity was reinstituted by performing an end-to-end anastomosis. The patient died on the 4th postoperative day due to fulminant development of irreversible multiple organ failure syndrome.
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DISCUSSION
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Gastric volvulus can be distinguished in two forms: a) acute gastric volvulus, and b) chronic (intermittent) gastric volvulus.2,5 The so-called chronic or intermittent volvulus has usually been found to occur in association with abdominal or thoracic abnormalities, such as diaphragmatic hernia, peptic ulcer, neoplasms, eventration of the diaphragm, or phrenic nerve disruption.2
Large gastic herniation through the hiatus resulting in chronic (intermittent) gastric volvulus is an unusual complication after pulmonary parenchyma resection.4 This postoperative event is more likely to occur on the left side, because the lower third of the esophagus lies more to the left and is affected by events in the left hemithorax (pneumonectomy, lobectomy, phrenic nerve interruption). Gastric volvulus in the abdomen can be the result of phrenic nerve dissection and elevation of the left hemidiaphragm that draws the attached (with the gastrosplenic ligament) fundus of the stomach in a higher position.2 As a result, air accumulated in the herniated fundus is difficult to evacuate (due to the higher position of the fundus), and can result in gastric volvulus around the oblique or transverse axis of the stomach.1,2
In the presented case, the high negative intrapleural pressure in the left hemithorax as detected by postoperative deviation of the mediastinum to the left side on postoperative chest X-Ray, was the result of the previous pneumonectomy. We suggest that a progressive vacuum mechanism was applied on a small pre-existing hiatal hernia, because of the raised negative intrapleural pressure which developed after pneumonectomy. Additionally, the normal positive intra-abdominal pressure resulted in progressive sucking of the gastric fundus into the left hemithorax, until most of the fundus, large curvature, and part of the omentum were moved into the left hemithorax. The higher position of the left hemidiaphragm subsequent to pneumonectomy could be an additional factor, by further deteriorating the diaphragmatic hiatus. Progressive gas distention of the herniated stomach resulted in intermittent volvulus of the organ and intermittent output obstruction. Ischemia of the herniated stomach due to torsion may compound the patient’s pain.
In this case diagnosis was based on radiographic imaging and the endoscopic appearance, as twisting of the stomach prohibited the endoscopist from reaching the pylorus. Post-pulmonary resection chest and abdominal X-Rays showing elevation of the left hemidiaphragm and/or abnormal gastric gas shadow in the left upper abdominal quadrant should raise suspicion of gastric volvulus. Other imaging findings which assist detection of the complication are images of hiatal hernia, upside-down stomach image, elevation of the left hemidiaphragm, image of a hairpin loop with fixation along with radiologic evidence of hiatal hernia. A barium swallow can reveal complete blockage, and endoscopy can confirm the diagnosis.2,3
The definitive treatment of this rare condition is surgical intervention. Reduction of the herniated stomach and, if the stomach is viable, a form of gastropexy and closure of the hiatus are the optimal surgical treatments. Gastrojejunostomy can be used to fix the stomach in an abdominal position. However, fixation of the stomach to the anterior chest wall (anterior gastropexy) is an alternative. Indeed, if anterior gastropexy has to be performed, special attention should be given to avoid any defects in the abdomen that could be the site of an internal hernia formation in the future.3,5 Nissen fundoplication could not be used in the presented case, as the gastric fundus had ischemic changes because of the volvulus. A laparoscopic approach should be avoided in cases of intrathoracic gastric volvulus, especially after a previous pneumonectomy, where the mediastinum is deviated to the midline and the reduction of the hernia may be problematic. Inflating the abdominal cavity by gas to proceed with laparoscopy and further distention of the abdomen may seriously affect the ventilation of the patient.
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REFERENCES
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- Young CK. A case of volvulus of stomach complicating left phrenic interruption and left lower lobectomy. Med J Malaya 1957;12:384–5.[Medline]
- Creedon PJ, Burman JF. Volvulus of the stomach: report of a case with complications. Am J Surg 1965;110:964–6.[Medline]
- Carlisle BB, Hayes CW. Gastric volvulus. An unusual complication after pneumonectomy. Am J Surg 1967;113:579–82.[Medline]
- 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. J Belge Radiol 1994;77:164–5.[Medline]
- Thorpe JA. Chronic gastric volvulus - aetiology and treatment. Br J Clin Pract 1981;35:161–2.[Medline]
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ABSTRACT
INTRODUCTION
