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Because the outflow tract obstruction is dynamic and affects the pulmonary circulation directly, the clinical picture and associated hemodynamic instability may be difficult to assess. SAM depends on loading conditions, prone positioning, and tachycardia, among other causes, and it may therefore develop as conditions change. Cannon waves noted in central venous pressure monitoring may provide a clue confirmed by transesophageal echocardiography. A high index of suspicion should be maintained for this complication of systemic AV valve replacement in ccTGA.
References Fig 1. Transesophageal echocardiography demonstrating systolic anterior motion of the anterior mitral leaflet into the pulmonary outflow tract. The single and double asterisks indicate the posterior and anterior leaflets of the mitral valve, respectively. (Ao ¼ aorta; LA ¼ left atrium; mLV ¼ morphological left ventricle; PA ¼ pulmonary artery; RA ¼ right atrium.)
Comment The incidence of pulmonary outflow tract obstruction in ccTGA may be up to 53% [1, 2]. Typically, this condition is caused by raised systemic ventricular pressures that lead to bowing of the ventricular septum into the pulmonary outflow tract [1, 3]. One previous description exists in the literature of septal displacement precipitating SAM in a patient with ccTGA [4], but none after tricuspid valve operations in several series [2, 5–7]. Our patient did not appear to have any ventricular aneurysmal component. Displacement of the replaced tricuspid systemic AV valve annulus by the sewing ring distorted the anatomy sufficiently to allow the relative redundancy of the anterior leaflet to become too close to the interventricular septum. With the cause of SAM now thought to be drag forces, rather than a Venturi effect [8], this process can be initiated even at the relatively lower pulmonary pressures. Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
Endoscopic Management of Early Upper Gastrointestinal Bleeding After Minimally Invasive Ivor-Lewis Esophagectomy Ren-Quan Zhang, MD,* Ning-Ning Kang, MD,* Yun Che, MD, Wan-Li Xia, MD, Zhai-Cheng Yu, MD, Hua-Guang Pan, MD, Wei Ge, MD, An-Guo Chen, MD, and Jun Wan, MD, PhD Department of Thoracic Surgery, First Affiliated Hospital of Anhui Medical University, Hefei City, China
Minimally invasive esophagectomy is now accepted as a regular treatment modality for esophageal cancer. Upper gastrointestinal (GI) bleeding is a common postoperative adverse event of esophagectomy. However, there are very few reports in the literature on endoscopic management of early upper GI bleeding after an esophagectomy. Here, we report the successful management of such an early case of GI bleeding after 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.03.124
FEATURE ARTICLES
An urgent mitral valve replacement, using a 33-mm St. Jude Medical mechanical prosthesis was undertaken uneventfully 48 hours after the initial surgical procedure. To accommodate the prosthesis, the ICD lead was removed, and epicardial leads were placed. The procedure was uneventful but the patient had a stormy postoperative course, with frequent ventricular ectopics required atrial overdrive pacing in the absence of his previous ICD. He developed fulminant sepsis with right lower lobe pneumonia, as well as acute renal failure requiring hemofiltration and high levels of vasopressor support. Acalculous cholecystitis also necessitated percutaneous cholecystostomy. Prolonged weaning from high levels of respiratory support required tracheostomy. Despite this early postoperative course, however, the patient continued to make good progress and was eventually discharged home, 5 weeks after the initial operation, in good health and in NYHA functional class I.
1. Hornung TS, Calder L. Congenitally corrected transposition of the great arteries. Heart 2010;96:1154–61. 2. Mongeon F-P, Connolly HM, Dearani JA, Li Z, Warnes CA. Congenitally corrected transposition of the great arteries: ventricular function at the time of systemic atrioventricular valve replacement predicts long-term ventricular function. J Am Coll Cardiol 2011;57:2008–17. 3. Reddy SCB, Chopra PS, Rao PS. Aneurysm of the membranous ventricular septum resulting in pulmonary outflow tract obstruction in congenitally corrected transposition of the great arteries. Am Heart J 1997;133:112–9. 4. Zurick AO, Menon V. Dynamic outflow tract obstruction in congenitally corrected transposition of the great arteries. Int J Cardiovasc Imaging 2010;26:617–9. 5. Van Son JAM, Danielson GK, Huhta JC, et al. Late results of systemic atrioventricular valve replacement in corrected transposition. J Thorac Cardiovasc Surg 1995;109:642–53. 6. Bogers AJ, Head SJ, de Jong PL, Witsenburg M, Kappetein AP. Long term follow up after surgery in congenitally corrected transposition of the great arteries with a right ventricle in the systemic circulation. J Cardiothorac Surg 2010;5:74. 7. Scherptong RWC, Vliegen HW, Winter MM, et al. Tricuspid valve surgery in adults with a dysfunctional systemic right ventricle: repair or replace? Circulation 2009;119:1467–72. 8. Sherrid MV, Gunsburg DZ, Moldenhauer S, Pearle G. Systolic anterior motion begins at low left ventricular outflow tract velocity in obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 2000;36:1344–54.
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thoracolaparoscopic esophagectomy by the use of endoscopic intrathoracic anastomosis. (Ann Thorac Surg 2016;101:1581–4) Ó 2016 by The Society of Thoracic Surgeons
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sophageal cancer is the eighth most common malignancy and the sixth most common cause of cancerrelated deaths on a global scale [1]. Esophagectomy is the preferred treatment for esophageal cancer because it provides the greatest possibility of a cure, and it is also the best palliative treatment for dysphagia. Minimally invasive esophagectomy is now accepted as a standard treatment modality for resectable esophageal cancer, and the advantages of minimally invasive techniques over open surgical techniques have been discussed previously [2, 3]. Upper gastrointestinal (GI) bleeding is one of the common postoperative adverse events of esophagectomy, and it has been reported to occur in 0.3% of patients [4]. However, there are very few literature reports on the management of early upper GI bleeding after an esophagectomy. Here we report the use of titanium endoscopic clips to successfully manage early postoperative GI bleeding. The patient was a 62-year-old man who received a diagnosis of esophageal carcinoma in the middle segment of the esophagus. Multiple biopsy specimens were taken, and the results showed high-grade intraepithelial neoplasia with carcinoma in a portion of the lesion. We performed a thoracolaparoscopic esophagectomy with intrathoracic anastomosis [5]. The procedure was completed smoothly, and intraoperative blood loss was about 50 mL. The postoperative staging was T1N0M0. On postoperative day 1, the patient developed experienced hematemesis, and his GI decompression tube drained large amounts of dark bloody fluid. A roentgenogram of the chest showed a distended intrathoracic stomach (Fig 1). The patient was treated initially with blood transfusion, omeprazole (8 mg/h), a hemostatic agent, and gastric lavage with ice water containing epinephrine, but his condition failed to improve. Forty-eight hours after the operation, with the approval of our hospital ethics committee, we performed gastroscopic bleeding control with the patient under general anesthesia. Many large blood clots were found in the esophagus and thoracic gastric conduit. After these clots were removed by repeated flushing, two oozing spots were identified at the distal stump of the thoracic gastric conduit, close to the pylorus (Figs 2, 3). These bleeding sites were sealed endoscopically with four titanium clips (Long Clip, Olympus, Japan) (Fig 4). After the endoscopic clipping, the hematemesis ceased, and the gastric drainage started to become clear. A roentgenogram of the chest revealed a normal
Fig 1. Roentgenogram of the chest showing a distended intrathoracic stomach after minimally invasive Ivor-Lewis esophagectomy.
intrathoracic stomach (Fig 5). No anastomotic or stump leakage was found in the GI tract by lipiodol-water imaging. The patient was discharged 2 weeks after the procedure. At the 1-year postoperative follow-up visit, he
Accepted for publication March 10, 2015. *Ren-Quan Zhang and Ning-Ning Kang contributed equally to this study. Address correspondence to Dr Wan, Department of Thoracic Surgery, First Affiliated Hospital of Anhui Medical University, 218 Jixi Rd, Hefei City, Anhui Province, 230022, China; email:
[email protected].
Fig 2. Endoscopic view showing two oozing spots at the distal stump of the thoracic gastric conduit, close to the pylorus.
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Fig 4. Endoscopic view of bleeding spots sealed with four titanium clips.
Fig 3. Diagram of bleeding spots at the distal stump of the thoracic gastric conduit, close to the pylorus.
was able to eat without difficulty or discomfort, and his gastroscopy showed a normal anastomosis and gastric stump.
Comment Acute upper GI bleeding is a common clinical emergency that entails a significant health and economic burden. In spite of new diagnostic modalities and endoscopic therapeutic interventions, the mortality rate has remained unchanged at around 10% [6]. Early postoperative upper GI bleeding may develop after an esophagectomy, particularly with intrathoracic anastomosis, resulting from a stress-induced ulcer or mechanical anastomotic failure. The bleeding may be located at the anastomosis, the stump of the thoracic gastric conduit, or the wall of the stomach remnant. Many mechanical factors can lead to postoperative bleeding, and they are difficult to differentiate clinically. The vessels may not be completely closed and sealed when the tissues are stapled. Sometimes stitches may penetrate vessels when
Fig 5. Roentgenogram of the chest 48 hours after endoscopic treatment for bleeding, showing a normal intrathoracic stomach.
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the anastomosis or the remnant stomach is embedded with the use of manual sutures. Endoscopic bleeding control with titanium clips is commonly used for the management of upper GI
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bleeding in nonsurgical patients [7]. However, this approach is considered risky in patients with early GI bleeding after an esophagectomy, because these patients are in critical condition. There is also some concern that endoscopic bleeding control with clips in the early postoperative period may disrupt or break down the anastomosis. Thus, there are few literature reports on the endoscopic treatment of early upper GI bleeding after esophagectomy. However, one benefit of endoscopy in such a situation is that the diagnosis and treatment can be done simultaneously in some patients. Some reports indicate that bleeding within 48 hours after operation in a patient with a stable hematocrit generally resolves with conservative management [8]. Our limited experience suggests that early upper GI bleeding after esophagectomy may be managed conservatively during the first 24 hours. If the patient’s condition fails to improve, gastroscopic bleeding control can be attempted once the patient’s condition is stabilized after active blood transfusion, fluid replacement, and antishock treatment have been applied. During endoscopic bleeding management, efforts must be made to avoid injury to the anastomosis or gastric conduit. Although there is still some hesitation to use endoscopy after esophagectomy, this treatment might be safe and effective in controlling postoperative upper GI bleeding. In addition, the use of endoscopic techniques as an initial management of postoperative GI hemorrhage after esophagectomy may help to avoid a second surgical operation. In conclusion, endoscopic management using titanium clips is effective for control of early upper GI bleeding after minimally invasive Ivor-Lewis esophagectomy.
References 1. Ministry of Health of the People’s Republic of China: China Health Statistical Yearbook. Beijing: Peking Union Medical College Publishing House; 2009:254. 2. Dolan JP, Kaur T, Diggs BS, et al. Impact of comorbidity on outcomes and overall survival after open and minimally invasive esophagectomy for locally advanced esophageal cancer. Surg Endosc 2013;27:4094–103. 3. Smithers BM, Gotley DC, Martin I, et al. Comparison of the outcomes between open and minimally invasive esophagectomy. Ann Surg 2007;245:232–40. 4. Kun L, Yun JW, Qing S, et al. Emergency reoperation for postoperative hemorrhage following partial esophagectomy for carcinoma of the esophagus and cardia of the stomach. J Dis Esophagus 2001;14:251–3. 5. Zhang RQ, Xia WL, Kang NN, et al. Pursestring stapled anastomotic technique for minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg 2012;94:2133–5. 6. Gado AS, Ebeid BA, Abdelmohsen AM, et al. Clinical outcome of acute upper gastrointestinal hemorrhage among patients admitted to a government hospital in Egypt. Saudi J Gastroenterol 2012;18:34–9. 7. Kato M, Jung Y, Gromski MA, et al. Prospective, randomized comparison of 3 different hemoclips for the treatment of acute upper GI hemorrhage in an established experimental setting. Gastrointest Endosc 2012;75:3–10. 8. Nguyen NT, Longoria M, Chalifoux S, Wilson SE. Gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 2004;14:1308–12. Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
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Minimally Invasive Surgical Repair for Congenital Bronchobiliary Fistula in an Adult Kwon Joong Na, MD, Joon Chul Jung, MD, Yoohwa Hwang, MD, Hyun Joo Lee, MD, PhD, In Kyu Park, MD, PhD, Chang Hyun Kang, MD, PhD, Jin-Young Jang, MD, PhD, and Young Tae Kim, MD, PhD Departments of Thoracic and Cardiovascular Surgery and General Surgery, Seoul National University Hospital, Seoul National University, Seoul; and Cancer Research Institute, Seoul National University, College of Medicine, Seoul, South Korea
Congenital bronchobiliary fistula (CBBF) is a very rare disease and usually requires surgical intervention at a young age. We report a case of CBBF in an adult who was treated successfully with a minimally invasive endoscopic operation. (Ann Thorac Surg 2016;101:1584–7) Ó 2016 by The Society of Thoracic Surgeons ongenital bronchobiliary fistula (CBBF) is a very rare disease that needs surgical resection for successful treatment. There have been very few reports of CBBF in adults, and all the patients underwent surgical resection of the fistula concomitant with pulmonary resection through a thoracotomy [1]. We report an 18-year-old man with CBBF who was successfully treated with a minimally invasive operation. To our knowledge, this is the first report of CBBF treated with a minimally invasive technique.
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An 18-year-old male patient visited our center for recurrent pneumonia and bilioptysis. At the age of 17 years, he was diagnosed with CBBF at another hospital after chest computed tomography (CT) and bronchoscopy. Subsequently, he underwent several attempts at endoscopic sphincterectomy and an endoscopic retrograde biliary drainage procedure. However, there was no improvement of symptoms, and he visited our center for surgical intervention. We decided to perform surgical resection of the fistula. Preoperative CT demonstrated an accessory bronchus originating from the right main bronchus (RMB) and connecting to the left hepatic duct (LHD). There were typical findings suggesting CBBF, which included air density in the LHD system and multiple pneumonic consolidations in the right middle and lower lobes (Figs 1A, 1B). Preoperative bronchoscopy revealed an orifice of the accessory bronchus on the medial wall of the RMB (Fig 1C). Because CBBF is known to be associated with malformations of the biliary tract system, we
Accepted for publication May 15, 2015. Address correspondence to Dr Kim, Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-gu, Seoul, 110-744, South Korea; email:
[email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.05.126
