INTRODUCTION: Conduit redundancy and dilatation are well-recognized late sequelae of colon conduit interposition for esophageal reconstruction. We present a rare case of symptomatic cardiac compression secondary to a massively dilated substernal colon conduit. In an era of mixed surgical and medical Intensive care units with medical intensivists taking care of surgical patients, a thorough understanding of surgical emergencies is essential.
CASE PRESENTATION: The patient is a 49-year-old male who underwent substernal colon interposition at 5 years of age for congenital esophageal atresia. He presented with a 24 hour history of inability to swallow, shortness of breath, and a left-sided supraclavicular mass which could not be reduced. He reported transient episodes of similar symptoms over several months prior to this presentation, which had previously resolved after “pushing the left neck mass into the chest”. Physical examination disclosed an apprehensive patient with a systolic blood pressure of 96/62, heart rate of 120, and respiratory rate of 30. Neck exam revealed jugular venous distention and a large tender supraclavicular mass just inferior to the estimated level of the esophagocolonic anastomosis, which was not reducible (figure 1). Laboratory data was remarkable for a white blood cell count of 16,300 and a mild lactate acidemia with an arterial pH of 7.28. Computed tomography showed massive distention of the substernal colon interposition filled with liquid and particulate matter, with secondary compression of the heart, ascending aorta, and right pulmonary artery (figure 2).The patient was emergently taken to operating room for conduit removal. An extended sternotomy incision from the left neck superiorly to the umbilicus inferiorly was utilized for exposure. After sternotomy, the conduit appeared ischemic and massively dilated with liquid and particulate matter. The gastrocolic anastomosis was found to be widely patent however substantially smaller in diameter than the conduit itself. The conduit was removed expeditiously. Immediately after conduit removal, the central venous pressure was noted to drop from 23 mm Hg to 12 mm Hg. Simultaneously, the systolic blood pressure increased by 20 to 30 mm Hg with a decrease in heart rate. A cervical end-esophageal fistula and tube gastrostomy for feeding were established. The patient made an uneventful postoperative recovery and ultimately underwent a substernal gastric reconstruction through a redo sternotomy approach.
DISCUSSIONS: Colon conduit redundancy and dilatation following interposition for esophageal reconstruction ultimately requires surgical intervention in an estimated 8-22% of cases. Commonly reported symptoms include dysphagia, regurgitation, and aspiration. Redundancy with dilatation of colonic interposition conduits in the substernal position may additionally result in retrosternal pain and neck swelling. Based on this patient’s chronic symptoms resulting in this acute event, we speculate that a progressive cycle of increased retention of liquid and particulate matter and ongoing low-grade ischemia led to massive conduit dilatation and secondary cardiac compression. A contributory factor to heart and great vessel compression in this case may have included a relative lack of redundancy into either pleural space as the conduit remained in the substernal position over time. Although a component of sepsis may have contributed to this patient’s overall presentation, the immediate improvement in cardiac hemodynamics following conduit removal is highly suggestive of cardiac compression as the primary pathophysiology. A MEDLINE search of the English speaking literature found only one previous report of cardiac compression attributed to a dilated substernal colon conduit.
CONCLUSION: This patient represents a rare but life threatening complication of cardiac compression resulting from a substernal colonic conduit surgery performed over 40 years ago. Earlier recognition of symptoms in such patients is important, especially for intensivists, as a delay in surgical intervention for cases of impending cardiac compression could be fatal.
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