Eur J Cardiothorac Surg 1999;16:371-373
© 1999 Elsevier Science NL
Abdominal abscess: late complication after gastroepiploic coronary artery bypass grafting
Clinton T. Lloyd,
Raimondo Ascione,
Shiv Gupta,
Gianni D. Angelini
Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK
Corresponding author. Tel.: +44-117-928-3145; fax: +44-117-929-9737
e-mail: g.d.angelini{at}bristol.co.uk
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Abstract
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The gastroepiploic artery is widely used an arterial conduit during coronary artery revascularisation surgery. We report an unusual complication of a 56-year-old man who developed a late intra-abdominal abscess extending into the mediastinum adjacent to the right ventricle more than 2 years after surgery. This was managed with percutaneous drainage and the patient made a full recovery. The case illustrates the potential problems associated with harvesting of this artery and the need for careful haemostasis.
Key Words: Gastroepiploic artery • Abscess • Coronary artery bypass graft
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1. Introduction
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The use of the gastroepiploic artery (GEA) as a conduit for myocardial revascularisation has now become widely accepted. The limiting factors with the use of this artery have been the risks associated with laparotomy and the concern of arterial spasm. We report an unusual long-term complication following harvesting and grafting of the right gastroepiploic artery to the posterior descending coronary artery.
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2. Case report
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A 56-year-old man was admitted electively to our unit and underwent successful myocardial revascularisation for ischaemic heart disease in 1995. During the operation access was gained to the abdomen by extending the sternotomy incision downward by 4 cm. The left internal mammary artery was anastomosed to the left anterior descending coronary artery and the right gastroepiploic artery was anastomosed to the posterior descending branch of the right coronary artery via a antegastric approach. There were no complications during the procedure. Postoperatively the patient was transfused 1 unit of packed red cells for a low measured haemaglobin but otherwise made an unremarkable recovery and was discharged home on day 6 with the wound well healed. He presented to our unit 2 years 4 months later with a 3-month history of increasing epigastric discomfort and two areas of erythematous swelling in the midline scar. The first at the lower edge of the sternum and the second at the lower end of the abdominal incision from which there was a small discharge of pus. Further enquiry revealed no anginal symptoms since the operation and no other abdominal symptoms. On examination he was well; apyrexial and abdominal examination revealed only minimal epigastric tenderness. Investigations showed normal full blood count (white cell count 6.8x109/l) and raised C-reactive protein (231 µg/l). A barium meal previously requested by his general practitioner showed only minimal gastro-oesophageal reflux. A computed tomography (CT) scan (Fig. 1A) revealed a large (20x25 cm) abscess within the upper peritoneal cavity, anterior to the stomach which was displaced posteriorly, and extending behind the sternum to the lower mediastinum adjacent to the right ventricle. The GEA graft was visible at the base of the abscess. A separate smaller (4x5 cm) abscess was situated extraperitoneally under the skin at the level of the lower swelling. Swab cultures from the discharge grew Staphylococcus aureus sensitive to Flucloxacillin. Under general anaesthetic the superficial abscess was drained and exploration of the base revealed no obvious communication with the peritoneal component. In view of concerns regarding the risk of damaging the GEA graft, the larger collection was drained under ultrasound guided percutaneous drainage with a 10 F drainage catheter – initially over 1200 ml and thereafter approximately 50–100 ml of pus per day. The patient was commenced on appropriate intravenous antibiotics and improved symptomatically within a few days. A CT scan repeated a week later (Fig. 1B) revealed marked resolution of both the peritoneal and thoracic abscess components and less posterior displacement of the GEA graft. The lower sternal wires were also removed as a potential nidus for the infection and the patient was discharged home after 10 days with the abdominal drain in situ. The drain was eventually removed 6 weeks after insertion and the patient continued on oral antibiotics for 3 months. A follow up CT scan showed complete resolution of the abscess, and a gastroscopy confirmed no obvious ulceration of the stomach or duodenum.
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Fig. 1. (A) A CT scan demonstrates the large intraperitoneal abscess (A) abutting the liver (L) and displacement of the stomach (S) posteriorly. (B) Resolution of the abscess after percutaneous drain placement (D).
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3. Discussion
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The use of the GEA as an additional coronary graft was first reported in 1987 and since then has been evaluated in a number of clinical studies [1]. Although predominantly used as conduit for the right coronary artery, it is also used to revascularise the branches of the left coronary artery. It has also been suggested that it may be the conduit of choice over the right internal thoracic artery for grafting of the right coronary artery [2]. It is of particular benefit to younger patients requiring multiple arterial grafts as demonstrated by its excellent early patency rate of 95% and 5-year patency rate of 82–95%. The enthusiasm for its routine use has, however, been tempered with concerns regarding its vascular reactivity and the potential to develop arterial spasm in the initial postoperative period as well as the complications associated with the laparotomy during harvesting. We have routinely used the GEA as a coronary graft in selected cases with minimal complications. This unusual complication of a late abscess has not been reported previously, although Sueda et al. reported a case of early severe mediastinitis infected by methicillin-resistant S. aureus following harvesting of the right GEA [3] which was treated successfully by omental transfer. The exact pathomechanism of the case we present is unknown, however, it seems likely that the patient developed a chronic suppurative infection in a haematoma from the harvested GEA at the time of the operation. Intra-abdominal bleeding is a known complication of the procedure that may require re-laparotomy, but the incidence of subclinical bleeding into the abdomen is probably underestimated. The time to presentation of over 2 years is indeed long for an iatrogenic infection, but the lack of evidence for any other potential source suggests this to be the cause. Ischaemic ulceration of the stomach [4] and gastric perforation [5] have both been described as complications following harvesting of the GEA. However, both the organism isolated and the normal endoscopy would suggest this as unlikely to be the cause of the abscess.
In conclusion, we consider the GEA to be an excellent arterial conduit and continue to use it in selected cases. Although this rare complication is unusual, it does highlight the potential problems associated with harvesting of the GEA and the need for careful haemostasis before closure of the abdomen.
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References
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Dietl C., Benoit C., Gilbert C., Woods E., Pharr W., Berkheimer M., et al. Which is the graft of choice for the right coronary and posterior descending arteries? Comparison of the right internal mammary artery and the right gastroepiploic artery. Circulation 1995;92(suppl 9):II92-II97.
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Sueda T., Kanehiro K., Morita S., Matsuura Y. Mediastinitis with an infection of methicillin-resistant Staphylococcus aureus treated by an omental transfer following CABG using a right gastroepiploic arterial graft: report of a case. Surg Today 1994;24(7):638-640.[Medline]
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Witkop J., Dillemans B., Grandjean J., Bams J., Ebels T. Gastric perforation after aortocoronary bypass grafting with the right gastroepiploic artery. Ann Thorac Surg 1994;58(4):1170-1171.[Abstract]
Received March 29, 1999;
received in revised form June 9, 1999;
accepted June 14, 1999.
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Abstract
1. Introduction
