Ann Thorac Surg 2005;80:1512-1513
© 2005 The Society of Thoracic Surgeons
Case report
Intrathoracic Gastrojejunostomy for Gastric Outlet Obstruction After Ivor Lewis Esophagogastrectomy
Cullen D. Morris, MD
a
,
Francis Owings, MD
b
,
Joseph I. Miller, Jr, MD
a
,
*
a Section of General Thoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
b Department of General Surgery, Crawford W. Long Hospital of Emory University, Atlanta, Georgia
Accepted for publication May 3, 2004.
* Address reprint requests to Dr Miller, 550 Peachtree St, Crawford W. Long Hospital, Medical Office Tower, Atlanta, GA30345 (Email: cullen_morris{at}emoryhealthcare.org).
 |
Abstract
|
|---|
Gastric outlet obstruction after esophagogastrectomy with a drainage procedure is unusual, but when encountered, its management can be formidable. A Rous-en-Y intrathoracic gastrojejunostomy was created in a 74-year-old woman 2 years after Ivor Lewis esophagogastrectomy for benign disease to treat severe gastric outlet obstruction at the native pylorus.
|
Introduction
|
|---|
Operative therapy for the patient with complex benign esophageal disease can be challenging, particularly if it involves reoperative surgery. Intolerance to food and liquid, regurgitation, and vomiting after esophagogastrectomy with gastric conduit and pyloroplasty are rarely caused by gastric outlet obstruction; and the management strategy for this complication may require an extensive redo operation [1, 2]. We describe the surgical treatment of a patient with endoscopically confirmed gastric outlet obstruction 2 years after esophagogastrectomy for severe esophageal stricture.
The patient, a 74-year-old woman, had primary repair of an iatrogenically induced esophageal perforation for benign stricture in 1990, and 11 years later required Ivor Lewis esophagogastrectomy with Heineke-Mikulicz pyloroplasty for recalcitrant esophageal stricture and pyloric stenosis from peptic ulcer disease. She did well until several months before admission when she began to experience weight loss with regurgitation and vomiting after eating and drinking. An extensive work-up ruled out malignancy and anastomotic stricture and confirmed gastric outlet obstruction at the pylorus.
The patient was positioned in a modified left decubitus position so that a simultaneous right thoracotomy and midline incision could be performed. After midline incision, the pylorus could not be examined secondary to extensive scarring at the esophageal hiatus. No specific cause of the gastric outlet obstruction could be identified, and there was no significant dilatation of the native stomach. A right anterior thoracotomy was performed through the sixth intercostal space. The left lobe of the liver was mobilized, and an anterior phrenotomy was created. The jejunum was divided at 40 cm from the pylorus, and a hand-sewn two-layer enteroenterostomy was created 45 cm from the cut end of the efferent limb. The efferent jejunal limb was delivered through the phrenotomy, antecolic, on a long pedicle of mesentery (Fig 1). A double-layer hand-sewn intrathoracic side-to-side gastrojejunostomy was then created with the nasogastric tube positioned superiorly to it. A 10-mm Jackson-Pratt drain was left along side the anastomosis, and two 36F chest tubes were placed in the right chest after lung expansion. A Witzel feeding jejunostomy was performed distal to the enteroenterostomy and was brought out through the left anterior abdominal wall.
View larger version (21K):
[in this window]
[in a new window]
|
Fig 1. After anterolateral right thoracotomy, the efferent jejunal limb was delivered through the anterior phrenotomy, antecolic, on a long pedicle of mesentery to create the intrathoracic gastrojejunostomy.
|
|
The patient went home 3 weeks after her operation on a soft diet. She was gaining weight and feeling well 5 months later at her outpatient office visit with no complaints of vomiting, regurgitation, or dysphagia.
|
Comment
|
|---|
Vomiting and regurgitation of food and drink occur not infrequently after esophageal reconstruction. In a review by Young and coworkers [3] of 255 patients undergoing esophageal resection and reconstruction for benign disease, 83 of 226 patients (37%) suffered from dysphagia, regurgitation, or vomiting postoperatively, and 9 (4%) eventually required surgery for this complication. However, regurgitation and vomiting due to gastric outlet obstruction after esophagogastrectomy and pyloroplasty are rare, and when medically unmanageable, reoperation is indicated [3]. In the present case, we present a usable technique requiring a midline incision, right thoracotomy, and an intrathoracic gastrointestinal anastomosis.
Since the hiatus and pylorus were engulfed in scar, they were surgically inaccessible. By opening the anterior diaphragm, we were able to use a loop of jejunum in a Rous-en-Y fashion to create an intrathoracic gastrojejunostomy in the right chest. Our loop was created antecolic, because the transverse mesocolon was shortened and densely adherent to the liver in this case. Historically, the Rous-en-Y gastrojejunostomy has been used to divert alkaline secretions causing bile reflux gastritis after antrectomy, and in 1990 Ellis and Gibb [4] reported on its use in the abdomen in esophageal reoperations. A hand-sewn anastomosis was used secondary to limitations in exposure and a desire to lessen the risk for anastomotic stricture, which may be increased with stapled repairs [5].
Esophageal reoperation for complex benign disease mandates an individualized approach; each patient presents a special challenge. Regurgitation and vomiting in the setting of esophageal resection and pyloroplasty can be managed with Rous-en-Y gastrojejunostomy through the right chest. Adherence to surgical principles of nutritional repletion should be maintained in these patients.
|
References
|
|---|
- Law S, Cheung MC, Fok M, Chu KM, Wong J. Pyloroplasty and pyloromyotomy in gastric replacement of the esophagus after esophagectomya randomized controlled trial. J Am Coll Surg 1997;184:630-636.[Medline]
- Fok M, Cheung SW, Wong J. Pyloroplasty versus no drainage in gastric replacement of the esophagus Am J Surg 1991;162:447-452.[Medline]
- Young MM, Deschamps C, Trastek VF, et al. Esophageal reconstruction for benign diseaseearly morbidity, mortality, and functional results. Ann Thorac Surg 2000;70:1651-1655.[Abstract/Free Full Text]
- Ellis FH, Gibb SP. Esophageal reconstruction for complex benign esophageal disease J Thorac Cardiovasc Surg 1990;99:192-199.[Abstract]
- Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomya review. Am J Surg 1995;169:634-640.[Medline]
This article has been cited by other articles:
|
|
|
|
 
X. B. D'Journo, J. Martin, L. Gaboury, P. Ferraro, and A. Duranceau
Roux-en-Y Diversion for Intractable Reflux After Esophagectomy
Ann. Thorac. Surg.,
November 1, 2008;
86(5):
1646 - 1652.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
