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Oesophagectomy remains an acceptable treatment option for oesophageal cancer. However, it is associated with relatively high morbidity with potentially devastating complications, especially for patients who have undergone previous thoracic surgery. The majority of these complications, however, can be minimised by prevention and early recognition. In this report we present a case of a patient whose right ventricle was injured during the oesophagectomy. We try to analyse the reasons for this complication and establish an algorithm of preoperative planning for such cases.
Despite advances in various medical therapeutic modalities for oesophageal cancer, surgery continues to be the treatment of choice for patients with resectable tumour. However, oesophagectomy still remains a high risk procedure with considerable morbidity and significant mortality.
Perioperative complications associated with oesophageal resection are generally related to the type of operation performed, the extent of the surgery, and also to the general condition of the patient. These complication can be roughly divided into two groups: technical, and those associated with cardiopulmonary aberrations.1 We report a case of an unusual, life threatening complication of an oesophagectomy conducted 5 years after surgery for mitral valve replacement.
A 68-year-old man, who was a heavy smoker, was admitted to our department with grade III dysphagia, and a weight loss of 5 kg during the previous month. The endoscopic examination and biopsy specimen showed an oesophageal squamous cell carcinoma located in the supracardiac region. The computed tomography (CT) scan showed a tumour <6 cm in diameter without any lymph node metastasis (ctT3 N0 M0, stage II A according to UICC).
Apart from the cancer, the patient also had a history of arterial hypertension and had undergone cardiac surgery for mitral valve replacement 5 years previously.
The scheduled surgical treatment for the patient consisted of a subtotal oesophagectomy, lymphadenectomy and reconstruction with a gastric tube via the retrosternal route. Unexpectedly, during the blind preparation of the retrosternal space, laceration of the right ventricle of the heart occurred and the patient developed hypovolaemic shock. At this point, an emergency sternotomy was performed, the laceration of the ventricle was sutured, and the operation was completed successfully.
Histopathological examination of the specimens revealed that the cancer was a well differentiated oesophageal squamous cell carcinoma (G1) that had invaded the entire wall of the oesophagus with lymph node metastasis (pT3 N1 M0, stage III according to UICC). The patient’s postoperative recovery was uneventful. Postoperative gastrointestinal studies revealed no anastomotic leakage and he was discharged without any complications. Because of his general state he was rejected for chemotherapy and died 13 months later from a heart attack.
Cardiac injury at the time of reoperation after a previous sternotomy is considered an unfortunate but inevitable complication which any surgeon dealing with thoracic or cardiac surgery could be faced with.2 The risk of catastrophic haemorrhage on sternal re-entry is estimated to be 0.5–1% with an associated mortality rate of 21%,3 and increases in patients with a history of mediastinitis, sternal wound infection and enlarged heart.4
The major cause of complications in such cases are adhesions between the posterior lamina of the sternum and the innominate vein, right ventricle, and sometimes also the extracardiac conduits and grafts.2,3 Since preparing the tunnel for the gastric tube behind the sternum is primarily a blind procedure, it carries an increased risk of injury to these structures. For that very reason a key factor before re-entering the retrosternal space is the careful diagnosis and anticipation of potential problems.
Therefore, the condition of the retrosternal adhesion should be routinely checked preoperatively. It is essential for the surgeon to become acquainted with the protocol of the previous intervention, as the conduct of the first operation sets up the morbidity of the second. Generally, the risk of haemorrhage should diminish if the pericardium was closed at the first operation. In our case, however, according to the protocol the pericardium was sutured after the mitral valve replacement. Thus, the actual state of the retrosternal space should also be assessed objectively and the surgeon should check a preoperative computed tomography (CT) scan in order to evaluate the distension of the right atrium or right ventricle, the position and size of the great vessels, and also the amount of space between the sternum and the heart or any patent grafts.2 Nonetheless, even if the heart is very close to the sternum, CT scans can indicate whether or not there is any fatty tissue between the heart and the sternum. If fatty tissue is present, there is less risk of haemorrhage with re-entry.5
However, the situation becomes even more complicated if the patient has had previous coronary artery bypass surgery. In that case, a CT scan is not sufficient to assess the risk of the bypass injury. At this juncture the patient should have the preoperative repeat catheterisation of the coronary vessels. Lack of movement of coronary artery grafts on the catheterisation films should raise the suspicion of a graft that is adherent to the sternum.2
Ultimately, if the estimated risk of blind tunneling is high, the surgeon should consider passing the gastric tube not via the retrosternal route, as in this case, but in the anatomical position of the oesophagus. This can be achieved by conventional open surgery, but also, if possible, using alternative surgical techniques such as thoracoscopic oesophageal dissection. This avoids the risk associated with the retrosternal adhesions, but also had its drawbacks.
Anterior mediastinal reconstruction helps in the prevention of tumour recurrence within the gastric conduit6,7 or permits avoidance of conduit irradiation if postoperative radiation therapy is needed for residual disease. Other possible advantages of anterior reconstruction include ease and efficiency of further interventions such as drainage for anastomotic leakage, reoperation for anastomotic strictures, or percutaneous endoscopic gastrostomy.8,9
In conclusion, we suggest that the patient who has undergone previous cardiac surgery and requires oesophageal resection needs not only routine preoperative assessment, but also a careful estimation of the retrosternal region.
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.