An unusual case of obstruction of the gastric conduit following esophagectomy—case report

Introduction

Esophagectomy is the treatment of choice for patients with early and locally advanced esophageal cancer. A variety of gastrointestinal symptoms such as delayed gastric emptying, early satiety, reflux, and dumping syndrome are not uncommon after esophagectomy (1-3). The reoperation rate after esophagectomy is reported at 15% with an associated postoperative mortality of 10% (4). Reoperations are associated with exponential physical decline, prolonged length of hospital stay, increased healthcare cost, and negative impact on long-term survival (5).

Indications for early reoperation after esophagectomy include necrosis of the gastric conduit, obstruction of the gastric conduit (OGC) post-esophagectomy hernia, and redundancy of the conduit resulting in impaired gastric emptying. We present this article in accordance with the CARE reporting checklist (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-9/rc).

Case presentation

An 82-year-old Caucasian male with T3N1 (per endoscopic ultrasound) distal (32–40 cm from the incisors) esophageal cancer (poorly differentiated adenocarcinoma with Signet ring features). The patient is status post neoadjuvant chemoradiation therapy (50.4 Gy, carboplatin and paclitaxel). Past medical history was significant for hypertension, hyperlipidemia and 40 pack-years (quit smoking 20 years ago). He had no prior abdominal surgery. The patient underwent an uncomplicated, totally minimally invasive Ivor-Lewis esophagectomy (MIE-laparoscopic abdominal/video-assisted surgery thoracic) using circular stapled anastomosis-DST XL [circular end to end anastomosis (EEA)] (Covidien, Minneapolis, MN, USA) 25 mm. Total operative time was 317 minutes. Fluid replacement: crystalloids 3,250 mL, blood loss 100 mL, urine output 400 mL. Computed tomography (CT) esophagram with oral contrast performed on postoperative day 4 showed dilation of gastric conduit (Figure 1). Upper endoscopy did not show any twist or redundancy; 100 units of botulinum toxin was injected into the pylorus in four quadrants to facilitate conduit emptying. Follow up imaging on day 8 did not show any changes in the size of the conduit and there was no passage of contract past the diaphragm. He was taken back to the operating room on day 10 for video-assisted thoracoscopic surgery (VATS) in left lateral decubitus position. Access to the right chest was done using the same trocar sites for the index procedure. In this video (Video 1, https://youtu.be/Zos6OYSIG4Q), we demonstrate the gastric conduit was entrapped between the right middle and lower lobes of the lung, causing mechanical obstruction (Figure 2). The conduit was carefully mobilized and dissected away from the right lower and middle lobes of the lung. The right lower lobe was pulled from underneath the conduit and its normal anatomical position was restored. Completion upper endoscopy did not show any twist or redundancy. Contrast study showed improvement of dilation and adequate flow of contrast. The patient’s postoperative recovery was unremarkable and was discharged home two weeks after the index surgery. Final pathology showed ypT3N0M0, residual foci of poorly differentiated carcinoma (stage IIB). All margins are negative for carcinoma. All 15 lymph nodes were negative for carcinoma. The patient was seen in the clinic, tolerating diet and doing very well. 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). The study was approved by institutional board of University of Florida (IRB number 202400263). Publication of this case report and accompanying images was waived from patient consent because this research involves only information collection and analysis involving the investigator’s use of identifiable health information and poses minimal risk.

Figure 1 CT esophagram showing dilated gastric conduit with non-passage of contrast at the level of the diaphragmatic hiatus. CT, computed tomography.

Figure 2 Intraoperative image showing the gastric conduit in between the right middle and lower lobes.

Discussion

Esophagectomy is a complex operation that is associated with significantly high morbidity and perioperative mortality (6-9). OGC is a rare complication after esophagectomy (10) and quite often warrants surgical intervention. The presentation of OGC includes vomiting or aspiration gastric contents leading to aspiration pneumonia and malnutrition. The etiology of OGC is related to either pyloric spam, post-operative hernia, obstruction due to narrowing at the level of the diaphragmatic opening or to excess omental flap, or twisted (volvulus) conduit. Apart from patients with pyloric spasm (which can manage with endoscopic dilation), we believe surgical intervention is indicated in most patients with OGC. We feel a logical approach was used to eliminate pyloric pathology as a source of gastric outflow obstruction before we embarked on surgical intervention. In our case, the gastric conduit was obstructed as it was entrapped between the right middle and lower lobes of the right lung. We hypothesize that the right lower lobe slid posteriorly to conduit, and as lung was inflated and expanded at the end of the procedure, the conduit was trapped between lobes causing mechanical obstruction. Since then, we have changed our practice to include careful and direct visualization of the gastric conduit as the lung is gradually fully expanded especially the middle and lower lobes making sure nothing slips underneath the conduit to avoid this potential complication. In addition, we made sure the conduit is straight, pulled down with no tortuosity.

Case reports quite often face scrutiny of recognition. However, we believe that some are unique and help guided or direct interested readers or researchers into managing unusual case presentations. To the best of our knowledge, this is the first reported case of obstruction of the conduit by the lung lobes.

Conclusions

Entrapment of the gastric conduit by the lung lobes is a rare complication after esophagectomy. Surgical intervention is necessary to remedy the mechanical problem. Inflation of the lung under direct visualization is an important measure to minimize the risk of this complication.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-9/rc

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-9/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-9/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). The study was approved by institutional board of University of Florida (IRB number 202400263). Publication of this case report and accompanying images was waived from patient consent because this research involves only information collection and analysis involving the investigator’s use of identifiable health information and poses minimal risk.

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/.

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