Laparoscopic Management of Obstructed Gastric Conduit After Minimally Invasive Esophagectomy Garrett Friedman, MD, Hannah Copeland, MD, Juan Andres Astudillo, MD, Marcos Michelotti, MD, and Jason Wallen, MD Loma Linda University Medical Center, Loma Linda, California
We describe a novel, minimally invasive method of managing an obstructed gastric conduit after minimally invasive esophagectomy. In addition, we briefly review the management of obstructed gastric conduit in patients status-post minimally invasive esophagectomy. On literature review, it was noted that gastrojejunostomy after esophagectomy was exceptionally rare. Only one other reported case of gastrojejunostomy after esophagectomy was found in the literature. This is the first reported case to our knowledge of laparoscopic gastrojejunostomy after minimally invasive esophagectomy (MIE). Laparoscopic gastrojejunostomy after minimally invasive esophagectomy for obstructed gastric conduit is technically feasible, and it effectively managed the obstruction in our patient. (Ann Thorac Surg 2014;97:e145–6) Ó 2014 by The Society of Thoracic Surgeons
O
bstruction of the gastric conduit after MIE is an unusual but potentially debilitating postoperative complication. We present the first reported case, to our knowledge, of laparoscopic management of this condition with the creation of a gastrojejunostomy. We present a case of a 57-year-old male patient who complained of nausea and postprandial emesis 1.5 years after MIE for esophageal adenocarcinoma. He also noted a 75-pound weight loss since the surgery. The laboratory values revealed severe malnutrition, with an albumin level of 2.8 g/dL. Abdominal radiographs did not indicate any evidence of bowel obstruction or ileus. Esophagram showed a possible duodenal obstruction (Fig 1), and a laparoscopic gastrojejunostomy was planned. A diagnostic laparoscopy was initially performed, which revealed that the gastric conduit and the third portion of the duodenum had been pushed anteriorly by a large retroperitoneal mass. Several small peritoneal implants were noted on the lateral abdominal wall, which was concerning for possible peritoneal carcinomatosis; however, rapid frozen sections were negative for carcinoma. Intraoperative esophagogastroduodenoscopy (EGD) revealed a nodular, friable retrogastric mass that was highly suggestive of recurrent carcinoma (Fig 2).
Fig 1. Preoperative esophagram indicating possible duodenal obstruction.
Biopsies of the mass were performed. The endoscope was able to pass the mass easily; however, it was unable to be advanced beyond the third portion of the duodenum because of an extrinsic distortion from the aforementioned mass.
Accepted for publication Nov 25, 2013. Address correspondence to Dr Wallen, 11234 Anderson St, Rm 21005 CP, Loma Linda, CA 92354; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2. Nodular, obstructing mass on intraoperative EGD. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.11.082
e146
CASE REPORT FRIEDMAN ET AL LAP GASTRO-J FOR OBSTRUCTED CONDUIT AFTER MIE
Fig 3. Gastrojejunostomy just before closure.
At this point, we decided to perform a laparoscopic gastrojejunostomy to bypass the obstructed gastric conduit. The previous jejunostomy site was readily identified, and the adhesive bands attaching it to the abdominal wall were taken down. This loop of jejunum was isolated and brought up to the gastric conduit. A gastrotomy was made proximal to the obstruction, and a gastrojejunostomy was created using an endo-GIA stapler followed by closure with five 0-0 Surgidac Endo-stitch sutures (Figs 3, 4). A completion esophagogastroduodenoscopy was performed, which revealed an intact anastomosis. An esophagram was performed on the first postoperative day; it showed a patent anastomosis without evidence of leak. The patient was given a clear liquid diet, which was well tolerated without nausea or emesis. Postoperative pain was minimal, and the patient was discharged home on the second postoperative day. The final pathologic analyses of the peritoneal implants and the gastric conduit were negative for carcinoma. The gastric conduit biopsy specimens showed only benign gastric mucosa with patchy inflammation. An endoscopic ultrasound examination for biopsy of the retroperitoneal mass was later performed, which confirmed recurrent adenocarcinoma.
Ann Thorac Surg 2014;97:e145–6
Fig 4. Closure of gastrojejunostomy using 0-0 Surgidac Endo-stitch sutures.
conduit obstruction, or in this case, extrinsic compression of the conduit by a retroperitoneal mass. Suspected obstruction of the gastric conduit should be initially evaluated with a contrast esophagram and followed-up with esophagogastroduodenoscopy if the esophagram is indicative of an obstructive process. Our patient was extremely symptomatic from the obstruction and was experiencing weight loss; therefore, a bypass procedure to palliate his symptoms was chosen. During a literature review, it was noted that performance of gastrojejunostomy after esophagectomy is exceptionally rare. Only one other reported case of gastrojejunostomy after esophagectomy was found in the literature; however, this case was performed open after an IvorLewis esophagectomy [1]. To our knowledge, this is the first reported case of laparoscopic gastrojejunostomy after MIE. We believe laparoscopic gastrojejunostomy is a safe, technically feasible and effective option for treating an obstructed gastric conduit after MIE. Our patient was able to advance his diet without difficulty and did not experience any complications. The patient expired 3 months after surgery due to his underlying metastatic disease. He was able to tolerate an oral diet until he expired. He did not require placement of a feeding tube, and he never required intravenous hydration.
Comment Obstructed gastric conduit after minimally invasive esophagectomy is an uncommon albeit well-known complication. The possible etiologies include recurrent carcinoma, lack of pyloroplasty causing relative gastric
Reference 1. Morris CD, Owings F, Miller JI Jr. Intrathoracic gastrojejunostomy for gastric outlet obstruction after Ivor Lewis esophagogastrectomy. Ann Thorac Surg 2005;80:1512–3.
We describe a novel, minimally invasive method of managing an obstructed gastric conduit after minimally invasive esophagectomy. In addition, we briefly review the management of obstructed gastric conduit in patients status-post minimally invasive esophagectomy. On literature review, it was noted that gastrojejunostomy after esophagectomy was exceptionally rare. Only one other reported case of gastrojejunostomy after esophagectomy was found in the literature. This is the first reported case to our knowledge of laparoscopic gastrojejunostomy after minimally invasive esophagectomy (MIE). Laparoscopic gastrojejunostomy after minimally invasive esophagectomy for obstructed gastric conduit is technically feasible, and it effectively managed the obstruction in our patient. (Ann Thorac Surg 2014;97:e145–6) Ó 2014 by The Society of Thoracic Surgeons
O
bstruction of the gastric conduit after MIE is an unusual but potentially debilitating postoperative complication. We present the first reported case, to our knowledge, of laparoscopic management of this condition with the creation of a gastrojejunostomy. We present a case of a 57-year-old male patient who complained of nausea and postprandial emesis 1.5 years after MIE for esophageal adenocarcinoma. He also noted a 75-pound weight loss since the surgery. The laboratory values revealed severe malnutrition, with an albumin level of 2.8 g/dL. Abdominal radiographs did not indicate any evidence of bowel obstruction or ileus. Esophagram showed a possible duodenal obstruction (Fig 1), and a laparoscopic gastrojejunostomy was planned. A diagnostic laparoscopy was initially performed, which revealed that the gastric conduit and the third portion of the duodenum had been pushed anteriorly by a large retroperitoneal mass. Several small peritoneal implants were noted on the lateral abdominal wall, which was concerning for possible peritoneal carcinomatosis; however, rapid frozen sections were negative for carcinoma. Intraoperative esophagogastroduodenoscopy (EGD) revealed a nodular, friable retrogastric mass that was highly suggestive of recurrent carcinoma (Fig 2).
Fig 1. Preoperative esophagram indicating possible duodenal obstruction.
Biopsies of the mass were performed. The endoscope was able to pass the mass easily; however, it was unable to be advanced beyond the third portion of the duodenum because of an extrinsic distortion from the aforementioned mass.
Accepted for publication Nov 25, 2013. Address correspondence to Dr Wallen, 11234 Anderson St, Rm 21005 CP, Loma Linda, CA 92354; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2. Nodular, obstructing mass on intraoperative EGD. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.11.082
e146
CASE REPORT FRIEDMAN ET AL LAP GASTRO-J FOR OBSTRUCTED CONDUIT AFTER MIE
Fig 3. Gastrojejunostomy just before closure.
At this point, we decided to perform a laparoscopic gastrojejunostomy to bypass the obstructed gastric conduit. The previous jejunostomy site was readily identified, and the adhesive bands attaching it to the abdominal wall were taken down. This loop of jejunum was isolated and brought up to the gastric conduit. A gastrotomy was made proximal to the obstruction, and a gastrojejunostomy was created using an endo-GIA stapler followed by closure with five 0-0 Surgidac Endo-stitch sutures (Figs 3, 4). A completion esophagogastroduodenoscopy was performed, which revealed an intact anastomosis. An esophagram was performed on the first postoperative day; it showed a patent anastomosis without evidence of leak. The patient was given a clear liquid diet, which was well tolerated without nausea or emesis. Postoperative pain was minimal, and the patient was discharged home on the second postoperative day. The final pathologic analyses of the peritoneal implants and the gastric conduit were negative for carcinoma. The gastric conduit biopsy specimens showed only benign gastric mucosa with patchy inflammation. An endoscopic ultrasound examination for biopsy of the retroperitoneal mass was later performed, which confirmed recurrent adenocarcinoma.
Ann Thorac Surg 2014;97:e145–6
Fig 4. Closure of gastrojejunostomy using 0-0 Surgidac Endo-stitch sutures.
conduit obstruction, or in this case, extrinsic compression of the conduit by a retroperitoneal mass. Suspected obstruction of the gastric conduit should be initially evaluated with a contrast esophagram and followed-up with esophagogastroduodenoscopy if the esophagram is indicative of an obstructive process. Our patient was extremely symptomatic from the obstruction and was experiencing weight loss; therefore, a bypass procedure to palliate his symptoms was chosen. During a literature review, it was noted that performance of gastrojejunostomy after esophagectomy is exceptionally rare. Only one other reported case of gastrojejunostomy after esophagectomy was found in the literature; however, this case was performed open after an IvorLewis esophagectomy [1]. To our knowledge, this is the first reported case of laparoscopic gastrojejunostomy after MIE. We believe laparoscopic gastrojejunostomy is a safe, technically feasible and effective option for treating an obstructed gastric conduit after MIE. Our patient was able to advance his diet without difficulty and did not experience any complications. The patient expired 3 months after surgery due to his underlying metastatic disease. He was able to tolerate an oral diet until he expired. He did not require placement of a feeding tube, and he never required intravenous hydration.
Comment Obstructed gastric conduit after minimally invasive esophagectomy is an uncommon albeit well-known complication. The possible etiologies include recurrent carcinoma, lack of pyloroplasty causing relative gastric
Reference 1. Morris CD, Owings F, Miller JI Jr. Intrathoracic gastrojejunostomy for gastric outlet obstruction after Ivor Lewis esophagogastrectomy. Ann Thorac Surg 2005;80:1512–3.
