Intra-cervical gastric conduit bulging after esophagectomy due to compression of the sternoclavicular joint: a report of two cases

Introduction

Esophagectomy is the primary definitive treatment for resectable tumors with or without neoadjuvant radiochemotherapy or perioperative chemotherapy (1). Compared with the posterior mediastinal route, the retrosternal (RS) route has gained more favor in recent years to avoid the gastric conduit having to pass through the esophageal cancer area, to limit complications of applying adjuvant radiotherapy or local recurrence, limit the incidence of reflux and improve the quality of life (2).

Nevertheless, this approach is associated with a higher incidence of anastomotic leakage and stenosis (3,4). The mechanism of this phenomenon is the compression of the sternoclavicular joint (SCJ) (Figure 1), which causes adverse effects on the anastomosis of blood flow towards the anastomosis (3). To minimize these complications, we placed the anastomosis away from the SCJ. However, that has left abundant of the gastric conduit in the cervical zone combined with the compression of the SCJ on the tip of the gastric conduit may cause gastric conduit bulging—which can affect the anastomosis as well as oral feeding and anesthetics. Here, we report two cases where compression by the SCJ leads to dilation of the intra-cervical gastric tube. We present this article in accordance with the CARE reporting checklist (available at https://aoe.amegroups.com/article/view/10.21037/aoe-23-29/rc).

Figure 1 Measurement of STD: the STD was defined as the minimum distance from the sternum to the anterior wall of the trachea in the sagittal section of preoperative cervical chest multi-detector row CT-scan: (A) the STD was 21.1 mm in the first patient; (B) the STD was 15.7 mm in the second patient. STD, sterno-tracheal distance; CT, computed tomography.

Case presentation

Case 1

The first case was a 57-year-old man without comorbidity. The sterno-tracheal distance (STD) was 21.1 mm on the preoperative computed tomography (CT) scan (Figure 1A). The patient underwent tri-incisional esophagectomy for middle esophageal cancer with 2-field lymph node dissection via thoracolaparoscopy followed by RS reconstruction using the wide gastric conduit. We laparoscopically created a RS tunnel. This involved dividing the diaphragmatic insertion at the xiphoid process to expose the posterior surface of the sternum. We then dissected an avascular plane along this surface, extending cranially to the base of the neck, using a custom-made T-shaped instrument (Figure 2). Additionally, the thoracic inlet was enlarged by ensuring the tunnel could accommodate four of the surgeon’s fingers, partially dividing the sternothyroid muscle posterior to the sternum. A side-to-end esophagogastric anastomosis was performed by a circular stapler and placed above the manubrium.

Figure 2 Dissect in the avascular plane along the posterior surface of the sternum.

On postoperative day (POD) 5, when we resumed oral feeding, there was a bulging at the site of the cervical incision, which dilation with swallowing, but the patient denied dysphagia. We maintain oral feeding and follow up for signs of conduit stenosis and anastomotic leak. The patient tolerated oral feeding and was discharged on POD 10. After one year, although the bulging still appeared (Figure 3), it was not enlarged, and he was doing well and denied any discomfort.

Figure 3 The gastric conduit bulging at 1-year follow-up: the bulging was not enlarged and only affected the cosmetics but was not functional.

Case 2

The second patient was a 74-year-old man who underwent the same esophagectomy protocol, and the anastomosis was placed above the manubrium as in the previous case. In this case, the STD was 21.1 mm on the preoperative CT scan (Figure 1B). The operation went well, but on POD 3, the patient also developed a bulging mass at the neck, which caused a stretcher and edema at the incision. We decided to perform local wound exploration. After opening the cervical incision, we found that the redundancy of the gastric conduit dilation was due to the compression by the SCJ again at the tip of the gastric conduit, while the anastomosis was intact. Therefore, we decided to push the redundant gastric tube back to the substernal cavity.

However, the bulging returned and gradually enlarged, and the patient developed progressive dysphagia combined with regurgitation. Therefore, he underwent surgery to repair the gastric conduit 2 months after the primary surgery. The intraoperative finding was a large bulging of the gastric conduit between the anastomosis and the manubrium (Figure 4A). After dissecting to expose entire of the intra-cervical gastric conduit, we found out that the dilation was localized in the anterior wall of the gastric. We opened the anterior surface of the tube to assess the stenosis of the anastomosis and the thoracic aperture, and there was no stenosis on either side with the surgeon’s finger could pass easily. So, we decided to transect the bulging only (Figure 4B) and primary closure of the gastric wall with Vycryl 3/0 interrupted suture. Intraoperative esophagogastroduodenoscopy confirmed passage of the scope through the cervical anastomosis and into the gastric conduit without difficulty. Postoperatively, the patient experienced an immediate improvement in swallowing liquids and solids. After one year of follow-up, the patient can tolerate a solid diet without further intervention.

Figure 4 Intraoperative findings: (A) a large bulging of the gastric conduit between the anastomosis and the manubrium; (B) the anterior surface of the conduit was opened to assess the stenosis of the anastomosis and the thoracic aperture, and the surgeon’s finger could pass easily. So, we decided to transect the bulging and primary closure.

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional committee and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Anastomotic stenosis and anastomotic leak are well-recognized for the morbidity of esophagectomy, adversely affecting patients’ quality of life. The mechanism is explained by the compression of the SCJ on the gastric graft after RS reconstruction, especially at the anastomotic site (3). Although there are several approaches to minimize excessive compression, none can be considered a comprehensive solution. Resection of the bony structures associated with osteomyelitis and chronic pain (5). Some authors opt to place the conduit in subcutaneous or posterior mediastinal rather than RS, which could increase the risk of postoperative complications. In comparison, placing the anastomosis above the SCJ seems more reasonable, with the benefits of being less invasive while maintaining the advantage of RS reconstruction and cervical anastomosis (3).

Nevertheless, that practice can lead to the redundancy of the gastric conduit in the cervical cavity combined with the compression of the SCJ, which can result in gastric conduit bulging, as observed in our two patients. The STD was 21.1 mm in the first case, which is relatively wide compared to some studies that concluded that the STD ≤13 mm is a relative contraindication for RS reconstruction (4). The bulge in this patient appeared after initial oral feeding without dysphagia. That could be explained by the fact that we have left an excessive gastric stump above the manubrium, so when the patient swallows too fast, the food will accumulate in the stump, leading to a bulge. We instructed the patient to eat slowly, and the symptoms improved gradually. Now, he tolerates a solid diet without any intervention. Compared to the second case, the STD was 15.7 mm—relatively narrow—and the bulge developed on POD 3; even the patient still maintained nothing by mouth. The early dilation of the gastric tube raised questions about structural stenosis, and it also caused increased pressure in the anastomosis. Therefore, we decided to perform local exploration to address the problem. However, we could not push the entire excessive gastric conduit back to the RS tunnel, and subsequently the patient had to undergo reoperation to transect the bulge. From the experience of two patients, we have routinely pulled the conduit down from the abdominal cavity to straighten the digestive tract after completing the anastomosis to reduce the redundancy of the gastric tube.

Conclusions

We have encountered two cases in which the intra-cervical gastric conduit bulges due to compression of the SCJ on the redundancy of the gastric stump. When using the RS route for reconstruction after esophagectomy, it is essential to straighten the gastric tube to ensure no excessive gastric conduit in the cervical zone.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://aoe.amegroups.com/article/view/10.21037/aoe-23-29/rc

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-23-29/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-23-29/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional committee and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Pasquali S, Yim G, Vohra RS, et al. Survival After Neoadjuvant and Adjuvant Treatments Compared to Surgery Alone for Resectable Esophageal Carcinoma: A Network Meta-analysis. Ann Surg 2017;265:481-91. [Crossref] [PubMed]
2. Gronnier C, Collet D. New Trends in Esophageal Cancer Management. Cancers (Basel) 2021;13:3030. [Crossref] [PubMed]
3. Kurahashi Y, Ishida Y, Kumamoto T, et al. Anastomosis behind the sternoclavicular joint is associated with increased incidence of anastomotic stenosis in retrosternal reconstruction with a gastric conduit after esophagectomy. Dis Esophagus 2021;34:doaa089. [Crossref] [PubMed]
4. Inoue S, Yoshida T, Nishino T, et al. The sterno-tracheal distance is an important factor of anastomotic leakage of retrosternal gastric tube reconstruction after esophagectomy. Esophagus 2020;17:264-9. [Crossref] [PubMed]
5. Petrov RV, Bakhos CT, Abbas AE. Robotic substernal esophageal bypass and reconstruction with gastric conduit-frequently overlooked minimally invasive option. J Vis Surg 2019;5:47. [Crossref] [PubMed]