Compression of the left atrium by a reconstructed gastric tube after subtotal oesophagectomy

I would like to report a patient who had cardiovascular instability after oesophagectomy. An elderly patient with oesophageal cancer underwent subtotal oesophagectomy through a median sternotomy. A gastric tube placed in the retro-mediastinal space was used for reconstruction. Cardiovascular instability (hypotension and tachycardia) developed immediately after surgery and hypovolaemia was suspected. Fluid resuscitation was not effective and a dopamine infusion was initiated. Transthoracic echocardiogram revealed the compression of the left atrium by a solid mass. CT showed compression of the left atrium by the gastric tube and decreased diameter of the left ventricle (Fig. 1). A chest tube was inserted into the right pleural cavity and the cardiovascular parameters stabilised dramatically. CT showing compression of the left atrium by the gastric tube (GT). Ao, aorta; PE, pleural effusion. There are multiple factors which caused compression of the left atrium in this patient. Firstly, the patient underwent subtotal oesophagectomy without a thoracotomy. Removal of the oesophagus via a right thoracotomy leads to a direct connection between the right pleural cavity and the mediastinum. In our patient there was no direct connection and a gastric tube was placed directly posterior to the heart. Secondly, our patient had a past history of pulmonary emphysema and bronchial asthma with hyperinflated lungs. Lastly, our patient developed bilateral pleural effusions postoperatively, which is common after thoracic lymph node dissection. Consequently, the contents of thoracic cavities (lungs and pleural effusion) compressed the mediastinum bilaterally. Compression of the left atrium mimicking cardiac tamponade has been reported in patients with type B aortic dissection [1], left ventricular pseudoaneurysm with subepicardial dissection [2], hiatus hernia and oesophageal carcinoma [3] and thymoma [4]. Transthoracic and transoesophageal echocardiography are reported to be useful in detecting a compressed left atrium. In our patient, transoesophageal echocardiography was not used because of the nature of the surgical procedure. This complication should be borne in mind when treating patients undergoing such surgery.