Case report
Gastric herniation due to rupture of diaphragmatic prosthesis in the postoperative period of pleuropneumonectomy due to mesothelioma: A complication to consider
Herniación gástrica por rotura de prótesis diafragmática en el postoperatorio de pleuroneumonectomía por mesotelioma: una complicación a tener en cuenta
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Alonso-Prieto, D. Pujol, M. Angustias Salmerón, M. de-Ceano Vivas-Lacalle, A. Ortiz Villalobos, M. Martínez Moreno, G. González Morán, R. Torres-Luna, J. Miró, F. Reinoso-Barbero" "autores" => array:10 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Alonso-Prieto" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Pujol" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Angustias Salmerón" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "de-Ceano Vivas-Lacalle" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Ortiz Villalobos" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Martínez Moreno" ] 6 => array:2 [ "nombre" => "G." "apellidos" => "González Morán" ] 7 => array:2 [ "nombre" => "R." "apellidos" => "Torres-Luna" ] 8 => array:2 [ "nombre" => "J." "apellidos" => "Miró" ] 9 => array:2 [ "nombre" => "F." "apellidos" => "Reinoso-Barbero" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935622000032" "doi" => "10.1016/j.redar.2021.12.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935622000032?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000446?idApp=UINPBA00004N" "url" => "/23411929/0000007000000003/v1_202304111726/S2341192923000446/v1_202304111726/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Gastric herniation due to rupture of diaphragmatic prosthesis in the postoperative period of pleuropneumonectomy due to mesothelioma: A complication to consider" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "156" "paginaFinal" => "159" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Cerra-Bergueiro, P. Rama-Maceiras, D. López-López, M. Gestal-Vázquez, M. Diaz-Allegue, M. Delgado-Roel" "autores" => array:6 [ 0 => array:3 [ "nombre" => "D." "apellidos" => "Cerra-Bergueiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "P." "apellidos" => "Rama-Maceiras" "email" => array:1 [ 0 => "pablo.rama.maceiras@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "D." "apellidos" => "López-López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Gestal-Vázquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Diaz-Allegue" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Delgado-Roel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herniación gástrica por rotura de prótesis diafragmática en el postoperatorio de pleuroneumonectomía por mesotelioma: una complicación a tener en cuenta" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 546 "Ancho" => 1250 "Tamanyo" => 91760 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A. Plain chest X-ray image showing a large chamber with hydro-aerial content in the left hemithorax and the nasogastric tube inside. B. Chest computed tomography image confirming the presence of the herniated gastric fundus in the thorax.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Extrapleural pneumonectomy (EPP) is the surgical approach for the treatment of malignant pleural mesothelioma.EPP involves en bloc resection of the visceral and parietal pleura, the ipsilateral lung, the pericardium and the hemidiaphragm<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>, and part of the patient's diaphragm has to be reconstructed with prosthetic material<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Despite meticulous surgical technique, a potentially serious complication is the early postoperative herniation of part of the abdominal contents into the thorax through a defect in the prosthesis with which the diaphragm is repaired. This herniation must be diagnosed and repaired urgently to prevent the herniated contents from undergoing ischaemia and necrosis within the thoracic cavity, resulting in a potentially lethal condition<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. We present the case of a patient who developed an acute gastric hernia into the thoracic cavity following EPP.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 56-year-old man with a medical history of dyslipidaemia and chronic anaemia, as well as radical prostatectomy and nephrectomy for prostate and renal neoplasms. He was being treated with iron, folic acid and pravastatin.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred to our centre with a diagnosis of malignant left pleural mesothelioma for surgical treatment. Apart from the presence of mesothelioma in the imaging tests, the routine preoperative study showed a serum creatinine level of 1.3<span class="elsevierStyleHsp" style=""></span>mg/dl. The patient's preoperative functional capacity was preserved and respiratory function tests showed a forced vital capacity of 3.78<span class="elsevierStyleHsp" style=""></span>l (75.9% of predicted) and a forced expiratory volume in the first second of 2.77<span class="elsevierStyleHsp" style=""></span>l (74% of predicted). A scan revealed a right lung perfusion of 65% and a left lung perfusion of 35%, so the patient was scheduled for left EPP.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the operating theatre, the operation was performed under general anaesthesia and selective one-lung ventilation, by fibrobronchoscopy-guided placement of a double-lumen tube n. 39 and combined with thoracic epidural block (level T5–T6). It consisted of an EPP via video-assisted thoracic surgery approach and left mini-thoracotomy, with en bloc resection of the diaphragm and pericardium. The pericardial defect was repaired with a 1<span class="elsevierStyleHsp" style=""></span>mm thick prosthesis and the diaphragm with a 2<span class="elsevierStyleHsp" style=""></span>mm thick prosthesis (W.L. Gore & associates, Inc, Flagstaff, Arizona, USA), the latter sutured to the remnants of the diaphragmatic pillars, hiatal musculature and chest wall. A nasogastric tube was placed to decompress the stomach and a chest drainage tube with water seal and no suction connection was left in place. The operation, which lasted 5<span class="elsevierStyleHsp" style=""></span>h, was carried out without incident and during it the patient tolerated one-lung ventilation without episodes of desaturation, remained haemodynamically stable and due to moderate bleeding only required the transfusion of a unit of red blood cell concentrate, for which he was extubated in the operating theatre and transferred to the postoperative resuscitation unit.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On admission, the chest X-ray showed correct expansion of the right lung and no filling of the pneumonectomy chamber was observed. In the first postoperative hours the patient presented mild hypotension (88/60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg), which was initially treated with 400<span class="elsevierStyleHsp" style=""></span>ml of fluids and low doses of noradrenaline (up to .05<span class="elsevierStyleHsp" style=""></span>mcg/kg/min), to maintain a systolic<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg and mean<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg blood pressure, with no evidence of signs of hypoperfusion or low output.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Sixteen hours after the operation, the patient reported mild but continuous epigastric pain, not accompanied by nausea, vomiting or vegetative cortex. Pulmonary auscultation revealed hydro-aerial sounds. A chest X-ray showed a chamber with hydro-aerial content in the left hemithorax (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Laboratory tests showed only a slight increase in creatinine to 1.6<span class="elsevierStyleHsp" style=""></span>mg/dl, with normal white blood cell count, lactate level and inflammatory markers (CRP and procalcitonin). Given the clinical suspicion of a post-surgical complication, a thoracoabdominal CT scan was performed, which confirmed herniation of the gastric fundus into the thoracic cavity (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was transferred to the operating theatre, where again under general anaesthesia and by video-assisted thoracic surgery approach, the viability of the herniated stomach was verified, its contents were reduced back into the abdomen and the mesh that closed the diaphragmatic defect was repaired and reinforced to prevent recurrence of the hernia. After this second operation, the patient remained on noradrenaline at the aforementioned doses and was transferred to resuscitation on mechanical ventilation. He was extubated in the following 12<span class="elsevierStyleHsp" style=""></span>h and the noradrenaline infusion was withdrawn at 24<span class="elsevierStyleHsp" style=""></span>h. The rest of the postoperative period was uneventful, also recovering baseline serum creatinine levels. He was discharged to the ward on the third postoperative day, after removal of the chest drain, with no further evidence of herniation on daily X-rays, and was discharged from hospital on the tenth postoperative day.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The herniation of abdominal contents through the prosthesis used to repair a diaphragmatic defect after EPP is a rare and potentially serious complication of mesothelioma surgery, which can have serious consequences and must be repaired urgently<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>. Displacement of the stomach or intestine into the thorax after these interventions usually occurs in the immediate postoperative period, so we must be aware of its characteristics and form of presentation in order to diagnose it early in our anaesthesia critical care units.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Herniation is facilitated by Valsalva manoeuvres or ileus in the immediate postoperative period, due to increased intra-abdominal pressure, and also by tension on the patch used to repair the resected diaphragm at surgery. In these interventions, in order to keep the abdominal viscera away from the area where postoperative radiotherapy will be administered, the diaphragmatic patch is usually fixed relatively taut, creating tension, which is the main weakness of any hernia repair<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. In contrast, the progressive accumulation of fluid in the thorax after removal of the chest drainage tube prevents later diaphragmatic hernia, although presentations have been reported even months after the initial operation<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>, the picture in such cases being suggestive of tumour recurrence<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The clinical presentation can sometimes be very subtle and non-specific. Herniation should be suspected in the presence of unexplained chest or epigastric pain, as in our patient, auscultation of hydro-aerial sounds in the chest, sudden cessation of air bubbling in the thoracic drainage, persistent nausea and vomiting, and haemodynamic instability that cannot be explained by other reasons. Herniation of bowel contents after right pneumonectomy is less common due to hepatic interposition<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. However, if liver herniation occurs, it may also be accompanied by signs of inferior vena cava compression<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Clinical suspicion should be confirmed by chest X-ray, or preferably by thoracoabdominal computed tomography, which usually shows an obvious displacement of the abdominal viscera into the pneumonectomy cavity, as occurred in this case<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. In this regard, some authors recommend that chest X-rays be performed daily in the early postoperative period to quickly detect this disease in the thorax<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Reduction of the herniated intestine or stomach and repair of the diaphragmatic defect are necessary to avoid irreversible injury to the abdominal organs and ischaemia of these viscera, secondary to compression or vascular torsion (due to the risk of necrosis and contamination of the thoracic cavity with intestinal or faecaloid material), which could have dire consequences<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. In cases previously reported by other authors, thoracotomy or laparoscopic approaches via the abdominal route were used for repair. Abdominal<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,10</span></a>. In the case presented, the surgeons decided to perform the procedure again using a minimally invasive thoracic approach to minimise complications and avoid opening the abdominal cavity.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In summary, herniation of gastric contents through the diaphragmatic prosthesis used to repair the defect created after extrapleural pneumonectomy should be suspected and diagnosed early, in order to reduce the herniated contents and avoid ischaemia of the abdominal viscera. High clinical suspicion, supported by imaging techniques, is key to detect this serious complication in our anaesthesia critical care units.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1882245" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1631451" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1882244" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1631452" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-07-19" "fechaAceptado" => "2021-11-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1631451" "palabras" => array:4 [ 0 => "Mesithelioma" 1 => "Diaphragmatic hernia" 2 => "Video-Assisted thoracic surgery" 3 => "Postoperative complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1631452" "palabras" => array:4 [ 0 => "Mesotelioma" 1 => "Hernia diafragmática" 2 => "Cirugía Torácica asistida por video" 3 => "Complicaciones posoperatorias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Extrapleural pneumonectomy, usually associated with pericardial and diaphragmatic reconstruction with prosthetic material, is one of the surgical techniques used in the treatment of malignant pleural mesothelioma. Herniation of the abdominal viscera towards the thorax through the prosthetic material at the diaphragmatic level is a rare but potentially serious complication of these procedures, which must be diagnosed quickly for urgent repair.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We present the case of a patient who presented with gastric herniation in the early postoperative period of a left pneumonectomy due to pleural mesothelioma. The clinical findings were mild, but supported by imaging tests, they confirmed the diagnostic hypothesis and facilitated the solution of the condition. Possible contributing factors are reviewed and the need for early diagnosis and treatment is emphasized to avoid ischemia of herniated abdominal viscera in the thoracic cavity, due to the risk of necrosis and contamination by fecaloid material.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La neumonectomía extrapleural, habitualmente asociada a reconstrucción pericárdica y diafragmática con material protésico, es una de las técnicas quirúrgicas empleadas en el tratamiento del mesotelioma pleural maligno. La herniación de vísceras abdominales hacia el tórax a través del material protésico a nivel diafragmático es una complicación rara, pero potencialmente grave de estos procedimientos, que debe de ser diagnosticada rápidamente para su reparación urgente.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un paciente que presentó una herniación gástrica en el postoperatorio precoz de una neumonectomía izquierda por un mesotelioma pleural. Los hallazgos clínicos fueron leves, pero apoyados en las pruebas de imagen, confirmaron la hipótesis diagnóstica y facilitaron la solución del cuadro. Se revisan los posibles factores contribuyentes y se incide en la necesidad de un diagnóstico y tratamiento precoz para evitar la isquemia de las vísceras abdominales herniadas en la cavidad torácica, por el riesgo de necrosis y contaminación por material fecaloideo.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 546 "Ancho" => 1250 "Tamanyo" => 91760 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A. Plain chest X-ray image showing a large chamber with hydro-aerial content in the left hemithorax and the nasogastric tube inside. B. Chest computed tomography image confirming the presence of the herniated gastric fundus in the thorax.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The management of the diaphragm during radical surgery for malignant pleural mesothelioma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.J. Sharkey" 1 => "R. Bilancia" 2 => "S. Tenconi" 3 => "A. Nakas" 4 => "D.A. 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