Interact CardioVasc Thorac Surg 2005;4:168-169. doi:10.1510/icvts.2005.105767
© 2005 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Strangulated intrapericardial herniation of the stomach after use of the right gastroepiploic artery for coronary artery bypass grafting
Yoshifumi Ikeda*,
Shoichi Tobari,
Naomi Morita and
Kota Okinaga
Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
Received 5 January 2005;
received in revised form 1 February 2005;
accepted 2 February 2005
*Correspondinging author. Tel.: +81-3-3964-1228; fax: +81-3-3962-2128.
E-mail address: yikeda{at}med.teikyo-u.ac.jp (Y. Ikeda).
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Abstract
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A 74-year-old woman with coronary artery disease had undergone coronary artery bypass grafting (CABG) with autologous vein grafts in 1999. She subsequently had recurrenct angina and underwent a second CABG in 2001 with the right gastroepiploic artery (GEA). The GEA pedicle was placed anterior to the stomach. In November 2004, the patient was admitted to the emergency room for back pain with nausea and vomiting. A repeat electrocardiogram did not show transient myocardial ischemia. A plain radiograph of the chest revealed the gas-filled dilatation of the stomach with fluid levels in the left base of the thorax. An upper gastrointestinal radiographic series using stomach tube revealed a strangulated intrapericardial gastric hernia. A computed tomographic scan with sagittal plane showed an intrapericardial hernia above the left lobe of the liver. Although herniation of the abdominal contents is a rare complication, it may be preventable. Techniques such as keeping the GEA pedicle small, minimizing the length of the diaphragmatic incision, placing interrupted sutures perpendicular to the musculotendinous fibers of the diaphragm, performing a gastropexy, and reinforcing the diaphragmatic incision with mesh may prevent this complication.
Key Words: Coronary artery bypass grafting; Right gastroepiploic artery; Hernia
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1. Introduction
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The right gastroepiploic artery (GEA) is frequently used as conduit for coronary artery bypass grafting (CABG). There is debate regarding the best route for the GEA pedicle. When the pedicle is placed posterior to the stomach and the liver, a greater length of pedicle is available for conduit to complete the coronary anastomosis. The retrogastric route also minimizes the risk of injury during a subsequent laparotomy, whereas the antegastric, antehepatic route has advantages such as ease of handling, ease of visual inspection for bleeding along the pedicle, and theoretic prevention of transdiaphragmatic herniation of the stomach because the GEA pedicle passes through the diaphragm above the left lobe of the liver [1–4]. We report a rare case of a strangulated intrapericardial herniation of the stomach after GEA for CABG using the antegastric, antehepatic route.
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2. Case report
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A 74-year-old woman with coronary artery disease had undergone CABG with autologous vein grafts to the left anterior descending, obtuse marginal, and right coronary arteries in 1999. She subsequently had recurrent angina and underwent a second CABG in 2001 with the GEA. The GEA pedicle was placed anterior to the stomach.
In November 2004, the patient was admitted to the emergency room for back pain with nausea and vomiting. She also had dyspnea in the supine position. A repeat electrocardiogram did not show transient myocardial ischemia. A plain radiograph of the chest revealed the gas-filled dilatation of the stomach with fluid levels in the left base of the thorax. An upper gastrointestinal radiographic series using stomach tube revealed a strangulated intrapericardial gastric hernia (Fig. 1). A computed tomographic scan with sagittal plane showed an intrapericardial hernia above the left lobe of the liver (Fig. 2). The patient underwent exploration through a subcostalis incision with right semi-lateral position. Two thirds of the patient's stomach and omentum were found in the pericardial sac. They were reduced into the abdominal cavity easily, and no ischemic changes of the stomach wall could be seen. The diaphragmatic defect was repaired with a polytetrafluoroethylene surgical membrane patch, leaving adequate space for the GEA pedicle. She did well in the postoperative period and was discharged a week later.
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Fig. 1. An upper gastrointestinal radiographic series using stomach tube revealed a strangulated intrapericardial gastric hernia.
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Fig. 2. A computed tomographic scan with sagittal plane showed an intrapericardial hernia above the left lobe of the liver.
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3. Discussion
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The possibility of a diaphragmatic hernia through the orifice for the GEA pedicle should be considered whenever a patient with this specific graft has acute abdominal symptoms such as pain, vomiting, hiccups, or a combination of these symptoms. Symptoms of esophagitis are absent, because this type of hernia causes no gastroesophageal reflux. The danger not only of gastric complications such as strangulation, ulceration, bleeding, or even perforation, but also of impairment of the GEA graft with myocardial ischemia or even infarction, indicate surgical treatment. Several factors can theoretically favor the occurrence of a hernia through the diaphragmatic orifice for the GEA graft. One is an excessive orifice having been made too large at the first operation or having widened afterwards. Second, the close apposition of the stomach and the diaphragmatic orifice of a retrohepatically routed GEA graft predisposes theoretically to gastric herniation, in contrast to the anterior route, in which the liver protects against possible gastric herniation [2–4]. The most likely cause of transdiaphragmatic herniation of the stomach in this patient was an overly large window for the GEA pedicle [1]. Factors leading to elevated intraabdominal pressure, such as ascites, obesity, chronic cough, pregnancy, or blunt thoracoabdominal trauma, could not be found in our patient. Because of the adhesion between GEA pedicle and skin incision, second abdominal operation was difficult. To decrease the risk of GEA pedicle injury, surgery through a subcostalis incision with right semi-lateral position was a useful method in this case.
Although herniation of the abdominal contents is a rare complication, it may be preventable. Techniques such as keeping the GEA pedicle small, minimizing the length of the diaphragmatic incision, placing interrupted sutures perpendicular to the musculotendinous fibers of the diaphragm, performing a gastropexy, and reinforcing the diaphragmatic incision with mesh may prevent this complication.
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References
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- Ansari M, Eucher P, De Canniere L. Strangulated giant transdiaphragmatic hernia: a rare complication of coronary artery bypass grafting with the right gastroepiploic artery. J Thorac Cardiovasc Surg 2002;123:358–359.[Free Full Text]
- Manetta F, Moores DW, Bennett EV, Edwards NM. Intrapericardial herniation of the stomach after use of the right gastroepiploic artery for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1998;115:479–480.[Free Full Text]
- Caes FL, Francois B, Van Nooten GJ. Transdiaphragmatic herniation of the stomach after right gastroepiploic artery grafting. J Thorac Cardiovasc Surg 1994;108:191–193.[Free Full Text]
- Pasic M, Carrel T, Von Segesser L, Turina M. Postoperative diaphragmatic hernia after use of the right gastroepiploic artery for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1994;108:189–191.[Free Full Text]
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Abstract
1. Introduction