Intrathoracic Stomach Research Articles

Tracheal Occlusion from an Intrathoracic Stomach

A patient presented with recurrent respiratory failure following esophagectomy. Systematic evaluation detected a previously unreported process causing this problem. Simple therapeutic measures were effective once the diagnosis was established.

Noninvasive Imaging of a Retrocardiac Spleen: Unusual Component of Paraesophageal Diaphragmatic Hernia

The findings on chest roentgenograms, cardiac ultrasound, computed tomography (CT), and radionuclide liver-spleen scan are described in a 54-year-old man with a paraesophageal diaphragmatic hernia. The CT revealed the spleen as a solid mass with a notched border adjacent to the intrathoracic retrocardiac stomach. The radionuclide scan showed splenic uptake above the diaphragm. The diagnosis in this case, which, to our knowledge, is the first such reported case, was confirmed at surgery.

Functional Results of Gastric Interposition Following Total Esophagectomy

Functional results of gastric interposition were evaluated in 35 patients at 3 to 84 months following esophagectomy. All patients were satisfied with the results of surgery, although 14 (40%) still experienced some degree of dysphagia. Transit times for radiolabeled solids across the cervical esophagus and anastomosis were not significantly different for the 14 symptomatic patients (mean 77 seconds) versus 21 asymptomatic patients (mean 55 seconds). Spontaneous emptying of the vagotomized intrathoracic stomach appeared complex, with mean percentage radionuclide clearances at 30 minutes (semisolid meal) calculated at 37% for 23 patients with early satiety (versus 42% asymptomatic) and at 38% for nine patients with reflux (versus 39% asymptomatic), all values comparable to emptying of the normal intra-abdominal stomach (35% clearance at 30 minutes). Our data suggest that the interposed stomach appears to retain its gastric identity rather than act as an inert conduit, and that although little correlation exists between postoperative symptoms and objective findings, the stomach remains a satisfactory esophageal substitute.

Total gastric transposition: An alternative to esophageal replacement in children

Total gastric transposition was performed in 21 children as an alternative procedure for esophageal replacement. The age at the operation ranged from 15 months to 11 years. Half of the children were less than 2 years old. Fifteen patients had esophageal atresia. The stomach was passed toward the neck either through the esophageal bed (6 cases, with concomitant blunt esophagectomy without thoracotomy) or the retrosternal route (15 cases). There was one death in the early postoperative period secondary to an anastomotic leak and acute mediastinitis in a case of pharyngogastric anastomosis. Three other patients developed cervical leak with spontaneous closure but this ultimately led to a late anastomotic stricture (more than 6 months) requiring endoscopic dilatation. Only one child needed more than three attempts of endoscopic dilatation. None of these patients required surgical revision. The mean follow-up was 60 months (range, 10 to 122 months). Despite bulky atonic intrathoracic stomach occuring in some children, only two patients developed regurgitation and symptoms of poor gastric emptying. There were neither early nor late respiratory problems. Excellent and good functional outcome were achieved in 85% and 15% of the patients, respectively. Two patients have not undergone a weight catch-up phase. The majority of the children have been between the 20th and 80th percentile for weight. Five children remain below the 20th and two below the 5th percentile. The remarkably low morbidity and mortality combined with satisfactory functional results indicate that the total gastric transposition is a safe and easy alternative surgical procedure for esophageal replacement in children.

Acute Leukemia in an Infant with Marfan's Syndrome: A Case Report

We describe a familial case of Marfan's syndrome with associated intrathoracic stomach detected during the neonatal period. The patient developed a primitive leukemia at 3 months of age. Acute leukemia in a patient with Marfan's syndrome has not previously been reported.

Case report: Complete laryngotracheoesophageal cleft: CT diagnosis and associated abnormalities

A case of complete laryngotracheoesophageal cleft is described in a male infant in which bronchoscopy could not be performed due to a narrow tracheal orifice. CT scan of the thorax demonstrated a common tracheal and oesophageal lumen extending inferiorly to the carina, with hypoplasia of the right lung and cardiac dextroposition. Contrast studies demonstrated a hypoplastic intrathoracic stomach. Chromosome analysis revealed satellites on the Y chromosome with karyotype 46XYqs.

Function of the intrathoracic stomach as esophageal replacement.

AbstractThe emptying, acid secretion, mucosal changes, and duodenogastric and gastroesophageal reflux of the intrathoracic stomach were studied in 12 patients together with the clinical course 6–12 months after esophageal replacement.Although no pyloroplasty had been performed, the emptying of a semisolid meal from the interposed stomach was significantly accelerated compared to the controls. No residual food was found in the stomach at endoscopy after an overnight fast. Distinctly accelerated gastric emptying correlated with spontaneous duodenogastric reflux across the denervated pylorus.Despite a persistent acid secretion of the vagotomized intrathoracic stomach, no pathologic gastroesophageal reflux and no esophagitis were found proximal to the cervical anastomosis. Gastric biopsies mostly revealed mild gastritis of the antral mucosa, whereas metaplasia was rare. The intrathoracic stomach does not need a drainage procedure to facilitate semisolid emptying. Postoperative reflux esophagitis is prevented by complete intrathoracic stomach transposition with cervical esophagogastrostomy.

Surgical management of large paraesophageal hernia with complete intrathoracic stomach.

AbstractBetween 1971 and 1986, the author operated on 30 patients, 23 women and 7 men, with large paraesophageal (PE) hernias and complete intrathoracic stomach. The average age of the patients was 70 years. Thirteen patients required urgent repair because of incarceration causing complete obstruction, bleeding, and, in one instance, perforation. Only 2 patients had a prior history of esophageal reflux. Surgery, always transabdominal, included excision of the sac, closure of the defect with pledgetted sutures, and anterior gastropexy. Four extremely poor‐risk patients underwent anterior gastropexy alone under local anesthesia. Two other patients underwent anterior gastropexy alone for different reasons. There were no deaths or major complications and no recurrences. The author's experience suggests that: (a) an abdominal approach is preferable to a transthoracic repair; (b) ancillary antireflux surgery, such as fundoplication, should be used only when indicated on the basis of a prior history of reflux esophagitis, which was the case in only 2 of our patients; (c) because the symptoms and complications of PE hernias result from the gastric volvulus rather than from the hernia per se, formal repair of the defect is not always necessary. Thus, patients whose general condition does not permit a major abdominal operation under general anesthesia can be completely relieved of their symptoms by an anterior gastropexy done under local anesthesia; (d) a PE hernia is a life‐threatening condition and elective repair should be recommended once the diagnosis is made.

A physical model of the intrathoracic stomach.

To determine whether duodenogastric reflux into the thoracic stomach could be caused by the transmission of negative intrapleural pressure fluctuations into the gastric lumen, a physical model is described and an equation calculated Pm + Pa - Pmb - (Sv.Pmb.Vmb/Pm) = Ppl - Sv.Vmb where Pm is intragastric pressure, Pa is atmospheric pressure, Pmb is end-expiratory gastric base pressure, Vmb is corresponding gastric volume, Sv is stiffness of gastric wall, and Ppl is intrapleural pressure. The validity of the model is demonstrated in six anesthetized mongrel dogs (18-31 kg) in which a thoracic stomach was constructed. The transmission of the intrapleural pressure fluctuations across the gastric wall proved to be greatly influenced by the gastric stiffness. The latter parameter varied from 0.05 to 1.97 cmH2O/ml, corresponding with a pressure transmission of 100 and 60%, respectively. Because high degrees of gastric stiffness are only present for large gastric volumes or when gastric peristalsis is present, it is concluded that, in general, the intrapleural pressure fluctuations are transmitted into the thoracic stomach. For this reason, respiratory efforts may play an important role in inducing duodenogastric reflux into the thoracic stomach.

Local recurrences after subtotal esophagectomy for squamous cell carcinoma.

From July 1982 to June 1985, 100 patients with squamous cell carcinoma of the thoracic esophagus had esophageal resection and reconstruction using an abdominal and right thoracotomy approach (Lewis-Tanner operation). Five patients died within 30 days. The remaining 95 patients were studied prospectively for evidence of local recurrences. It was found that anastomotic recurrences occurred in eight patients, and mediastinal recurrences involving the intrathoracic stomach occurred in seven patients over a mean follow-up period of 13 months. The total local recurrence rate was 16% (15 of 95 patients). The incidence of anastomotic recurrence was shown to be related only to the length of the proximal resection margin and not related to tumor differentiation or lymph node metastases. A proximal resection margin of less than 5 cm measured at operation had a 20% risk of developing an anastomotic recurrence, and a margin of between 5 to 10 cm had an 8% risk. Mediastinal recurrences that encroached on the intrathoracic stomach were found to be related more to the extent of lateral spread of the primary tumor in the mediastinum than to the length of the resection margins. Postoperative radiotherapy in patients with palliative resections decreased the incidence of local recurrences. To reduce the incidence and consequences of local recurrence after esophagectomy, it is suggested that in patients with tumors in the upper thorax, a more complete esophagectomy is warranted, postoperative radiotherapy should be given to patients with short resection margins, and in patients with extensive mediastinal spread, use of the retrosternal route for reconstruction is preferred.

Gastric functions in patients with the intrathoracic stomach after esophageal surgery.

Functions of the stomach placed in the posterior mediastinum after esophagectomy were studied in 20 esophageal carcinoma patients. Seven were long-term survivors who lived more than 5 years after operation, and five of them showed normal fasting serum gastrin levels and good or fair gastric acid secretion. Of 13 patients who had their operations within 3 years before the study, 11 showed high fasting serum gastrin levels and poor gastric acid secretion. The hepatobiliary and alimentary scintigrams with double isotopes demonstrated a time lag between the excretion of the food from the stomach and the excretion of bile into the bowels, regardless of the postoperative periods. Absorption of vitamin B12 was normal in patients who lived more than 2 years after operation. The intraluminal pressure and pH studies in long-term survivors showed that our operative technique, the posterior invagination esophagogastrostomy, was effective in preventing a gastroesophageal reflux in the anastomosis.

Colon interposition for esophagus in children

In 25 years, from 1959 to 1984, esophageal substitution was performed in 32 patients. In most, the transverse colon was used, brought through the left chest on a vascular pedicle of the left colic artery. Indications for operation included: 21, esophageal atresia; 5, caustic injury; 3, peptic stricture; 2, esophageal varices with previous splenectomy; and 1, cartilagenous hamartoma of the esophagus. Six patients had failed prior reconstructions (1, gastric tube; 2, intrathoracic stomach; 1, presternal jejunum; 1, sloughed colon segment, 1, extensive stricture after primary repair). There was one postoperative death from fluid overload early in the series. Two patients had a localized leak at the upper anastomosis in the neck; neither resulted in stricture. One patient had a side leak in the lower intrathoracic colon, probably from an anchoring suture placed too deeply. Most patients had pyloroplasty with their operation. Four who did not required one later. Four patients required late reoperation for redundancy of the lower colon segment which emptied poorly; one lower colon was revised for stricture from exstrinsic compression at the substernal hiatus and another one for an inflammatory pseudopolyp with bleeding. There was no loss of a colon segment from ischemia. There is follow-up on all but one patient. Nineteen are more than ten years postoperative (mean of 18 years). Growth was assessed in that group. In atresia patients growth correlated with weight preoperatively and the presence or absence of associated anomalies. In the others growth was excellent in all but one patient. In our experience the colon conduit provides an excellent substitute esophagus for pediatric patients. The operation should have relatively low rate of major complications, most of which are avoidable, and most of which can be corrected to give a satisfactory long-term result.

Giant paraesophageal hiatus hernia with intrathoracic stomach and colon: the case for early repair.

Giant paraesophageal hiatus hernia with intrathoracic stomach and colon: the case for early repair.

Gastric histology and function in patients with intrathoracic stomach replacement after esophagectomy.

The histological changes and gastric function alterations in 19 patients who had intrathoracic stomach replacement following esophagectomy were studied. Atrophic gastritis was noted in 13 of the 19 patients. The mechanical response of the stomach to distention by food was largely retained. The basal and maximal acid output was reduced markedly, and the serum gastrin was elevated. An association between the degree of gastritis, the percentage of gastric motility at rest, and acid secretion is demonstrated. These changes are consistent with patients with duodenal ulcer following vagotomy and dyloroplasty. Postprandial elevation in serum gastrin was noted in patients with or without vagotomy. The lack of significant difference in integrated gastrin response suggests that the vagus may not be important in the control of postprandial gastrin release.

Intrathoracic stomach: when does it obstruct?

Large esophageal and paraesophageal gastric herniations may occasionally produce gastric obstruction and strangulation. Seven cases of gastric intrathoracic herniation of varying degree, including 2 with obstruction, are presented with diagrams of the anatomy in each case. The cases with obstruction are discussed in relation to existing theories of the mechanism of obstruction: (a) tightness of the hernial ring; (b) acute volvulis of the herniated stomach; and (c) subdiaphragmatic redescent of the fundus with fundic distension and crowding of the hernial orifice. It is concluded that the last mechanism is the most common, but that a combination of mechanisms produces the obstruction in some cases.

Paraesophageal hernia.

THE multiplicity of terms that have been used to describe herniation of the stomach alongside the esophagus and into the posterior mediastinum suggest the confusion which exists concerning both the pathophysiology and the management of this disorder. Up-side-down stomach, rolling hernia, intrathoracic stomach, parahiatal, and paraesophageal hernia are only a few of the terms applied to this problem. With few exceptions, this condition has not been separated in the literature from sliding hernia, and yet the sequelae and management of the two conditions are entirely different. In textbooks published as recently as 1958,¹illustrations of what are called parahiatal hernia show a component of the diaphragm between the herniated stomach and the esophagus, with a separate opening adjacent to the esophageal hiatus through which the stomach reportedly herniates. A substantial segment of the diaphragm lying between the herniated stomach pouch and esophagus is described, but the anatomical details of

The intrathoracic stomach in childhood

Summary Clinical, roentgenographic, and laboratory data concerning a child of 7 years, 10 months of age in whom the stomach was placed in the chest in the neonatal period are recorded. Physical development is below average, but the growth pattern is not significantly different from that of a 5-year-old sibling or the child's father. Except for the intrathoracic position of the stomach, contrast roentgenograms show no abnormality. No anastomatic stricture, abnormality of motility, or interference with gastric emptying is found in this child. It is hoped that others with experience with such patients report their progress so that this approach to esophageal atresia may be better evaluated.

The serious significance of hiatus hernia, its complications and modern methods of surgical management.

Until recent years esophageal hiatus hernia has been a very poorly understood disorder that carried a high incidence of serious complications and a disorder for which no satisfactory treatment has been available. Most of the problems, however, regarding this lesion have been solved, and a satisfactory corrective surgical procedure has been developed which gives good results, with a low to insignificant morbidity and mortality rate. Three general varieties of esophageal hiatus hernia are ordinarily recognized—sliding hiatus hernia with redundant esophagus, congenitally short esophagus with intrathoracic stomach, and paraesophageal hiatus hernia (Fig. 1). The sliding variety of hiatus hernia is certainly the commonest and is responsible for the great majority of the serious complications. As pointed out by Sweet in 1952, 1 the vast majority of hiatus hernias appear by roentgenographic examination to be associated with a truly short esophagus. In almost every instance, however, it is usually discovered at

Gastroesophageal incompetence, partial intrathoracic stomach, and vomiting in infancy.

In 1947, Neuhauser and Berenberg (22) described the mechanism for some cases of persistent vomiting in infancy under the term cardioesophageal relaxation or chalasia. The free flow of a barium mixture between the stomach and the persistently dilated esophagus, under the influence of position and gravity (Fig. 1), was attributed to temporary neuromuscular dysfunction involving the diaphragm and the intrinsic gastroesophageal musculature. Local disease in the region of the gastroesophageal junction or in the central nervous system was believed to account for some cases. The condition was to be differentiated from “congenital short esophagus” and partial intrathoracic stomach due to diaphragmatic hernia; prompt and gratifying cessation of symptoms was said to occur if the infant was maintained in an erect position. This postural treatment impeded reflux of gastric contents into the esophagus, and within three to four weeks clinical and radiologic recovery took place. Subsequently, English observers (2, 6), also concerned with the problem of vomiting in children, reported that partial thoracic stomach (Fig. 2) was a more common cause for gastroesophageal incompetence than chalasia. Moreover, the development of what had previously been called “congenitally short esophagus” (Fig. 3) was shown to occur as a sequel to the gastroesophageal incompetence of the malpositioned cardiac orifice. Largely through the work of the British group, it now appears clear that the condition previously known as congenital short esophagus probably represents shortening due to cicatricial contraction of a chronically inflamed esophagus irritated by reflux of gastric contents in the course of persistent vomiting. Experimental studies in animals (7) have shown that direct stimulation of the vagus nerve, or of the gallbladder, the peritoneum, or other intra-abdominal structures, can result in reflex contraction of the esophagus which, if the thorax is open, can produce a definite esophageal hiatus hernia of the stomach. Why the herniation does not occur, although the contraction does, if the thorax is closed, has not been explained. The irritation of the reflux esophagitis is thought to be able to produce such reflex shortening of the esophagus. This disordered arrangement of structures, according to popular theory, then aggravates any pre-existing cardioesophageal insufficiency and further reflux occurs to the extent that cicatricial scarring not only produces irreversible change but may actually lead to stricture formation. Although the majority of infants with partial thoracic stomach apparently respond to postural treatment comparable to that used for chalasia, surgery has been considered for the prevention of strictures.

Thoracic stomach simulating left ventricular failure.

Case Reports1 December 1950THORACIC STOMACH SIMULATING LEFT VENTRICULAR FAILUREHENRY H. HAFT, M.D., F.A.C.P., DANIEL K. ADLER, M.D.HENRY H. HAFT, M.D., F.A.C.P.Search for more papers by this author, DANIEL K. ADLER, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-33-6-1472 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptINTRODUCTIONAlthough the subject of diaphragmatic hernia has appeared in the medical literature with increasing frequency during recent years, it is still felt that not enough emphasis has been placed on it as a mimic of other abdominal conditions as well as of various cardiac and pulmonary diseases. Levy and Duggan1found 26 hiatal hernias in their series of 1,220 patients—an incidence of 2.1 per cent. Harrington2states that at the Mayo Clinic from 1926 through 1939, 650 patients were found to have diaphragmatic hernias. The actual incidence is probably greater than that reported because some patients with hiatal hernias...Bibliography1. LevyDuggan MDLB: Hiatus hernia of the stomach, South. M. J. 24: 351, 1941. CrossrefGoogle Scholar2. Harrington SW: Diagnosis and treatment of various types of diaphragmatic hernia, Am. J. Surg. 1: 377, 1940. Google Scholar3. Ross JR: Personal communication. Google Scholar4. Harrington SW: Personal communication. Google Scholar5. Schiff L: Personal communication. Google Scholar6. Crohn BB: Personal communication. Google Scholar7. Sussman ML: Personal communication. Google Scholar8. Harrington SW: The surgical treatment of the more common types of diaphragmatic hernia: esophageal hiatus, traumatic, pleuroperitoneal hiatus, congenital absence and foramen of Morgagni, Ann. Surg. 122: 546, 1945. CrossrefMedlineGoogle Scholar9. Truesdale PE: Diaphragmatic hernia at the esophageal hiatus, the short esophagus and thoracic stomach, New England J. Med. 212: 240, 1935. CrossrefGoogle Scholar10. Harrington SW: Roentgenologic consideration in the diagnosis and treatment of diaphragmatic hernia, Am. J. Roentgenol. 49: 185, 1943. Google Scholar11. Aufses AH: Asymptomatic traumatic diaphragmatic hernia mistaken for pulmonary tuberculosis, J. Mt. Sinai Hosp. 8: 143, 1941. Google Scholar12. Bowen A: Volvulus of an inverted intrathoracic stomach complicating diaphragmatic hernia: case report, Am. J. Digest. Dis. 3: 923, 1937. CrossrefGoogle Scholar13. HermanSinger ME: Para-esophageal hiatal hernia, New York State J. Med. 46: 1020, 1946. MedlineGoogle Scholar14. Stoll HF: A case of diaphragmatic hernia in which marked cyanosis and dyspnea were the predominating symptoms, Ann. Int. Med. 10: 395, 1936. LinkGoogle Scholar15. McGinnSpear SLM: Diaphragmatic hernia presenting the clinical picture of acute cor pulmonale, New England J. Med. 224: 1014, 1941. CrossrefGoogle Scholar16. Reid WD: Hiatus hernia simulating cardiac infarction, New England J. Med. 223: 50, 1940. CrossrefGoogle Scholar17. Harrington SW: Esophageal hiatus diaphragmatic hernia: diagnosis and treatment of 123 cases, J. Thoracic Surg. 8: 127, 1938. CrossrefGoogle Scholar18. BeckhHuffman WJ: The importance of diaphragmatic hernia in the differential diagnosis or coronary artery disease, Stanford M. Bull. 3: 181, 1945. MedlineGoogle Scholar19. Jones CM: Studies on the mechanism of the pain of angina pectoris with particular relation to hiatus hernia, Tr. A. Am. Physicians 57: 139, 1942. Google Scholar20. TruesdaleHuntLeigh PEELOC: The role of obstruction in diaphragmatic hernia, Tr. New England J. Surg. 23: 81, 1941. Google Scholar21. Jones CM: Hiatus esophageal hernia, New England J. Med. 225: 963, 1941. CrossrefGoogle Scholar22. Moschcowitz E: The simultaneous association of hiatus hernia and coronary disease, J. Mt. Sinai Hosp. 4: 272, 1937. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Syracuse, New York*Received for publication June 1, 1948. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byDie Erkrankungen des ZwerchfellsTHE GASTROCARDIAC SYNDROME 1 December 1950Volume 33, Issue 6Page: 1472-1479KeywordsHeart diseasesHerniaPulmonary diseasesStomach ePublished: 1 December 2008 Issue Published: 1 December 1950 PDF downloadLoading ...