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Case Report Bariatric Times • January 2014 Dysphagia Lusoria: Five Years Following Gastric Bypass Surgery by WASEF ABU-JAISH MD, FACS; MOLLY WASSERMAN, MD; MOHAMMAD JAFFERJI, MS-III; and VISHAL SHAH, MS-III A 21 B FIGURE 1. Upper endoscopy showed no abnormality. Bariatric Times. 2014;11(1):21–23. ABSTRACT Aberrant right subclavian artery is a congenital malformation of the aortic arch which is most often asymptomatic but a small percentage of patients can develop symptoms during their adult life. The authors report a rare case of an adult patient with symptomatic aberrant right subclavian artery five years following Roux-en-Y gastric bypass for morbid obesity. intervention and sought another opinion in her home town. The patient was discharged with instructions to follow up with a cardiothoracic surgeon and our bariatric clinic as an out-patient. KEYWORDS DISCUSSION Obesity, Roux-en-Y gastric bypass (RYGB), aortic arch; esophageal motility disorders, complications, dysphagia lusoria Continued from page 1 CASE REPORT A 59-year-old Caucasian woman with a history of an open RYGB operation (2006) presented to a local emergency department with the chief complaint of a one-month history of progressively worsening epigastric pain, chest pain, and dysphagia with associated foaming at the mouth. Her symptoms initially occurred 30 minutes postprandially and were associated with lying supine; as the month progressed, pain also began occurring with sitting and standing. Two days prior to presenting at our hospital, she had presented to an outside hospital with similar complaints. Extensive cardiac workup was negative for an acute coronary syndrome and she was discharged home with instructions to follow up at the bariatric clinic. Her symptoms worsened, and she presented to our hospital with increased chest pain, dysphagia, and hypersalivation. She reportedly had been tolerating soft foods and liquids, but had difficulty eating solids. Her pain was associated with nausea and non-bilious emesis with her remaining review of systems being negative. The patient's past medical history prior to the gastric bypass surgery comprised type 2 diabetes, hypercholesterolemia, hypertension, gastroesophageal reflux disease (GERD), and stress urinary incontinence. Her past surgical history was significant for a total abdominal hysterectomy with bilateral salpingo-oopherectomy, open appendectomy, open cholecystectomy, left rotator cuff repair, and bilateral carpal tunnel release. Upon arrival, the patient was hemodynamically stable. Except for mild epigastric tenderness to deep palpation, her exam was unremarkable. Laboratory findings were significant for hypokalemia and hypomagnesaemia, but hemogram, liver function tests, lipase, and cardiac enzymes were normal. An acute abdominal series showed no intra-abdominal free air or clear evidence of obstruction. Upper endoscopy showed no obvious cause of the patient's dysphagia. The gastric pouch was normal in size without evidence of bile reflux or gastro-gastric fistula. The gastro-jejunal anastomosis was patent without evidence of stricture or marginal ulceration (Figure 1). The patient subsequently underwent an upper GI series with a small bowel follow-through (Figures 2A and 2B) demonstrating abnormal tortuosity and tapering of the mid- to upper-thoracic esophagus in the region of the aortic arch. A computed tomography (CT) scan of the chest with contrast demonstrated an aberrant right subclavian artery that was compressing the esophagus (Figures 3–5). Regardless of cardiothoracic surgery's recommendations, the patient declined any surgical Aberrant right subclavian artery, or arteria lusoria, is a congenital malformation of the aortic arch in which four vessels arise sequentially from the arch in the following manner: right common carotid artery, left common carotid artery, left subclavian artery, aberrant right subclavian artery. It is most often asymptomatic, but a small percentage of patients can develop symptoms, including dysphagia, tracheal compression, upper extremity ischemic complications, or aneurysmal dilatation, requiring surgical intervention. Initially described by Bayford5,6 in 1794, this aberration is the most common congenital intrathoracic aortic arch abnormality7 with a prevalence of 0.5 to 2.5 percent8,9. In normal embryologic development, the right subclavian artery is formed by fusion of the persistent right dorsal aorta proximally with the right seventh intersegmental artery distally6. Aberrancy of the right subclavian artery occurs when there is involution of the right fourth vascular arch and proximal right dorsal aorta, and persistence of the seventh intersegmental artery which originates from the proximal descending thoracic aorta. The usual path for this aberrant vessel is to course superiorly and to the right through the posterior mediastinum7. The aberrant vessel crosses behind the esophagus 80 to 84 percent of the time, with the remainder of cases crossing either between the esophagus and the trachea (12.7–15%) or in front of the trachea (4.2–5%)7. Up to 60 percent of patients with this anomaly have an aberrant artery in which the lumen at the origin is wider than that of the rest of the thoracic subclavian artery, resulting in an infundibulum, also known as a "Kommerell's diverticulum"7. When children with this aberrancy are symptomatic, they present with respiratory difficulties including stridor, cough, and respiratory infections.10 Asymptomatic aberrant right subclavian arteries in adulthood are generally found incidentally. Five percent of adults with this anomaly are symptomatic, such as the patient presented in this case report. Dyspnea, chronic coughing, and dysphagia, termed dysphagia lusoria, are the usual presenting symptoms in adulthood. These symptoms are likely due to the development of atherosclerosis or fibromuscular dysplasia with dilation of a Kommerell's diverticulum compressing on the trachea or esophagus11 leading to increased rigidity of the esophagus or fibrous transformation of the paratracheal and esophageal tissues6,10. Imaging techniques that are most helpful in the diagnosis of an aberrant right subclavian artery include a barium-contrast esophagogram, demonstrating the characteristic diagonal compression defect at the level of the third and fourth vertebral levels, CT scanning, and angiography10. Identification of this anomaly preoperatively is critically important,7 especially as this aberrant vascular pattern may pose a challenge for endovascular clinicians. Recent investigation into the use of multidetector computed tomography (MDCT) has shown it to be a useful diagnostic tool in evaluating vascular abnormalities as a cause for dysphagia13. Due to the rarity of this condition, there is no standard-ofcare for the treatment of an