Aoyama Shu, Miyazaki Yasuhiro, Motoori Masaaki, Hirota Masashi, Itami Takefumi, Matsumoto Sayaka, Hirano Masataka, Aomatsu Michihiro, Goto Takasumi, Kitahara Mutsunori, Ozato Yuki, Nishizawa Yujiro, Komatsu Hisateru, Inoue Akira, Kagawa Yoshinori, Tomokuni Akira, Iwase Kazuhiro, Nishi Hiroyuki, Fujitani Kazumasa
Department of Gastroenterological Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, Japan.
Department of Cardiovascular Surgery, Osaka General Medical Center, Osaka, Japan.
Surg Case Rep. 2024 Feb 28;10(1):48. doi: 10.1186/s40792-024-01850-9.
Cardiac tamponade is a rare postoperative complication of esophageal cancer surgery, which leads to rapid hemodynamic changes and can be fatal if not treated properly and promptly. Herein, we report a case of cardiac tamponade after thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution for esophageal cancer that was successfully treated with surgical drainage.
An 86-year-old man with lower thoracic esophageal cancer underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution. No intra-operative complications were observed. On the first postoperative day, tachycardia and hypotension were observed, and pericardial effusion was identified on computed tomography images. The patient was diagnosed with obstructive shock secondary to cardiac tamponade. As percutaneous puncture drainage was not possible due to the presence of a retrosternal gastric tube, pericardiotomy with a small left anterior thoracotomy was performed, and a large amount of hematogenous fluid was drained, which instantly improved circulation. On the second postoperative day, the patient showed decreased pulse pressure, and computed tomography revealed a residual and enlarged hematoma around the right ventricle. The patient underwent surgical drainage and another pericardiotomy with a small right anterior thoracotomy was performed to drain the hematoma. At this time, multiple injuries to the fatty tissue, epicardium, and myocardium with active bleeding were observed on the anterior surface of the right ventricle near the root of the pulmonary artery. In this patient, the ascending aorta ran further to the right and dorsal sides than usual, causing the anterior wall of the right ventricle near the root of the pulmonary artery to be closer to the back of the sternum. This abnormality may have contributed to injury during the creation of the retrosternal pathway, leading to cardiac tamponade.
Cardiac tamponade after esophagectomy can occur because of manipulation during creation of the retrosternal route, with an anomaly in the aortic position being present in this case. Gentle manipulation and selection of the reconstruction route according to the patient's condition are necessary in cases with such anatomical abnormalities.
心脏压塞是食管癌手术后罕见的并发症，可导致快速的血流动力学变化，若未得到及时恰当治疗可能致命。在此，我们报告一例食管癌胸腔镜下食管次全切除术及胸骨后胃管重建术后发生心脏压塞的病例，该病例通过手术引流成功治愈。
一名86岁的胸段下段食管癌男性患者接受了胸腔镜下食管次全切除术及胸骨后胃管重建术。术中未观察到并发症。术后第一天，观察到心动过速和低血压，计算机断层扫描图像显示有心包积液。患者被诊断为心脏压塞继发梗阻性休克。由于存在胸骨后胃管，无法进行经皮穿刺引流，遂行左前胸部小切口心包切开术，引出大量血性液体，循环立即得到改善。术后第二天，患者脉压降低，计算机断层扫描显示右心室周围有残留且增大的血肿。患者接受手术引流，并再次行右前胸部小切口心包切开术以引流血肿。此时，在肺动脉根部附近的右心室前表面观察到脂肪组织、心外膜和心肌多处损伤并有活动性出血。在该患者中，升主动脉比平时更偏向右侧和背侧走行，导致肺动脉根部附近的右心室前壁更靠近胸骨后方。这种异常可能在胸骨后路径创建过程中导致了损伤，进而引发心脏压塞。
食管切除术后心脏压塞可能由于胸骨后路径创建过程中的操作引起，本病例存在主动脉位置异常。对于存在此类解剖异常的病例，轻柔操作并根据患者情况选择重建路径很有必要。
