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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 di€erentiated 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 o€er 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 o€ering 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. Bri€a 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.