Successful resuscitation from acute coronary syndrome during mediastinoscope-assisted transhiatal esophagectomy: a case report.

Background: Although unexpected cardiac arrest is a very rare intraoperative complication, strategies regarding preoperative screening and procedures to be taken in the event of an emergency need to be well established.

Case Presentation: A man in his late 70 s diagnosed with thoracic esophageal cancer, cT3N1M0, and cStage III was admitted. His metabolic equivalents were 4 or more. Electrocardiogram (ECG), ultrasound cardiography, and hematological examinations revealed no severe abnormalities. Computed tomography (CT) showed highly calcified coronary arteries. We performed mediastinoscope-assisted transhiatal esophagectomy. Procedures in the mediastinum involving access from the neck and abdomen were completed uneventfully. Middle mediastinal lymph node dissection and gastrointestinal reconstruction with the patient in the prone position were scheduled for later. However, before the change in position, pulseless nonsustained ventricular tachycardia (VT) suddenly occurred and caused blood pressure to drop sharply to below 30 mmHg. The VT disappeared in approximately 20 s, and there was a return to sinus rhythm after cardiac resuscitation; however, the ECG showed a decrease in the ST segments of leads II, III, and aVF. Immediately thereafter, the patient was transferred to the cardiac catheterization laboratory for percutaneous coronary intervention. Cardiac catheterization revealed diffuse stenosis of 90% in the left anterior descending branch of the coronary artery (segment no. 6). Plain old balloon angioplasty and stent placement were performed. Dual antiplatelet therapy was needed. On the next day, thoracoscopic esophagectomy was performed in the left lateral decubitus position, followed by cervical esophagostomy in the supine position. He developed acute respiratory distress syndrome and thoracic aortic dissection on the 5th postoperative day (POD) and intraperitoneal bleeding on the 16th POD. On the 105th POD, laparoscopic-assisted cervical esophagogastric anastomosis was performed. Parkinson's disease was diagnosed on the 126th POD. On the 313th POD, the patient was discharged.

Conclusion: Surgeons should be familiar with the guidelines for patient screening and management of intraoperative cardiac arrest. In patients with severe coronary artery calcification, further investigation such as coronary angiography CT may be necessary before esophagectomy. Furthermore, highly invasive surgery should be performed in well-equipped hospitals.