Gastropleural fistula due to gastric perforation after lobectomy for lung cancer
http://www.100md.com
《血管的通路杂志》
a Department of Thoracic Surgery, Toneyama National Hospital, Toneyama 5-1-1 Toyonaka, Osaka 560-8552, Japan
b Department of Surgery, Osaka Koseinenkin Hospital, Fukushima 4-4-1, Osaka 553-0003, Japan
Abstract
We report a case of acute gastropleural fistula due to gastric perforation after a left lower lobectomy for lung cancer. A 76-year-old male, who received a left hemicolectomy 20 years previously, came to our hospital for surgical treatment of lung cancer, which was performed uneventfully as a left lower lobectomy with combined resection of the diaphragm. On the postoperative day 2, acute dilatation of the stomach followed by gradual cardiopulmonary collapse, and then gastric perforation into the thorax occurred. The perforated stomach wall and diaphragm became paper-thin and necrotic, though the abdominal cavity was free of contamination. This life-threatening condition was treated by an emergency thoracotomy and partial gastrectomy through the thorax, as the left hemidiaphragm was remarkably elevated. An oeganoaxial torsion gastric volvulus caused by anatomic rotation following the lobectomy was speculated as the disease process, with loss of suspended tissue of the gastro-colic ligament from the left hemicolectomy being a possible predisposing factor. Such an episode is rare, however, it should be looked for during perioperative care following a lobectomy.
Key Words: Gastric volvulus; Acute gastropleural fistula; Lobectomy
1. Introduction
In the stomach gastric necrosis and perforation are extremely uncommon because of a rich blood supply [1]. Further acute gastric volvulus is a rare, though potentially life-threatening condition that requires proper and immediate surgical intervention [2,3]. Recently, operative morbidity and mortality of lobectomy for lung cancer have become satisfactorily low, though, unrecognized complication may occur despite the sophisticated perioperative care and surgical techniques. We herein report a case of gastric perforation into the thoracic cavity following left lower lobectomy, discussing the etiology and clinical disease entity.
2. Case report
A 76-year-old man was admitted to the Toneyama National Hospital for surgical treatment of lung cancer in the left lower lobe adjacent to the diaphragm. Twenty years previously, he received a left hemicolectomy for colon cancer. A chest X-ray and chest computed tomography (CT) image showed a well-circumscribed rounded mass 6 cm in size in the left lower lobe at stage cT3N0. A scheduled operation was performed, and the left lower lobectomy with combined resection of the membranous portion of the diaphragm (3x3 cm in size) was performed successfully. On the second postoperative day, the patient showed acute dilatation of the stomach with minimum abdominal symptoms, shown in Fig. 1, and we were unable to advance the nasogastric tube into the stomach to decompress the acute dilatation. Soon, respiratory distress increased, and the patient was placed on mechanical ventilation with circulatory support. However, he fell into cardiopulmonary collapse with lactic acidosis. Suddenly the patient developed shock status and massive gastric juice was pulled from the chest tube, after which an emergency thoracotomy was performed. During the surgical exploration, a 5x5 cm defect in the wall of the stomach and diaphragm was found in the muscular part of the posterior diaphragm (Fig. 2), which had become paper-thin and totally necrotic. The location of the defect was different from the site of the combined resection at initial surgery. The esophago-gastric junction was palpated by inserting a finger from the defect. Due to elevation of the diaphragm the operative approach was easily performed via a thoracotomy through the fourth intercostal space. The necrotic gastric fundus was widely resected by repositioning the stomach, and the diaphragm was plicated. Following the thoracic approach, a laparotomy was performed, which showed the abdominal cavity to be free of contamination from gastric perforation. When the emergency procedure was finished, the patient recovered rapidly, and mechanical ventilatory support was discontinued 24 h later. Although leakage developed 2 weeks after surgery, which was repaired through laparotomy followed by curing of empyema, the patient was discharged 3 months after the initial surgery.
3. Discussion
We unexpectedly encountered a gastric perforation of the thorax, a life-threatening complication, following a lobectomy for lung cancer, which has not been reported in English literature. A rich blood supply usually protects the stomach from ischemia, even in cases of acute dilatation [1]. However, in the present patient, gastric necrosis rapidly progressed into cardiopulmonary collapse. We speculated that the mechanism of acute gastric perforation following the lobectomy was likely to be acute gastric volvulus. In contrast to gastric dilatation after surgery, gastric volvulus is an extremely rare condition that results in a catastrophic outcome unless prompt surgical intervention is employed [2,3]. Including cases with children [3], the most common encountered patterns of gastric volvulus can be classified into 2 types, organoaxial torsion and meso-enteroaxial torsion, and we considered the present case to be categorized into organoaxial type, which is apt to cause strangulation [2]. Typical symptomatic features were observed, including minimum abdominal findings when the volvulized stomach was in an intrathoracic position, a gas-filled viscous in the lower chest and upper abdomen shown by the chest radiograph images, and obstruction at the site of the volvulus demonstrated by an emergency upper gastrointestinal series.
Several predisposing factors have been considered for the condition, including alternations of gastrosplenic, gastrophrenic, and gastrocolic ligament, and diaphragmatic eventration [4]. In particular, loss or hyperlaxity of the peritoneal attachment, or diaphragmatic eventration may be primary contributors. A distinctive case report of gastric volvulus after a coronary bypass procedure has been published [5], which was caused in that patient by a release of the greater curvature for use of the right gastroepiploic artery. In the present case, we speculated a similar mechanism, that is the division of the gastrocolic ligament for the left colectomy, namely an abnormal ligamentous laxity, was a predisposing factor, while the left lower lobectomy might have induced an elevation of left hemidiaphragm, causing the stomach to undergo an organoaxial twist. Thoracic surgeons should keep in mind that a change in thoracic configuration following left lung resection can affect the configuration of the abdominal organs when their suspension apparatus is impaired.
References
Turan M, Sen M, Canbay E, Karadayi K, Yildiz E. Gastric necrosis and perforation caused by acute gastric dilatation: report of a case. Surg Today 2003;33:302–304.
Carter R, Brewer LA 3rd, Hinshaw DB. Acute gastric volvulus. A study of 25 cases. Am J Surg 1980;140:99–106.
Wasselle JA, Norman J. Acute gastric volvulus: pathogenesis, diagnosis, and treatment. Am J Gastroenterol 1993;88:1780–1784.
Oh A, Gulati G, Sherman ML, Golub R, Kutin N. Bilateral eventration of the diaphragm with perforated gastric volvulus in an adolescent. J Pediatr Surg 2000;35:1824–1826.
Michel LA, Buche M, de Canniere L, Chenu P. Gastric volvulus after coronary bypass. Lancet 1997;349:251.(Shin-ichi Takeda, Soichir)
b Department of Surgery, Osaka Koseinenkin Hospital, Fukushima 4-4-1, Osaka 553-0003, Japan
Abstract
We report a case of acute gastropleural fistula due to gastric perforation after a left lower lobectomy for lung cancer. A 76-year-old male, who received a left hemicolectomy 20 years previously, came to our hospital for surgical treatment of lung cancer, which was performed uneventfully as a left lower lobectomy with combined resection of the diaphragm. On the postoperative day 2, acute dilatation of the stomach followed by gradual cardiopulmonary collapse, and then gastric perforation into the thorax occurred. The perforated stomach wall and diaphragm became paper-thin and necrotic, though the abdominal cavity was free of contamination. This life-threatening condition was treated by an emergency thoracotomy and partial gastrectomy through the thorax, as the left hemidiaphragm was remarkably elevated. An oeganoaxial torsion gastric volvulus caused by anatomic rotation following the lobectomy was speculated as the disease process, with loss of suspended tissue of the gastro-colic ligament from the left hemicolectomy being a possible predisposing factor. Such an episode is rare, however, it should be looked for during perioperative care following a lobectomy.
Key Words: Gastric volvulus; Acute gastropleural fistula; Lobectomy
1. Introduction
In the stomach gastric necrosis and perforation are extremely uncommon because of a rich blood supply [1]. Further acute gastric volvulus is a rare, though potentially life-threatening condition that requires proper and immediate surgical intervention [2,3]. Recently, operative morbidity and mortality of lobectomy for lung cancer have become satisfactorily low, though, unrecognized complication may occur despite the sophisticated perioperative care and surgical techniques. We herein report a case of gastric perforation into the thoracic cavity following left lower lobectomy, discussing the etiology and clinical disease entity.
2. Case report
A 76-year-old man was admitted to the Toneyama National Hospital for surgical treatment of lung cancer in the left lower lobe adjacent to the diaphragm. Twenty years previously, he received a left hemicolectomy for colon cancer. A chest X-ray and chest computed tomography (CT) image showed a well-circumscribed rounded mass 6 cm in size in the left lower lobe at stage cT3N0. A scheduled operation was performed, and the left lower lobectomy with combined resection of the membranous portion of the diaphragm (3x3 cm in size) was performed successfully. On the second postoperative day, the patient showed acute dilatation of the stomach with minimum abdominal symptoms, shown in Fig. 1, and we were unable to advance the nasogastric tube into the stomach to decompress the acute dilatation. Soon, respiratory distress increased, and the patient was placed on mechanical ventilation with circulatory support. However, he fell into cardiopulmonary collapse with lactic acidosis. Suddenly the patient developed shock status and massive gastric juice was pulled from the chest tube, after which an emergency thoracotomy was performed. During the surgical exploration, a 5x5 cm defect in the wall of the stomach and diaphragm was found in the muscular part of the posterior diaphragm (Fig. 2), which had become paper-thin and totally necrotic. The location of the defect was different from the site of the combined resection at initial surgery. The esophago-gastric junction was palpated by inserting a finger from the defect. Due to elevation of the diaphragm the operative approach was easily performed via a thoracotomy through the fourth intercostal space. The necrotic gastric fundus was widely resected by repositioning the stomach, and the diaphragm was plicated. Following the thoracic approach, a laparotomy was performed, which showed the abdominal cavity to be free of contamination from gastric perforation. When the emergency procedure was finished, the patient recovered rapidly, and mechanical ventilatory support was discontinued 24 h later. Although leakage developed 2 weeks after surgery, which was repaired through laparotomy followed by curing of empyema, the patient was discharged 3 months after the initial surgery.
3. Discussion
We unexpectedly encountered a gastric perforation of the thorax, a life-threatening complication, following a lobectomy for lung cancer, which has not been reported in English literature. A rich blood supply usually protects the stomach from ischemia, even in cases of acute dilatation [1]. However, in the present patient, gastric necrosis rapidly progressed into cardiopulmonary collapse. We speculated that the mechanism of acute gastric perforation following the lobectomy was likely to be acute gastric volvulus. In contrast to gastric dilatation after surgery, gastric volvulus is an extremely rare condition that results in a catastrophic outcome unless prompt surgical intervention is employed [2,3]. Including cases with children [3], the most common encountered patterns of gastric volvulus can be classified into 2 types, organoaxial torsion and meso-enteroaxial torsion, and we considered the present case to be categorized into organoaxial type, which is apt to cause strangulation [2]. Typical symptomatic features were observed, including minimum abdominal findings when the volvulized stomach was in an intrathoracic position, a gas-filled viscous in the lower chest and upper abdomen shown by the chest radiograph images, and obstruction at the site of the volvulus demonstrated by an emergency upper gastrointestinal series.
Several predisposing factors have been considered for the condition, including alternations of gastrosplenic, gastrophrenic, and gastrocolic ligament, and diaphragmatic eventration [4]. In particular, loss or hyperlaxity of the peritoneal attachment, or diaphragmatic eventration may be primary contributors. A distinctive case report of gastric volvulus after a coronary bypass procedure has been published [5], which was caused in that patient by a release of the greater curvature for use of the right gastroepiploic artery. In the present case, we speculated a similar mechanism, that is the division of the gastrocolic ligament for the left colectomy, namely an abnormal ligamentous laxity, was a predisposing factor, while the left lower lobectomy might have induced an elevation of left hemidiaphragm, causing the stomach to undergo an organoaxial twist. Thoracic surgeons should keep in mind that a change in thoracic configuration following left lung resection can affect the configuration of the abdominal organs when their suspension apparatus is impaired.
References
Turan M, Sen M, Canbay E, Karadayi K, Yildiz E. Gastric necrosis and perforation caused by acute gastric dilatation: report of a case. Surg Today 2003;33:302–304.
Carter R, Brewer LA 3rd, Hinshaw DB. Acute gastric volvulus. A study of 25 cases. Am J Surg 1980;140:99–106.
Wasselle JA, Norman J. Acute gastric volvulus: pathogenesis, diagnosis, and treatment. Am J Gastroenterol 1993;88:1780–1784.
Oh A, Gulati G, Sherman ML, Golub R, Kutin N. Bilateral eventration of the diaphragm with perforated gastric volvulus in an adolescent. J Pediatr Surg 2000;35:1824–1826.
Michel LA, Buche M, de Canniere L, Chenu P. Gastric volvulus after coronary bypass. Lancet 1997;349:251.(Shin-ichi Takeda, Soichir)