1. Vascular anomaly as a rare cause of dysphagia after bariatric surgery
Kolec S, Plamper A, Wenzel P, Rheinwalt K
Department of Bariatric and Metabolic Surgery, St. Franziskus-Hospital, Schönsteinstr. 63, Cologne, Germany
Patient
Anatomic excursion
In 70% of cases the right sublcavian artery branches out from the brachiocephalic trunk which leads off the proximal aortic arch. If the right subclavian artery originates directly from the proximal descending aorta, it leads retroesophageally to the right arm. This variant is called lusorian artery and can be found in 0,5% up to 1,8%. Should this artery very rarely lead to symptomatic compression of the esophagus, then this phenomenon is described as lusoric dysphagia. [1-4]
We present a 36-year-old female patient with an initial BMI of 45 kg/m² (106 kg/ 153cm). Obesity-associated co-morbidities were sleep apnea, hypertension, hyperuricemia and reactive depression. Other relevant morbidities included stable Crohn‘s disease and a complicated cardiac arrhythmia (AVNRT) for which she had a cardiac pacemaker in situ. Preoperative psychological assessment did not reveal abnormalities. Dysphagia was never reported.
Clinical course
Discussion
Because of preexisting Crohn‘s disease we decided to do a laparoscopic sleeve resection which was performed uneventfully in February After an initial uncomplicated recovery the patient complained of severe dysphagia both for liquids and solids. Gastroscopy and radiography revealed an angulation in the distal sleeve which was stepwise dilated up to 40mm without improvement of the symptoms. At the laparoscopic revision we converted the sleeve to a Roux-en-Y gastric bypass (RNYGB) as a last resort in May At 30ml pouch size the length of the alimentary limb was kept particularly short (50cm) to ensure the anastomosis could be reached gastroscopically in view to her Crohn’s disease. To facilitate weight loss however we kept the biliopancreatic limb rather long (150cm). Unfortunately this procedure also had no effect on her dysphagia. Repeated diagnostic procedures could not demonstrate  any significant pathology. The patient received concomitant psychosomatic treatment. Under the assumption of a (non-existing) stenosis of her gastrojejunostomy, in a further hospital an open residual gastrectomy was performed in October The histology of the resected gastroenteric anastomosis was without pathological findings. The dysphagia persisted. Esophageal manometric studies were normal. In yet another hospital her esophagojejunostomy was dilated 3 times to max. 15mm under the assumption of a stenosis. This did not lead to any improvement, either. Finally a thoracic CT showed an aberrant outlet of her right subclavian artery out of her proximal aorta, a so-called lusorian artery. An unsuccessful conservative approach was taken in the form of swallow training with adjuvant psychosomatic treatment. A vascular surgical correction was taken into consideration but not yet performed because the radiography did not show a relevant functional stenosis of the upper esophagus. The patient’s present BMI is 21 kg/m² at around 50kg. This equates to an EWL of over 100%. Thus the patient is at risk of becoming underweight. She is able to swallow fluids, yet remains intolerant to solids.
The lusoric malformation was preexistent preoperatively when it was completely asymptomatic. Perhaps the esophageal dysfunction manifested itself in response to the functional changes in the upper gastrointestinal tract following surgery. Or should we assume a pathological duplicity in that the vascular structure was altered by a coincidental rigid atherosclerotic plaque or aneurysmatic expansion in such a way that it may have led to a functional and mainly subjective alteration of the swallow process? The bottom line is that the lusoric malformation in combination with upper gastrointestinal surgery led to severe dysphagia and weight loss. In the absence of a pathological radiography the indication for vascular surgical correction remains doubtful. Thus, psychological and nutritional treatment are the principal options. [1-4]
Summary / Conclusion
The (lusoric) malformation of the right subclavian artery may become symptomatic with dysphagia only after bariatric surgery. Post-bariatric dysphagia in exclusion of other common findings should take into account the differential diagnosis of lusorian malformation to avoid unnecessary further operations on the upper gastrointestinal tract (as happened in our case). Vascular surgical correction is indicated only if a morphological and/or functional stenosis can be proved on radiography.
References:
Bennett, A L, Cock C, Heddle R, Morcom R K; Dysphagia lusoria: a late onset presentation; World J Gastroenterol, 2013; 19; 15; 2433–2436.
Hart P A, Kamath P S, Dysphagia lusoria, Mayo Clin Proc. 2012; 87; 3; e17.
Venugopal R R, Krishnajirao S P, Narayan M, Kolwalkar J P A novel approach for the treatment of dysphagia lusoria. Eur J Cardiothorac Surg
2013; 43; 2;
Dandelooy J, Coveliers J P M, Van Schil P E Y, Anguille S, Dysphagia lusoria, CMAJ, 2009; 181; 8: 498
A. carotis communis sinistra
A. carotis communis dextra
Esophagus
A. carotis
communis
sinistra
A. carotis
communis
dextra
A. subclavia
dextra
A. subclavia
sinistra
A. lusoria
A. subclavia
sinistra
Truncus brachiocephalicus
A. subclavia
dextra as
A. lusoria
Arcus aortae
Arcus aortae
Aorta
ascendens
Aorta
descendens
Trachea
Postoperative
contrast
swallow
Lusorian notch
A. lusoria
Esophagus
A. lusoria