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• W2054850008 abstract "For most patients with esophageal cancer, esophagectomy is an effective therapy. Perioperative management is critical for clinical outcomes after the operation. Great efforts should be made to avoid postoperative complications. We report myxedema coma, an emergency condition caused by severe hypothyroidism, after a patient underwent esophagectomy for esophageal cancer. The patient was successfully treated with intravenous levothyroxine. We strongly recommend that physicians test the thyroid hormone levels in patients with risk factors. If myxedema coma occurs, immediate use of intravenous levothyroxine is effective for this lethal complication. For most patients with esophageal cancer, esophagectomy is an effective therapy. Perioperative management is critical for clinical outcomes after the operation. Great efforts should be made to avoid postoperative complications. We report myxedema coma, an emergency condition caused by severe hypothyroidism, after a patient underwent esophagectomy for esophageal cancer. The patient was successfully treated with intravenous levothyroxine. We strongly recommend that physicians test the thyroid hormone levels in patients with risk factors. If myxedema coma occurs, immediate use of intravenous levothyroxine is effective for this lethal complication. Esophageal cancer is the sixth most frequent tumor disease worldwide [1Kollarova H. Machova L. Horakova D. Janoutova G. Janout V. Epidemiology of esophageal cancer- an overview article.Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2007; 151: 17-28Crossref PubMed Scopus (81) Google Scholar]. Esophagectomy remains the standard and effective surgical treatment for early-stage tumors confined to the esophagus and paraesophageal region. Unfortunately, many fatal complications can occur after radical esophagectomy and reconstruction of the esophagus. To date, surgical resection is the only curative option for esophageal cancer, implying that improving the outcomes of the operation is an effective way to reduce mortality. Perioperative management is therefore very important for patient outcomes.Hyperthyroidism crisis has been widely regarded as a severe complication for patients with hyperthyroidism undergoing thoracic operations; however, hypothyroidism after the operation draws less attention. Myxedema coma caused by severe hypothyroidism has a very low incidence, but it is a medical emergency with high mortality. We report a rare case of myxedema coma after esophagectomy in an esophageal cancer patient.A 58-year-old man presented with a 4-month history of epigastric pain. He was diagnosed with esophageal squamous cell cancer in the lower esophagus by endoscopy and analysis of the biopsy specimen. He had been diagnosed 8 years earlier with hyperthyroidism and had been treated with radioactive iodine 131, after which the results of thyroid function tests were normal and stable during follow-up visits. Because of this history of radioactive iodine 131 treatment for hyperthyroidism, we tested his thyroid function 3 days before the operation, and the results were normal. Lung function tests showed no signs of abnormality. The electrocardiogram showed left anterior fascicular block, and the cardiac ultrasound examination was unremarkable. Chest and abdominal computed tomography found no metastasis of cancer. Other laboratory tests, including the complete blood count, blood coagulation test, and blood biochemistry, revealed normal results, and no contraindication for the operation was identified.Radical esophagectomy and reconstruction of the esophagus by gastric tube under the aortic arch through the left thorax was performed successfully on hospital day 9. The patient's vital signs monitored in intensive care unit were stable during the first postoperative day, and he was transferred out of the intensive care unit.The patient was treated with prophylactic antibiotic therapy and received regular nutritional and fluid support. Except for complaints of incisional pain, his condition remained stable. By 40 hours after the operation, however, the patient began to present with somnolence and dyspnea, and his pulse oxygen saturation level decreased to 85%. We immediately put an oxygen mask on the patient, and blood was drawn for examination. The blood gas analysis revealed a partial pressure of oxygen of 50 mm Hg, partial pressure of carbon dioxide of 45 mm Hg, and power of hydrogen of 7.22, so we initiated orotracheal intubation and mechanical ventilator-assisted ventilation. Other support was also given to maintain the electrolytes and acid-base balances.The patient remained unconscious, and his respiratory function stayed unstable for the next 2 days. A chest roentgenogram showed no signs of respiratory infection, atelectasis, pleural effusion, or aerothorax. Cranial computed tomography revealed no positive findings. Because the patient had a history of hyperthyroidism and iodine 131 therapy, we considered the possibility of thyroid function abnormality after the stress of the operation.Concentrations of thyroid hormones on postoperative day 5 were 14.090 mU/L for thyroid stimulating hormone, 1.04 pmol/L for free triiodothyronine, and 2.45 pmol/L for free thyroxine. Intravenous levothyroxine (300 μg) was immediately given, and a dosage of 60 μg daily was maintained. The patient's condition gradually improved. By the second day after the initial use of levothyroxine, the patient regained consciousness. The next day he was able to maintain effective respiration without a ventilator and was extubated. By postoperative day 15, the patient was able to take a semi-liquid diet, and he was discharged with oral thyroid hormone replacement therapy.CommentEsophagectomy has been generally accepted as an operation with high complication rate, and proper perioperative management is a key point for patient recovery. Myxedema coma after esophagectomy is a rare event, especially for a patient with normal thyroid hormone levels preoperatively. Myxedema coma is an emergency condition with a high mortality rate. It results from severe hypothyroidism and usually occurs as long-standing hypothyroidism or is secondarily precipitated by acute stress events such as infection, cold exposure, a major operation, or medications.The clinical manifestation of myxedema coma may vary in different patients, but the presentation usually includes decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation. The laboratory findings can show the distinctive thyroid stimulating hormone, free triiodothyronine, and free thyroxine changes. Early diagnosis and treatment are crucial for the successful rescue.Thyroid function may change in some patients undergoing major operations. One of the most important manifestations is the decrease of serum triiodothyronine and thyroxine concentrations. The causes for these changes vary considerably in different patients [2Utiger R.D. Altered thyroid function in nonthyroidal illness and surgery To treat or not to treat?.N Engl J Med. 1995; 333: 1562-1563Crossref PubMed Scopus (123) Google Scholar]. For most patients, these decreases have no pathophysiologic consequences; but for this patient, the changes led to a potentially life-threatening situation. The acute severe stress of the operation for esophageal cancer caused a decrease of serum triiodothyronine and thyroxine concentrations, while at the same time the needs for thyroid hormone after this major operation increased dramatically. In addition, the function and compensation ability of the thyroid gland had been impaired by the previous iodine 131 radiotherapy. Thus, the compensation of the thyroid gland was not sufficient to meet this increasing metabolic requirement in a relative short period, and as a result, the patient presented with the severe hypothyroidism manifesting as myxedema coma.The clinical evidence of myxedema coma postoperatively is usually complicated and hidden. We believe that the pathophysiologic changes for patients after major operations (altered mental status, blood pressure, hypoventilation) may overlap with myxedema coma or they may counteract each other (changed heart rate, body temperature). This makes it difficult to confirm the diagnosis of myxedema, as had occurred in our patient, whose primary symptoms of coma and hypoventilation were nonspecific. So, early diagnosis and treatment can be difficult. Fortunately, the incidence of myxedema coma after surgery is extremely low. The relevant reports we found included a 46-year-old woman after hip replacement [3Ragaller M. Quintel M. Bender H.J. Albrecht D.M. Myxedema coma as a rare postoperative complication.Anaesthesist. 1993; 42: 179-183PubMed Google Scholar] and a 92-year-old patient after an urgent operation for a digestive problem [4Fritsch N. Tran-Van D. Dardare E. Gentile A. Deroudilhe G. Fontaine B. The myxoedema coma exists, we met it.Ann Fr Anesth. 2007; 26: 795-798PubMed Google Scholar].Comprehensive support therapy, including mechanical ventilation if necessary, rewarming the body temperature, and treatment of the hypotension, bradycardia, and hyponatremia is essential for this life-threatening condition. More important, intravenous thyroid hormone replacement therapy should be given immediately. The best medication for thyroid replacement remains controversial. Some endocrinologists recommend initially administering 200 to 500 μg of intravenous levothyroxine, followed by 50 to 100 μg/d [5Kearney T. Dang C. Diabetic and endocrine emergencies.Postgrad Med J. 2007; 83: 79-86Crossref PubMed Scopus (52) Google Scholar]. This patient was successfully rescued with 300 μg of levothyroxine, followed by 60 μg/d. At the same time, attention should be given to the risk of cardiac complications.Myxedema coma, a rare postoperative complication, is lethal if not immediately and properly managed; thus, early diagnosis is critical for this emergency complication. We strongly recommend that physicians test the thyroid hormone level in patients with risk factors, especially for the patients with thyroid gland diseases and in postoperative patients presenting with unexplainable unconsciousness, hypothermia, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation. If myxedema coma occurs, immediate intravenous levothyroxine is effective for this severe complication. Esophageal cancer is the sixth most frequent tumor disease worldwide [1Kollarova H. Machova L. Horakova D. Janoutova G. Janout V. Epidemiology of esophageal cancer- an overview article.Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2007; 151: 17-28Crossref PubMed Scopus (81) Google Scholar]. Esophagectomy remains the standard and effective surgical treatment for early-stage tumors confined to the esophagus and paraesophageal region. Unfortunately, many fatal complications can occur after radical esophagectomy and reconstruction of the esophagus. To date, surgical resection is the only curative option for esophageal cancer, implying that improving the outcomes of the operation is an effective way to reduce mortality. Perioperative management is therefore very important for patient outcomes. Hyperthyroidism crisis has been widely regarded as a severe complication for patients with hyperthyroidism undergoing thoracic operations; however, hypothyroidism after the operation draws less attention. Myxedema coma caused by severe hypothyroidism has a very low incidence, but it is a medical emergency with high mortality. We report a rare case of myxedema coma after esophagectomy in an esophageal cancer patient. A 58-year-old man presented with a 4-month history of epigastric pain. He was diagnosed with esophageal squamous cell cancer in the lower esophagus by endoscopy and analysis of the biopsy specimen. He had been diagnosed 8 years earlier with hyperthyroidism and had been treated with radioactive iodine 131, after which the results of thyroid function tests were normal and stable during follow-up visits. Because of this history of radioactive iodine 131 treatment for hyperthyroidism, we tested his thyroid function 3 days before the operation, and the results were normal. Lung function tests showed no signs of abnormality. The electrocardiogram showed left anterior fascicular block, and the cardiac ultrasound examination was unremarkable. Chest and abdominal computed tomography found no metastasis of cancer. Other laboratory tests, including the complete blood count, blood coagulation test, and blood biochemistry, revealed normal results, and no contraindication for the operation was identified. Radical esophagectomy and reconstruction of the esophagus by gastric tube under the aortic arch through the left thorax was performed successfully on hospital day 9. The patient's vital signs monitored in intensive care unit were stable during the first postoperative day, and he was transferred out of the intensive care unit. The patient was treated with prophylactic antibiotic therapy and received regular nutritional and fluid support. Except for complaints of incisional pain, his condition remained stable. By 40 hours after the operation, however, the patient began to present with somnolence and dyspnea, and his pulse oxygen saturation level decreased to 85%. We immediately put an oxygen mask on the patient, and blood was drawn for examination. The blood gas analysis revealed a partial pressure of oxygen of 50 mm Hg, partial pressure of carbon dioxide of 45 mm Hg, and power of hydrogen of 7.22, so we initiated orotracheal intubation and mechanical ventilator-assisted ventilation. Other support was also given to maintain the electrolytes and acid-base balances. The patient remained unconscious, and his respiratory function stayed unstable for the next 2 days. A chest roentgenogram showed no signs of respiratory infection, atelectasis, pleural effusion, or aerothorax. Cranial computed tomography revealed no positive findings. Because the patient had a history of hyperthyroidism and iodine 131 therapy, we considered the possibility of thyroid function abnormality after the stress of the operation. Concentrations of thyroid hormones on postoperative day 5 were 14.090 mU/L for thyroid stimulating hormone, 1.04 pmol/L for free triiodothyronine, and 2.45 pmol/L for free thyroxine. Intravenous levothyroxine (300 μg) was immediately given, and a dosage of 60 μg daily was maintained. The patient's condition gradually improved. By the second day after the initial use of levothyroxine, the patient regained consciousness. The next day he was able to maintain effective respiration without a ventilator and was extubated. By postoperative day 15, the patient was able to take a semi-liquid diet, and he was discharged with oral thyroid hormone replacement therapy. CommentEsophagectomy has been generally accepted as an operation with high complication rate, and proper perioperative management is a key point for patient recovery. Myxedema coma after esophagectomy is a rare event, especially for a patient with normal thyroid hormone levels preoperatively. Myxedema coma is an emergency condition with a high mortality rate. It results from severe hypothyroidism and usually occurs as long-standing hypothyroidism or is secondarily precipitated by acute stress events such as infection, cold exposure, a major operation, or medications.The clinical manifestation of myxedema coma may vary in different patients, but the presentation usually includes decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation. The laboratory findings can show the distinctive thyroid stimulating hormone, free triiodothyronine, and free thyroxine changes. Early diagnosis and treatment are crucial for the successful rescue.Thyroid function may change in some patients undergoing major operations. One of the most important manifestations is the decrease of serum triiodothyronine and thyroxine concentrations. The causes for these changes vary considerably in different patients [2Utiger R.D. Altered thyroid function in nonthyroidal illness and surgery To treat or not to treat?.N Engl J Med. 1995; 333: 1562-1563Crossref PubMed Scopus (123) Google Scholar]. For most patients, these decreases have no pathophysiologic consequences; but for this patient, the changes led to a potentially life-threatening situation. The acute severe stress of the operation for esophageal cancer caused a decrease of serum triiodothyronine and thyroxine concentrations, while at the same time the needs for thyroid hormone after this major operation increased dramatically. In addition, the function and compensation ability of the thyroid gland had been impaired by the previous iodine 131 radiotherapy. Thus, the compensation of the thyroid gland was not sufficient to meet this increasing metabolic requirement in a relative short period, and as a result, the patient presented with the severe hypothyroidism manifesting as myxedema coma.The clinical evidence of myxedema coma postoperatively is usually complicated and hidden. We believe that the pathophysiologic changes for patients after major operations (altered mental status, blood pressure, hypoventilation) may overlap with myxedema coma or they may counteract each other (changed heart rate, body temperature). This makes it difficult to confirm the diagnosis of myxedema, as had occurred in our patient, whose primary symptoms of coma and hypoventilation were nonspecific. So, early diagnosis and treatment can be difficult. Fortunately, the incidence of myxedema coma after surgery is extremely low. The relevant reports we found included a 46-year-old woman after hip replacement [3Ragaller M. Quintel M. Bender H.J. Albrecht D.M. Myxedema coma as a rare postoperative complication.Anaesthesist. 1993; 42: 179-183PubMed Google Scholar] and a 92-year-old patient after an urgent operation for a digestive problem [4Fritsch N. Tran-Van D. Dardare E. Gentile A. Deroudilhe G. Fontaine B. The myxoedema coma exists, we met it.Ann Fr Anesth. 2007; 26: 795-798PubMed Google Scholar].Comprehensive support therapy, including mechanical ventilation if necessary, rewarming the body temperature, and treatment of the hypotension, bradycardia, and hyponatremia is essential for this life-threatening condition. More important, intravenous thyroid hormone replacement therapy should be given immediately. The best medication for thyroid replacement remains controversial. Some endocrinologists recommend initially administering 200 to 500 μg of intravenous levothyroxine, followed by 50 to 100 μg/d [5Kearney T. Dang C. Diabetic and endocrine emergencies.Postgrad Med J. 2007; 83: 79-86Crossref PubMed Scopus (52) Google Scholar]. This patient was successfully rescued with 300 μg of levothyroxine, followed by 60 μg/d. At the same time, attention should be given to the risk of cardiac complications.Myxedema coma, a rare postoperative complication, is lethal if not immediately and properly managed; thus, early diagnosis is critical for this emergency complication. We strongly recommend that physicians test the thyroid hormone level in patients with risk factors, especially for the patients with thyroid gland diseases and in postoperative patients presenting with unexplainable unconsciousness, hypothermia, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation. If myxedema coma occurs, immediate intravenous levothyroxine is effective for this severe complication. Esophagectomy has been generally accepted as an operation with high complication rate, and proper perioperative management is a key point for patient recovery. Myxedema coma after esophagectomy is a rare event, especially for a patient with normal thyroid hormone levels preoperatively. Myxedema coma is an emergency condition with a high mortality rate. It results from severe hypothyroidism and usually occurs as long-standing hypothyroidism or is secondarily precipitated by acute stress events such as infection, cold exposure, a major operation, or medications. The clinical manifestation of myxedema coma may vary in different patients, but the presentation usually includes decreased mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation. The laboratory findings can show the distinctive thyroid stimulating hormone, free triiodothyronine, and free thyroxine changes. Early diagnosis and treatment are crucial for the successful rescue. Thyroid function may change in some patients undergoing major operations. One of the most important manifestations is the decrease of serum triiodothyronine and thyroxine concentrations. The causes for these changes vary considerably in different patients [2Utiger R.D. Altered thyroid function in nonthyroidal illness and surgery To treat or not to treat?.N Engl J Med. 1995; 333: 1562-1563Crossref PubMed Scopus (123) Google Scholar]. For most patients, these decreases have no pathophysiologic consequences; but for this patient, the changes led to a potentially life-threatening situation. The acute severe stress of the operation for esophageal cancer caused a decrease of serum triiodothyronine and thyroxine concentrations, while at the same time the needs for thyroid hormone after this major operation increased dramatically. In addition, the function and compensation ability of the thyroid gland had been impaired by the previous iodine 131 radiotherapy. Thus, the compensation of the thyroid gland was not sufficient to meet this increasing metabolic requirement in a relative short period, and as a result, the patient presented with the severe hypothyroidism manifesting as myxedema coma. The clinical evidence of myxedema coma postoperatively is usually complicated and hidden. We believe that the pathophysiologic changes for patients after major operations (altered mental status, blood pressure, hypoventilation) may overlap with myxedema coma or they may counteract each other (changed heart rate, body temperature). This makes it difficult to confirm the diagnosis of myxedema, as had occurred in our patient, whose primary symptoms of coma and hypoventilation were nonspecific. So, early diagnosis and treatment can be difficult. Fortunately, the incidence of myxedema coma after surgery is extremely low. The relevant reports we found included a 46-year-old woman after hip replacement [3Ragaller M. Quintel M. Bender H.J. Albrecht D.M. Myxedema coma as a rare postoperative complication.Anaesthesist. 1993; 42: 179-183PubMed Google Scholar] and a 92-year-old patient after an urgent operation for a digestive problem [4Fritsch N. Tran-Van D. Dardare E. Gentile A. Deroudilhe G. Fontaine B. The myxoedema coma exists, we met it.Ann Fr Anesth. 2007; 26: 795-798PubMed Google Scholar]. Comprehensive support therapy, including mechanical ventilation if necessary, rewarming the body temperature, and treatment of the hypotension, bradycardia, and hyponatremia is essential for this life-threatening condition. More important, intravenous thyroid hormone replacement therapy should be given immediately. The best medication for thyroid replacement remains controversial. Some endocrinologists recommend initially administering 200 to 500 μg of intravenous levothyroxine, followed by 50 to 100 μg/d [5Kearney T. Dang C. Diabetic and endocrine emergencies.Postgrad Med J. 2007; 83: 79-86Crossref PubMed Scopus (52) Google Scholar]. This patient was successfully rescued with 300 μg of levothyroxine, followed by 60 μg/d. At the same time, attention should be given to the risk of cardiac complications. Myxedema coma, a rare postoperative complication, is lethal if not immediately and properly managed; thus, early diagnosis is critical for this emergency complication. We strongly recommend that physicians test the thyroid hormone level in patients with risk factors, especially for the patients with thyroid gland diseases and in postoperative patients presenting with unexplainable unconsciousness, hypothermia, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and hypoventilation. If myxedema coma occurs, immediate intravenous levothyroxine is effective for this severe complication." @default.
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• W2054850008 title "Myxedema Coma After Esophagectomy" @default.
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