A 74-year-old male, who had undergone 3 stent coronary implantation procedures in the previous 6 months, presented to the hospital with progressive dyspnea and recurrent chest pain. The patient’s medical history was noted for esophageal cancer treatment that consisted of a radical esophagectomy, gastric pull-up followed by chemotherapy and radiotherapy. Esophageal cancer recurrence was ruled out. A transthoracic echocardiography revealed severe aortic regurgitation, moderate mitral regurgitation and a left ventricular ejection fraction of 44%.
The patient underwent a dual valve replacement procedure with a bioprothesis aortic valve (23 mm Magna Ease, Edwards Lifesciences, CA, USA) and mechanical mitral valve (25 mm ON-X, CryoLife, GA, USA). The patient required 7 days of inotropes and intensive unit care. On postoperative (PO) day 8, a right-sided chylothorax was diagnosed, and treated with simple drainage and low-fat medium chain triglycerides diet. On PO day 18, the patient evolved with acute respiratory deterioration and hypoxemia. Chest auscultation revealed peristaltic sounds on the left side. Chest x-ray revealed right pleural effusion and abdominal contents within the left chest cavity (Fig. 1a). Despite pleural effusion drainage, the patient had only slightly improved the respiratory status (Fig. 1b). A chest computerized tomography confirmed the presence of a large portion of the transverse and descending colon in the left hemithorax with no radiological sign of intestinal necrosis (Fig. 2). The diaphragmatic hernia measured 15 cm and filled the whole transverse dimension of the left chest on the anterior-posterior view. A transthoracic echocardiogram ruled out acute cardiac complications. Clinical deterioration was evidenced by increased oxygen requirements to 5 L/min, tachypnea, tachycardia and confusion.
Urgent diaphragmatic hernia repair was indicated and performed by laparoscopy. The patient was placed in a dorsal position with hyperextension of the upper third of his abdomen. Laparoscopic surgery was performed through two 12 mm trocars on the left and right paraumbilical region and three 5 mm trocars were used in the subcostal region, one on the right side and two on the left. The 10 mm 30G camera was inserted through the left paraumbilical incision. A large quantity of peritoneal adherences was taken down with harmonic synergy blades (Ethicon, OH, USA) under direct vision. A large diaphragmatic hernia was identified with a large portion of the transverse colon and omentum within the left chest cavity. Once the majority of the colon was reduced the dissection of the hernial sac from the right and from the left hiatal pillars toward the mediastinum and the apex of the left chest. Pealing the sac off was mandatory for a complete reduction and repair of the hernia. As expected, the apical portion was the most laborious however with proper exposure the dissection was safely performed. The colon stayed passively in the abdominal cavity. The repair of the hiatal hernia was performed by approximating the left and right pillars with non-absorbable stiches. A Biodesign Hiatal Hernia Graft (Cook Medical, IN, USA) was placed surrounding the hiatus. A prolene mesh (Ethicon, OH, USA) was used to close the anterior space. Both grafts were fixed with tacker fixation device (Medtronic, MN, USA). The final result was satisfactory.
The patient had postoperative ischemic colitis and interstitial alveolar left lower lobe infiltrate. This was managed with a conservative treatment based on antibiotics and parenteral nutrition. A Pleur-X chronically indwelling catheter system (Becton Dickinson, NJ, USA) was installed in the patient before discharge, 3 months after surgery. One year after discharge, the patient was readmitted with increased dyspnea. A right sided chylothorax, secondary to Pleur-X infection, was diagnosed. The drainage system was changed, antibiotic treatment was given for 2 weeks and the patient is now doing well.
