Oct 31, 2017 - Postoperative Acute Tension Gastrothorax Mimicking Tension ... when the stomach herniates through the diaphragm secondary to trauma or a.
Cardiothoracic Surgery SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM
Postoperative Acute Tension Gastrothorax Mimicking Tension Pneumothorax Joshua Wong* Supriya Gupta Jayanth Keshavamurthy and Norman Thomson Medical College of Georgia, Augusta, GA INTRODUCTION: Hiatal hernia is a common disorder typically repaired laparoscopically. As with all invasive procedures, complications may occur postoperatively. The following case describes tension gastrothorax, initially misdiagnosed as a tension pneumothorax, as a rare acute complication of hiatal hernia repair.
CARDIOTHORACIC SURGERY
CASE PRESENTATION: A 64-year-old female with type III paraesophageal hernia underwent laparoscopic repair. On postoperative day 1, the patient developed acute respiratory distress. Chest X-ray showed a large air-fluid collection in the left hemithorax with concerns for tension pneumothorax (fig. 1). Two tube thoracotomies were placed without improvement in status. A nasogastric tube was placed and visualized at the mid mediastinum just below the level of the carina (fig. 2). CT scan with contrast demonstrated the entire stomach in the chest without volvulus and with adequate blood flow. During laparoscopic repair, crural sutures were observed to be intact but some tearing of the crus was noted. The fundus of the stomach had dehisced the previous fundoplication, herniating into the chest. Although multiple areas of the stomach appeared ischemic, no areas of necrosis were seen. Fundoplication was redone and gastronomy tube was placed and secured. Chest X-ray visualized good lung expansion. DISCUSSION: Tension gastrothorax occurs when the stomach herniates through the diaphragm secondary to trauma or a congenital defect into the thoracic cavity. This compresses the lung and other structures in the mediastinum causing the patient to present with respiratory distress or hemodynamic instability, mimicking the clinical presentation of a pneumothorax [2]. Hence, a high clinical suspicion of gastrothorax should be considered for patients undergoing surgeries involving the diaphragm. On chest X-ray, gastrothorax may be mistaken for pneumothorax. Findings suggestive of gastrothorax include gas bubbles, air-fluid levels within a mass, compression atelectasis of the lower lobe, or irregularities of the diaphragm [3]. CT with contrast clarifies the position of the stomach providing a clear diagnosis. Current literature recommends that initial management of tension gastrothorax begin with decompression via a nasogastric tube to alleviate symptoms before surgery for definitive repair [1, 2]. CONCLUSIONS: Tension gastrothorax is a rare postoperative complication which should be considered in patients with respiratory distress following interventions involving the diaphragm. Reference #1: Nishijima D, Zehbtachi S, Austin R. Acute posttraumatic tension gastrothorax mimicking acute tension pneumothorax. The American Journal Of Emergency Medicine. 2007;25(6):734.e5-6. Reference #2: Tadler S, Burton J. Intrathoracic stomach presenting as acute tension gastrothorax. The American Journal Of Emergency Medicine. 1999;17(4):370-371. Reference #3: Takahiro S, et al. A survival case of tension gastrothorax due to hiatal hernia, the key of saving is thoracotomy. American Journal Of Emergency Medicine. 2017;35(1):e3. DISCLOSURE: The following authors have nothing to disclose: Joshua Wong, Supriya Gupta, Jayanth Keshavamurthy, Norman Thomson No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.063
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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