Ann Thorac Surg 2006;82:1910-1913
© 2006 The Society of Thoracic Surgeons
Case Reports
Laparoscopic and Thoracoscopic Ivor Lewis Esophagectomy after Roux-en-Y Gastric Bypass
Ninh T. Nguyen, MD*,
Cam-Ly Tran, MD,
Dmitri V. Gelfand, MD,
Esteban Varela, MD,
Ken Chang, MD,
Michael Stamos, MD,
Samuel E. Wilson, MD
Department of Surgery, University of California Irvine Medical Center, Orange, California
Accepted for publication February 22, 2006.
* Address correspondence to Dr Nguyen, Department of Surgery, University of California Irvine Medical Center, Orange, CA 92868. (Email: ninhn{at}uci.edu).
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Abstract
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Roux-en-Y gastric bypass is a commonly performed procedure for the treatment of morbid obesity. Esophagectomy in patients with a history of Roux-en-Y gastric bypass presents a difficult technical challenge for the surgeon. In this report we describe a technique of minimally invasive Ivor Lewis esophagogastrectomy in a patient who had had an open Roux-en-Y gastric bypass. Minimally invasive esophagectomy was performed with resection of the Roux limb using the gastric remnant as the conduit for gastrointestinal reconstruction.
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Introduction
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Roux-en-Y gastric bypass is a commonly performed procedure for the treatment of morbid obesity. The Nationwide Inpatient Sample projects the number of bariatric surgical procedures to reach more than 100,000 annually with the majority of procedures being gastric bypass [1]. With the increasing number of patients undergoing bariatric surgery in the United States, it is important for general and thoracic surgeons to be aware of the altered anatomy in these patients as they may require operative intervention for the treatment of benign or malignant esophageal lesion.
The preferred treatment for resectable esophagus cancer (stage I–III) is either an Ivor Lewis esophagogastrectomy or a blunt transhiatal esophagectomy as popularized by Orringer and colleagues [2]. Both of these techniques use the stomach as the conduit for gastrointestinal reconstruction. More recently, minimally invasive surgical techniques for esophagectomy have been described [3–4]. Esophageal cancer in patients who have had a prior Roux-en-Y gastric bypass raise a challenging technical decision for the operating surgeon. In this report we describe our technique of minimally invasive Ivor Lewis esophagogastrectomy for resection of esophagus cancer in a patient with a history of open Roux-en-Y gastric bypass.
A 51-year-old woman presented with a 10-year history of gastroesophageal reflux, esophageal Barrett's metaplasia, and morbid obesity. The patient underwent an open Roux-en-Y gastric bypass in 2001 for the treatment of morbid obesity. Her reflux symptoms improved dramatically after her surgery with loss of more than 70% of her excess body weight. Recently an upper endoscopy performed for Barrett's esophagus surveillance demonstrated a small nodule immediately above the gastroesophageal junction. Biopsy of the nodule confirmed Barrett's esophagus with high-grade dysplasia. The patient subsequently underwent a repeat endoscopy and biopsy that demonstrated moderately differentiated adenocarcinoma. An endoscopic esophageal ultrasound showed a T1N0 lesion and the computed tomography of the chest and abdomen did not reveal any evidence of metastatic disease. A positron emission tomographic study was not performed because the esophageal mass appeared to be a T1N0 lesion. A colonic mesentery angiogram was not performed as the gastric remnant was planned to be the primary conduit for reconstruction. A bowel preparation was not given preoperatively.
The role for esophagectomy with a curative intent was discussed with the patient. She was informed that the technique of laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy is currently being performed only at certain centers in the United States. One of the advantages of the Ivor Lewis technique for this patient is the construction of an intrathoracic anastomosis to minimize the tension on the esophagogastric anastomosis as the previous Roux-en-Y gastric bypass may reduce the available length of gastric conduit. In addition, the need for resection of the Roux limb was also discussed to avoid a blind loop syndrome. This retrospective case report was approved by the Institutional Review Board of the University of California Irvine Medical Center. The patient consent was waived.
The abdominal phase of minimally invasive Ivor Lewis esophagogastrectomy is described as follows. The patient was intubated with a double-lumen tube for single left lung ventilation. The patient was placed supine. Five abdominal trocars were introduced. Extensive adhesiolysis was performed. The anatomy of the previous gastric bypass consisted of a retrocolic and retrogastric gastrojejunostomy. The gastric pouch and the jejunal Roux limb were mobilized. The left gastric vessels leading to the gastric pouch were divided with a linear stapler. The gastric remnant was mobilized by dividing the gastrocolic omentum with care to preserve the right gastroepiploic vessels and the short gastric vessels. The gastric pouch was separated from the jejunal Roux limb using a linear stapler and the tip of the gastric remnant was sutured to the gastric pouch in preparation for a transthoracic gastric pull-up. The distal esophagus was then circumferentially mobilized into the mediastinum. A Penrose drain was placed around the distal esophagus and positioned in the mediastinum, to be used for esophageal retraction in the thoracic phase of the operation. The remaining jejunal Roux limb was mobilized away from the transverse mesocolon and resected immediately above the level of the jejunojejunostomy. The transverse mesocolon and small bowel mesenteric defects were closed with interrupted sutures. A needle catheter jejunostomy tube was placed within the jejunal common channel.
The thoracic phase of minimally invasive Ivor Lewis esophagogastrectomy is described as follows. The patient was repositioned to a left lateral decubitus position. Under single lung ventilation, three thoracic trocars were introduced and a small (4 cm) thoracotomy was constructed in the right thoracic cavity. A wound protector was placed at the thoracotomy site. The mediastinal pleura overlying the distal esophagus was divided until the Penrose drain was visualized. The Penrose drain was used for esophageal retraction during mobilization of the thoracic esophagus up to the level of the azygous vein. The azygous vein was divided using a linear stapler. The surgical specimen consisting of the distal esophagus and attached gastric remnant was pulled through the esophageal hiatus into the right chest. The esophagus was divided above the level of the azygous vein. The surgical specimen was removed through the 4-cm thoracotomy site.
A 25-mm circular stapler anvil was inserted transthoracically and placed into the esophageal stump and secured with a pursestring suture. A gastrotomy was created at the tip of the gastric conduit. A 25-mm circular stapler was placed transthoracically into the gastric remnant for construction of the esophagogastric anastomosis. The stapled anastomosis was reinforced with interrupted Lembert sutures. A nasogastric tube was inserted. The gastrotomy was closed with a linear stapler. A 28-French chest tube was inserted for postoperative drainage.
The operative time was 3 hours and 15 minutes for the laparoscopic portion of the procedure, and 2 hours for the thoracoscopic portion of the procedure. The estimate blood loss was 125 mL. No intraoperative or postoperative blood transfusion was required. Grossly, the esophagus showed Barrett's metaplasia and a single nodule present at the gastroesophageal junction. Histologic findings showed Barrett's metaplasia with a focus of intramucosal carcinoma. The margins were negative for Barrett's metaplasia and carcinoma. All 18 lymph nodes within the surgical specimen were negative for carcinoma.
The patient was extubated in the operating room and transferred to the intensive care unit. An intravenous patient-controlled analgesia pump with morphine infusion was used for pain control. The patient was transferred to the surgical floor on postoperative day 2. A jejunostomy tube feeding was started. A gastrograffin contrast study was performed on postoperative day 5 and demonstrated no leak (Fig 1). Both the nasogastric and chest tubes were removed. The patient was discharged home on postoperative day 6. There were no postoperative complications. With a 3.5 month follow-up, there had been no wound recurrence at the chest or abdominal trocar incisions.
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Fig 1. Postoperative chest roentgenogram showing the gastric conduit (arrow) in the right chest cavity.
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Comment
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This report describes our technique of laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy for the treatment of esophageal cancer in a patient who had had a Roux-en-Y gastric bypass. As Roux-en-Y gastric bypass is becoming a commonly performed procedure for the treatment of morbid obesity, it is inevitable that a number of these patients will require operative intervention for the treatment of benign or malignant upper gastrointestinal pathology. Surgeons specializing in the management of upper gastrointestinal disorder must understand the altered anatomy of the Roux-en-Y gastric bypass to provide optimal surgical care for these patients.
In our patient, the initial approach was laparoscopy for evaluation of the Roux-en-Y gastric bypass anatomy and to perform lysis of adhesions. The gastric pouch and jejunal Roux limb were mobilized away from the gastric remnant. The gastric remnant was mobilized from adjacent tissues and assessed for adequacy of its length for reconstruction. In addition, we resected the entire Roux limb to the level of the jejunojejunostomy to prevent stasis and possible blind loop syndrome (Fig 2). A jejunostomy tube was placed within the common channel for postoperative feeding. The gastric remnant was pulled into the right chest for gastrointestinal reconstruction (Fig 3). Allen and colleagues [5] described open esophagectomy for esophageal cancer in patients with Roux-en-Y gastric bypass or vertical banded gastroplasty. Similar to our technique, they described the use of the gastric remnant as the conduit for gastrointestinal reconstruction in two of three cases. The gastric remnant has also been used for management of complications arising from the Roux-en-Y gastric bypass. Rundall and colleagues [6] described a case of gastric pouch necrosis requiring esophageal diversion. The gastric remnant was later used as the conduit for a transhiatal reconstruction of gastrointestinal continuity.
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Fig 3. Schematic view showing resection of esophagus, gastric pouch, and jejunal Roux limb with construction of an intrathoracic esophagogastrostomy.
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In summary, esophagogastrectomy after Roux-en-Y gastric bypass raises a technical problem for the operating surgeon. In this report, we describe the technique of minimally invasive esophagogastrectomy with resection of the Roux limb and gastrointestinal reconstruction using the gastric remnant. As Roux-en-Y gastric bypass continues to be a common procedure for the treatment of morbid obesity, surgeons caring for patients with upper gastrointestinal disorders must appreciate the complexity of altered anatomy for proper planning of reoperative intervention. General and thoracic surgeons performing esophagectomy may wish to consider collaboration with a bariatric surgeon in planning and executing this complex operation.
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References
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- Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures JAMA 2005;294:1960-1963.[Free Full Text]
- Orringer MB, Marshall B, Iannettoni, MD. Transhiatal esophagectomy: clinical experience and refinements Ann Surg 1999;230:392-400.[Medline]
- Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients Ann Thorac Surg 2003;238:486-495.
- Nguyen NT, Follette DM, Lemoine PH, Roberts PF, Goodnight Jr JE. Minimally invasive Ivor Lewis esophagectomy Ann Thorac Surg 2001;72:593-596.[Abstract/Free Full Text]
- Allen JW, Leeman MF, Richardson JD. Esophageal carcinoma following bariatric procedures JSLS 2004;8:372-375.[Medline]
- Rundall BK, Denlinger CE, Parrino GP, Foley EF, Jones DR. Laparoscopic gastric bypass complicated by gastric pouch necrosis: considerations in gastroesophageal reconstruction J Gastrointest Surg 2005;9:938-940.[Medline]
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Abstract
Introduction
