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Diseases of the Esophagus (1999) 12, 312±313 Ó 1999 ISDE/Blackwell Science Asia Case report Simultaneous transhiatal esophagectomy and coronary artery bypass grafting without cardiopulmonary bypass J. M. Jones,1 A. A. Melua,2 V. Anikin,2 G. Campalani1 Departments of 1Cardiac and 2Thoracic Surgery, Royal Victoria Hospital, Belfast, UK SUMMARY. A 69-year-old patient underwent simultaneous transhiatal esophagectomy for carcinoma of the esophagogastric junction and benign spindle cell gastric tumor and coronary artery bypass grafting without cardiopulmonary bypass. A standard technique of transhiatal esophagectomy was used. The long saphenous vein was grafted to the left anterior descending artery and to the distal circum¯ex artery. The total theatre time was 6.5 h and the total ischemic time was 19 min. The patient made a good recovery and was discharged on day 18. He is enjoying an active lifestyle 6 months post-operatively. initially performed by the thoracic team and cardiopulmonary bypass equipment available throughout. A mobile tumor of the lower esophagus with a separate nodule in the anterior gastric wall close to the primary tumor and enlarged celiac nodes were found. When the esophageal tumor was found to be resectable, harvesting of the left long saphenous vein (LSV) started. Standard transhiatal esophagectomy with regional lymphadenectomy, pyloromyotomy, and feeding jejunostomy was performed. The separate gastric nodule was included in the specimen. The cervical esophagogastric anastomosis was carried out using continuous single-layer Vicryl suture (Ethicon, Edinburgh, UK). Upon completion of the esophagectomy, the laparotomy and cervical wounds were closed and the patient underwent repeat skin preparation and draping in order to decrease the risk of sternal wound infection. CABG was then commenced via median sternotomy. Cardiopulmonary bypass (CPB) machine was on standby and heparin was administered intravenously in a dose of 1 mg kg)1 body weight (maximum activated clotting time was 255 s). The heart was stabilized with an OPCAB Midline Multi-Vessel Set retractor (Cardiothoracic Systems, Cupertino, CA, USA) and stabilization sutures. The short-acting beta-blocker Esmolol (Gensia Europe, Bracknell, Berkshire, UK) was administered in a dose of 20 mg, reducing the heart rate to 40 beats per minute. A mean blood pressure at the level of 50 mmHg was maintained and myocardial ischemic preconditioning for 5 min was used before the LAD anastomosis. LSV grafts were anastomosed CASE REPORT A 69-year-old man awaiting coronary artery bypass grafting (CABG) was admitted urgently with an inferolateral myocardial infarction (CK 878 iu l±1, AST 110 iu l±1, LDH 877 iu l±1), melena and an ironde®cient anemia (Hb 7.4 g dl±1, MCV 72.1 ¯, serum Fe 4 lmol l±1, TIBC 60 lmol l±1, serum ferritin 7 lmol l±1). Previously performed coronary angiography revealed severe proximal left anterior descending artery (LAD) stenosis, severe stenosis of a dominant circum¯ex, and occlusion of the posterior descending artery (PDA). Echocardiography on admission con®rmed mild left ventricular dysfunction with anterobasal hypokinesis. Barium swallow, ¯exible esophogogastroduodenoscopy with biopsy of the lesion and computed tomography scanning showed a polypoid, ulcerating, poorly dierentiated adenocarcinoma at the esophagogastric junction with regional lymphadenopathy but without evidence of invasion into surrounding tissue or distant metastases. Simultaneous procedures were considered, in view of the persistent bleeding from the ulcerated tumor, to avoid the risk of perioperative myocardial infarction and intraoperative heparin-induced bleeding from the tumor. The operation was performed 7 weeks after the myocardial infarction by thoracic and cardiac surgical teams. An upper midline laparotomy was Address correspondence to: J. M. Jones, Department of Cardiac Surgery, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK. Tel: (+44) 123 289 4998; Fax: (+44) 123 231 2907. 312 Simultaneous transhiatal esophagectomy and CABG without CPB 313 to the distal LAD and distal circum¯ex artery using continuous 7-0 Prolene suture (Ethicon, Edinburgh, UK). Grafting of the PDA was not performed because of its small diameter. The total ischemic time was 19 min and the total theatre time was 6 h and 30 min. Post-operatively, inotropes were required for 5 days. Extubation took place on post-operative day 5. Jejunal feeding was commenced on day 3 but was subsequently stopped for 5 days as a result of ileus and then recommenced. A water-soluble contrast study on day 11 con®rmed an intact anastomosis and oral intake was commenced. The patient made a good recovery and was discharged home on post-operative day 18. Pathology con®rmed a 6 ´ 3 cm anaplastic tumor in®ltrating through the muscular layers lying close to the serosal surface. Adjacent esophageal mucosa showed Barrett's metaplasia. Three paraesophageal lymph nodes were present, one showing metastatic tumor, and one celiac node was almost completely replaced with metastatic tumor. The separate lesion was a benign intramural gastric stromal tumor consisting of spindle cells. On review at 6 months, he remains free from angina and enjoys an active lifestyle. DISCUSSION There are reports of CABG being carried out simultaneously with lung procedures,1 abdominal aortic aneurysm repair,2 and cholecystectomy.3 A literature search revealed only one case report of combined transthoracic esophagectomy and CABG.4 However, in contrast to that report, in this case the esophagus was removed transhiatally and CABG was performed without the use of CPB. This patient had persistent bleeding requiring blood transfusion, after admission to hospital, from a tumor which was considered operable on the basis of preoperative assessment. He also had critical coronary artery disease as indicated by his myocardial infarction and coronary angiogram. Radiotherapy does not oer the prospect of cure and, particularly in the presence of severe ischemic heart disease, it was not considered to be the best option. Esophagectomy in the presence of ischemic heart disease is a high-risk procedure but it was considered, with simultaneous coronary revascularization, to be the only option oering hope for cure in this case. A staged approach was rejected owing to concern over heparin-induced bleeding from the ulcerated tumor if CABG was performed ®rst and, also, to the risk of perioperative myocardial infarction if the esophagectomy was the initial procedure. The decision not to use CPB was made because patients undergoing CPB have a signi®cant risk of post-operative bleeding5 due to heparinization, inadequate heparin reversal, protamine excess, or transient impairment of platelet function during passage through the extracorporeal circuit. Also, in patients undergoing a concomitant procedure, bleeding may arise from the area of esophageal dissection or, as in this patient, from an ulcerated tumor which had already bled. There is also evidence of immunosuppression following CPB.6 Therefore, by performing CABG without CPB as part of a simultaneous procedure for malignant tumors, the opportunity for further tumor growth and dissemination may be reduced. In order to decrease the risk of sternal wound infection, the cervical and laparotomy wounds were closed before median sternotomy and the patient had repeat skin preparation and draping. This case demonstrates that, in complex situations, it is possible to perform simultaneous transhiatal esophagectomy and coronary artery bypass grafting safely without cardiopulmonary bypass. References 1. Danton M H D, Anikin V A, McManus K G, McGuigan J A, Campalani G. Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature. Eur J Cardiothorac Surg 1998; 6: 667±672. 2. Autschbach R, Falk V, Walther T et al. Simultaneous coronary bypass and abdominal aortic surgery in patients with severe coronary disease ± indication and results. Eur J Cardiothorac Surg 1995; 9: 678±683. 3. Koike R, Kimura H, Sugihara J et al. Simultaneous coronary artery bypass grafting and cholecystectomy: a report of three cases. Kyobu Geka 1991; 2: 145±150. 4. Bria N P, Norton R. Simultaneous oesophagectomy and CABG for cancer and ischaemic heart disease. Eur J Cardiothorac Surg 1993; 7: 557±558. 5. Harker L A. Bleeding after cardiopulmonary bypass. N Engl J Med 1986; 314: 1446±1447. 6. Hisatomi K, Isomura T, Kawara T. Changes in lymphocyte subsets, mitogen responsiveness and interleukin-2 production after cardiac operations. J Thorac Cardiovasc Surg 1989; 98: 580±591.