Tension enterothorax
London, UK
* E-mail: combeer{at}doctors.org.uk
Editor—Diaphragmatic herniation of abdominal contents is a recognized complication of transhiatal surgery. We report a case of late tension enterothorax after an Ivor Lewis oesophagectomy complicated and exacerbated by massive haemorrhage into the herniated bowel.
A 61-yr-old man presented with sudden onset severe abdominal pain, initially epigastric in origin but rapidly spreading to the whole abdomen. He had an Ivor Lewis oesophagectomy 10 months previously for adenocarcinoma. Significant examination findings were tachycardia (98 beats min–1), hypertension 142/114 mm Hg, and capillary refill time 5 s. Initial investigations revealed haemoglobin (Hb) of 14.6 g dl–1, white cell count 26.3x10–9 litre–1, and a metabolic acidosis with pH 7.3, base deficit 4.9 mmol litre–1, and lactate 2.9 mmol litre–1. Chest X-ray showed some shadowing in the left lower and mid-zones. Abdominal X-ray was unremarkable. Before further imaging with an abdominal CT scan, his condition deteriorated and his pulse rose to 110 beats min–1 and arterial pressure dropped to 80/40 mm Hg. His Hb was noted to have decreased to 6.8 g dl–1. His neck veins had become distended and a central venous catheter was easily inserted. It was thought at this stage that he was having a massive gastrointestinal haemorrhage, transfusion of blood commenced, and upper gastrointestinal endoscopy performed which demonstrated absence of bleeding down to the third part of the duodenum. By the end of the endoscopy, his Hb had dropped further to 5.8 g dl–1, despite transfusion of 4 units of packed red cells. A left upper quadrant mass was now apparent and a ruptured spleen or splenic artery aneurysm was suspected.
He was transferred to theatre for a laparotomy where anaesthesia was induced with a modified rapid sequence induction with propofol 20 mg, alfentanil 500 µg, and rocuronium 50 mg and the trachea intubated. His systolic pressure fell to 40 mm Hg requiring an initial bolus of adrenaline 500 µg followed by an infusion of 0.5 µg kg–1 min–1. Gelofusine, blood, and fresh frozen plasma infusions, guided by laboratory results, were given with the adrenaline to maintain a mean arterial pressure above 65 mm Hg. Laparotomy revealed no intra-abdominal bleeding but a bulging left hemidiaphragm through which blood was aspirated. A new diagnosis of ruptured thoracic aneurysm was made and the patient's abdomen was closed and he was transferred for a thoracic CT scan with contrast which revealed a tension enterothorax with mediastinal shift to the right side (Fig. 1). Thoracotomy revealed hugely dilated loops of infarcted small bowel with associated haemorrhage. The herniated bowel was reduced and infarcted bowel resected. The adrenaline requirement immediately decreased to 0.1 µg kg–1 min–1 upon opening the chest. Ventilation was maintained via a single lumen tube throughout the whole procedure and anaesthesia maintained with sevoflurane in oxygen to maintain MAC 0.8–1.0. Ventilation pressures were unfortunately not recorded during the procedures and arterial blood gases at the start of the thoracotomy, with FIO2 1.0, were pH 6.98, PaCO2 9.94 kPa, PaO2 41.3 kPa, base deficit 13.1 mmol litre–1, lactate 7.7 mmol litre–1. After operation, he was transferred to the intensive care unit where inotropic and ventilatory support were successfully weaned and his trachea was extubated 30 h after operation.
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Diaphragmatic herniation after oesophagectomy is an uncommon occurrence with a reported frequency of 0.4–2%1 2 and can be early or late, symptomatic or asymptomatic. The only significant factor for diaphragmatic herniation is extended enlargement of the hiatus at the original operation.2 The colon is more likely to herniate.1 Once within the thoracic cavity, the herniated contents will stay there due to the transdiaphragmatic pressure gradient. We could find no reports in the literature of tension enterothorax complicated and exacerbated by gastrointestinal haemorrhage after oesophagectomy.
Symptomatic diaphragmatic hernia can present with acute abdominal pain, signs of intestinal obstruction or respiratory distress.3–5 There was a delay in diagnosis in our patient due to the lack of obvious bowel loops on the preoperative chest X-ray. Initial herniation and strangulation probably caused the sudden onset pain; the massive haemorrhage then exacerbated the situation and caused the tension enterothorax and cardiovascular instability. For the symptomatic patient requiring operation, anaesthesia and surgery carry high rates of morbidity and mortality.2
Anaesthetic management should be similar to that for any patient requiring high-risk thoracic surgery with associated haemorrhage. Reduction of a diaphragmatic hernia will usually require a thoracotomy and therefore insertion of a double-lumen endotracheal tube (DLT) should be considered. We were able to ventilate the lungs via a single lumen endotracheal tube as no intrathoracic dissection was anticipated by the surgeon. A double lumen tube could have been inserted or a bronchial blocker or endobronchial intubation used if one lung ventilation (OLV) were required. We believe that by avoiding OLV, we prevented an increase in shunt fraction once the tension enterothorax was decompressed and therefore avoided further problems with respect to oxygenation in a compromised patient. It has been advised that in cases of herniated abdominal contents that a DLT should always be used to avoid ventilation of the collapsed lung and therefore exacerbating the mass effect and cardiovascular instability,4 but in our patient the combination of strangulated, dilated bowel, and gastrointestinal haemorrhage kept the left lung collapsed to such an extent that the pressures we used to ventilate the lungs could not overcome the pressure in the left hemithorax.
In conclusion, diaphragmatic herniation after oesophagectomy is rare and can lead to life-threatening complications. It should be considered in any patient with acute abdominal pain and a previous history of transhiatal surgery.
References
1 Heitmiller RF, Gillinov M, Jones B. Transhiatal herniation of colon after esophagectomy and gastric pull-up. Ann Thorac Surg (1997) 63:554–6.
2 van Sandick JW, Knegjens JJ, van Lanschot JJB, Obertop H. Diaphragmatic herniation following oesophagectomy. Br J Surg (1999) 86:109–12.[CrossRef][Web of Science][Medline]
3 Hamaloglu E, Topaloglu S, Törer N. Diaphragmatic herniation after transhiatal esophagectomy. Dis Esophagus (2002) 15:186–8.[CrossRef][Web of Science][Medline]
4 Williams DJ, Sandby-Thomas MGF. Anaesthetic management of acute gastric volvulus in an adult. Br J Anaesth (2003) 90:96–8.
5 Fumagalli U, Rosati R, Caputo M, et al. Diaphragmatic acute massive herniation after laparoscopic gastroplasty for esophagectomy. Dis Esophagus (2006) 19:40–3.[CrossRef][Web of Science][Medline]
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