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J Thorac Cardiovasc Surg 1994;108:189-191
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Postoperative diaphragmatic hernia after use of the right gastroepiploic artery for coronary artery bypass grafting

Clinic for Cardiovascular Surgery
University Hospital Zurich
Zurich, Switzerland

To the Editor:

Along with the internal thoracic arteries, the right gastroepiploic artery is now an established arterial graft for myocardial revascularization, especially in the setting of reoperation or when no suitable vein is available. ^1,2 This type of operation is seldom associated with an increased risk for postoperative complications other than those of standard coronary artery bypass grafting. ³ We describe the case history of a patient who had an incarcerated postoperative diaphragmatic hernia after myocardial revascularization with the right gastroepiploic artery graft, a complication specific only for this type of coronary artery bypass graft.

A 56-year-old man with severe three-vessel coronary artery disease and New York Heart Association class III angina pectoris, as well as a history of bronchial asthma, underwent uneventful coronary artery bypass grafting. Because only a single 30 cm long segment of the great saphenous vein was available because of previous vein stripping, we used two arterial conduits for myocardial revascularization, the left internal thoracic artery and the right gastroepiploic artery. The patient received five distal anastomoses: the left internal thoracic artery was implanted into the left anterior descending artery, the vein segment was used for revascularization of the first and second obtuse marginal branches of the left circumflex artery and for the diagonal branch, and the right gastroepiploic artery was implanted into the right posterior descending artery. The pedicle of the right gastroepiploic artery was brought into the pericardial sac through a hole in the diaphragm, passing the stomach and the liver posteriorly. The postoperative course was complicated by instability of the sternum because of several episodes of cough associated with acute exacerbation of asthma, and the sternum was refixed 3 weeks after the coronary artery operation. Neither clinical nor laboratory examinations revealed sternal infection. After the second operation the patient continued to have several episodes of productive cough. The therapy for asthma consisted of inhaled corticosteroids supplemented by inhaled ß-adrenergic agonists and theophylline administered intravenously.

On the sixth day after the second operation the patient was constipated with mild diffuse abdominal complaints. A plain roentgenogram of the abdomen and the chest revealed an enormous amount of air in the bowels with a minimal left-sided pleural effusion. After a rectal enema, the bowel was evacuated of a massive stool and the patient's clinical condition improved. Two days later, the patient had several episodes of brief, upper abdominal colic pain. A plain roentgenogram revealed several air-filled small bowel loops in the projection of the left lower part of the heart (Fig. 1, A). Subsequent gastoduodenoscopy revealed normal findings of the stomach and the duodenum. The second chest roentgenogram showed a large left-sided pleural effusion associated with gas-filled loops of intestine with multiple fluid levels in the left upper part of the abdomen and in the left lower side of the thorax (Fig. 1, B). An ultrasonic examination confirmed the suspected diagnosis of a diaphragmatic hernia, with loops of small bowel showing intensive peristaltic waves in the left pleural cavity (Fig. 2).

View larger version (103K): [in this window] [in a new window]   Fig. 1. A, Chest roentgenogram showing loops of air-filled bowel in the left-upper abdomen as well as in the projection of the heart shadow with minimal left-sided pleural effusion. B, Radiographic examination performed 6 hours later shows a large opacity of the left pleural cavity and air-filled loops of intestine with multiple fluid levels in the left upper part of the abdomen and left lower part of the chest.

View larger version (104K): [in this window] [in a new window]   Fig. 2. Aand B, Ultrasonic examination of the chest revealed loops of the small bowel in the left pleural cavity and a left-sided pleural effusion with pulmonary compression. Note the typical ultrasonic finding of a transverse section of the small bowel (B). S, Spleen; D, diaphragm; L, compressed lung; PE, pleural effusion; I, loops of intestine.

A word of caution is warranted regarding the evaluation of postoperative pleural effusion and its eventual drainage after the use of the right gastroepiploic artery graft for coronary revascularization. The radiographic examination in the setting of a diaphragmatic hernia may reveal a basal opacity that may be confused with that of pleural fluid or basal consolidation. In this clinical setting, postoperative diaphragmatic hernia should be considered as a possible cause of a left-sided pleural effusion.

References

1. Pym J, Brown PM, Charrette EJP, Parker JO, West RO. Gastroepiploic-coronary anastomosis: a viable alternative bypass graft. J THORAC CARDIOVASC SURG 1987;94:256-9.[Abstract]
   
2. Mills NL, Everson CT. Right gastroepiploic artery: a third arterial conduit for coronary bypass. Ann Thorac Surg 1989;47:706-11.[Abstract]
   
3. Suma H, Wanibuchi Y, Terada Y, Fukada S, Takayama T, Furuta S. The right gastroepiploic artery graft: clinical and angiographic midterm results in 200 patients. J THORAC CARDIOVASC SURG 1993;105:615-23.[Abstract]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Miralem Pasic Thierry Carrel Marko Turina Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pasic, M. Articles by Turina, M. Search for Related Content PubMed PubMed Citation Articles by Pasic, M. Articles by Turina, M.