Marked Reversible ST-T Abnormalities Induced by Cardiac Compression From a Retrosternal Gastric Tube Used to Reconstruct the Esophagus After Tumor Resection A Case of a Diabetic Patient and Mini-Review of 7 Reported Patients

Abstract

SUMMARYA 69-year-old male patient with type 1 diabetes mellitus had been under treatment at our outpatient clinic since the age of 65. He had previously undergone surgery for esophageal cancer at the age of 55; the excised portion of the esophagus was replaced by a retrosternal gastric tube. He was admitted to our hospital for suspected pneumonia on April 8, 2004. An electrocardiogram (ECG) on admission showed marked ST depression in leads V 1 and V 2 , and prominent negative T waves in leads I and aVL; however, the T waves unexpectedly flattened after 2 minutes and the ST depression resolved after about 4 hours. On January 7, 2005, we performed a deep breathing test to analyze the effects of movements of the thoracic wall and intrathoracic structures on the ECG. In this test, deep inspiration induced ST depression reaching 0.5 mV in leads V 1 to V 3 ; this resolved on switching to deep expiration. ECG changes together with chest computed tomography images supported the concept that the ST-T abnormalities were induced by cardiac compression caused by expansion of the gastric tube between the sternum and heart. We have reviewed 7 other similar reported cases. (Int Heart J 2006; 47: 475-482) Key words: Electrocardiography, ST-T segment, Esophageal cancer, Deep breathing test, Chest computed tomography, Echocardiography, Diabetes mellitus, Retrosternal reconstruction, Gastric tube, Cardiac compression ELECTROCARDIOGRAPHY (ECG) is a useful tool for detecting ischemic heart disease, particularly in diabetic patients, because they often lack typical symptoms suggesting myocardial ischemia. However, it has been pointed out that ECG abnormalities resembling myocardial ischemia may be induced by extracardiac factors.1,2) Recently, compression of the heart by a retrosternal gastric tube TAKATO, ET AL used for esophageal reconstruction after resection of esophageal tumors has increasingly received attention as a new extracardiac factor that can induce prominent but reversible ECG abnormalities. [3][4][5][6][7][8] Resection of the esophagus followed by retrosternal reconstruction with a gastric tube is the most common surgical treatment for esophageal cancer in Japan. The diabetic patient presented in this report demonstrated marked reversible abnormalities in ECGs recorded 14 years after retrosternal gastric tube reconstruction was performed following resection of an esophageal tumor. CASE REPORTA 69-year-old male patient who had been under treatment for type 1 diabetes mellitus at our outpatient clinic since the age of 65 was admitted for suspected pneumonia on April 8, 2004. He had previously undergone retrosternal esophageal reconstruction using a gastric tube after excision of an esophageal tumor at the age of 55. He had never complained of any pain or discomfort in his chest that suggested ischemic heart disease. On admission, his chief complaints were cough and chills. His height was 166 cm and weight was 46.1 kg. He had a high fever of 39.9°C associated with a sinus tachycardia of 122/min. His blood pressure was...

Impact of the method of reconstruction after oncologic oesophagectomy on quality of life — a prospective, randomised study

“…The stomach is the most convenient oesophageal substitute, and is most widely used because it has a reliable blood supply and can be easily connected to the remaining oesophagus with a single anastomosis. However, the traditional whole-stomach reconstruction may frequently be related to postoperative complications (i.e., anastomotic fistula, delayed gastric emptying and impairment of pulmonary function) because it usually incurs high tension in the site of anastomosis, shows a tendency to decreased gastric peristalsis function and compresses intrathoracic structures (i.e., the heart, the lung) [12][13][14][15].…”

“…(2) This technique enhances the vascularisation in the site of anastomosis, facilitating the healing process [12]. (3) After tubulisation, the stomach shows less tendency to dilatation, relieving its compression on the intrathoracic structures [13,14,8]. (4) The gastric tube seems to preserve most of the original gastric motor characteristics, contributing as a good substitute for the original oesophagus and stomach [16].…”

Reversible Inferolateral ST-Segment Elevation Associated with Small Bowel Obstruction

“…It has been postulated that distension of hollow organs like the stomach, the gallbladder, or even reconstructed gastric or jejunal tubes following esophageal resection might cause direct cardiac compression leading to electrophysiological changes presented as ST-segment abnormalities [2, 3]. In our cases, increased intra-abdominal pressure might have led to relative displacement or compression of the inferior surface of the heart resulting into change in the mean QRS axis and/or voltage [4–6].…”

“…Coppola et al described myriad of disorders causing ST elevation including cardiac causes such as pericarditis, myocarditis, Brugada's syndrome, aortic dissection, Prinzmetal's angina, Takotsubo (stress-induced) cardiomyopathy, and hypertrophic cardiomyopathy; pulmonary causes such as pulmonary embolism, pneumothorax, and atelectasis; gastrointestinal causes like cholecystitis, pancreatitis; and other conditions like drug induced, hyperkalemia and hemorrhagic cerebrovascular disease [1]. To our knowledge, there are only three cases describing the ST-segment elevation in acute intestinal obstruction and very few cases reporting ST elevation due to other gastrointestinal pathology such as esophageal perforation and gastric tube insertion and inflation [2, 3]. In the first case, the patient had history of abdominal surgeries and presented with obvious symptoms of intestinal obstruction so we interpreted the ECG changes as a reflection of the intra-abdominal pathology and avoided invasive coronary angiography.…”

10p for an angiogram: the cardio-oesophageal reflex

“…This is called the cardio-oesophageal reflex. Direct cardiac compression from external structures, such as a gastric tube following oesophageal reconstruction, has also been shown to induce reversible ST-T abnormalities 2. There are also a few isolated case reports in the literature of ischaemic ECG changes in patients with acute pancreatitis, acute cholecystitis and pneumonia 3 4 5…”