Right Ventricular Extrinsic Compression Tamponade Caused by Dilation/Necrosis of a Coloplasty Performed for Esophageal Squamous Cell Carcinoma

Abstract

In the context of dysphagia, an infiltrating squamous cell carcinoma of the esophagus was diagnosed in a 43-year-old woman with a history of two liver and one kidney transplants as a result of Alagille syndrome. An esophagectomy with retrosternal left coloplasty (esocolic, gastrocolic, and colocolic anastomoses) was performed. On postoperative day 2, her hemodynamic status deteriorated resulting in significant increases in norepinephrine doses (from 0.33 to 2 micg/kg/min). Transthoracic echocardiography was difficult to perform because the patient had limited imaging windows. Transesophageal echocardiography was contraindicated due to the nature of her surgery. An emergency thoraco-abdominal CT scan showed that the coloplasty was dilated, ischemic, and compressing the right ventricle anteriorly. Emergency surgery revealed mediastinitis with necrosis of the coloplasty. Surgical decompression of the coloplasty led to rapid improvement in hemodynamics, requiring only reduced doses of norepinephrine.

In the context of dysphagia, an infiltrating squamous cell carcinoma of the esophagus was diagnosed in a 43-year-old woman with a history of two liver and one kidney transplants as a result of Alagille syndrome [1]. Due to anatomical constraints secondary to the liver transplantations, an Ivor Lewis esophagectomy could not be performed. An esophagectomy with retrosternal left coloplasty (esocolic, gastrocolic, and colocolic anastomoses) was then performed [2]. Postoperative systemic inflammatory response syndrome was treated with intravenous fluids and norepinephrine infusion in the ICU. Despite appearing to initially improve, her hemodynamic status deteriorated on day 2 resulting in significant increases in norepinephrine doses (from 0.33 to 2 micg/kg/min), increased heart rate (tachycardia between 110 and 140 bpm), and a significant variation in the arterial pressure wave, punctuated by mechanical ventilation. In addition, the patient rapidly developed oligo-anuria. Transthoracic echocardiography was difficult to perform because the patient had limited imaging windows. Transesophageal echocardiography was contraindicated due to the nature of her surgery. An emergency thoraco-abdominal CT scan showed that the coloplasty was dilated, ischemic, and compressing the right ventricle anteriorly (Fig. 1a, b). Figure 1c shows the significant compression of the right ventricular outflow tract. The inferior and superior vena cava were also dilated.

Fig. 1.

a Axial section of the thoraco-abdominal CT shows extrinsic compression of the right ventricle by the necrotic coloplasty, represented by an asterisk. b Sagittal CT sections show necrotic dilatation of the plasty, represented by an asterisk. c Sagittal section shows the compression of the right ventricular outflow tract, represented by a black triangle. d Operative findings revealed complete necrosis of the plasty

Emergency surgery revealed mediastinitis with necrosis of the coloplasty, so it was removed (Fig. 1d). Decompression of the coloplasty led to rapid improvement in hemodynamics, requiring only reduced doses of norepinephrine.

Declarations

Consent for publication

The patient has given her consent to publication.

Conflict of interest

Sébastien Tanaka declares no conflict of interest. Tigran Poghosyan was a member of the boards of Gore Scientific, Bariatek Scientific, and Novo Nordisk Scientific. Philippe Montravers received consulting fees from Menarini, MSD, Viatris, and Mundipharma. He participated in advisory boards for Pfizer, MSD, and Viatris.