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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
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M.A. Cuesta and D.L. van der Peet
Besides, some patients experienced pneumothorax (1.9–6.7 %). Early postoperative
complications included pulmonary complications (1.3–4 %). Some patients experienced persistent and severe chest pain, which prolonged the time to hospital discharge” [ 3 ].
The possibility of complications must never be discounted. Diffi culties in fi nding
the plane during the dissection and tears of the mucosa can be regarded as the causes
for the complication of the patient here. It is possible that dissection in the wrong
plane induced the ischemia and perforation. The aggressive approach by diagnosis
and relaparoscopy eventually solved the complication.
References
1. Boeckstaens GE, Annese V, des Varannes SB, et al. Pneumatic dilation versus laparoscopic
Heller’s myotomy for idiopathic achalasia. N Engl J Med. 2011;364:1807–16.
2. Zaninotto G, Constantini M, Rizzetto C, et al. Four hundred laparoscopic myotomies for
esophageal achalasia: a single centre experience. Ann Surg. 2008;248:986–93.
3. Wang L, Li YM. Recurrent achalasia treated with Heller myotomy: A review of the literature.
World J Gastroenterol. 2009;14:7122–26.
Chapter 12
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Case on Esophagojejunostomy Leakage
Following Extended Total Gastrectomy
Jose L. Garcia Sabrido and Wenceslao Vasquez Jimenez
Keywords Esophagojejunostomy • Gastrectomy • Gastric cancer • Leakage • Stent •
Lymphadenectomy
First Patient
Diagnosis and Indication for Surgery
In view is a 55-year-old female patient, without a previous medical history, who had
an ulcerated lesion of 3 cm at the lesser curvature of the stomach. The biopsy was
positive for poorly differentiated adenocarcinoma and signet ring cells. The tumor
was staged by means of CT scan and endoscopic ultrasonography as T3N + M0. The
patient was treated by neo-adjuvant systemic chemotherapy according to the
MAGIC protocol scheme (three cycles of epirubicin, cisplatin, and fl uorouracil) [ 1 ].
Operation
After three cycles of chemotherapy, and after an interval of 6 weeks, the patient
underwent open surgery. A total gastrectomy with lymphadenectomy type D2 resection with splenic preservation was performed. The reconstruction consisted of an
end-to-side esophagojejunostomy carried out with a 21-mm circular stapler. The
Roux-en-Y loop was 60 cm (Fig. 12.1 ). Two Jackson-Pratt drains were placed in the
right and left subdiaphragmatic spaces at the esophagojejunal anastomosis.
J. L. G. Sabrido , M.D. (*) • W. V. Jimenez , M.D., Ph.D.
Department of Surgery , Gregorio Marañon Hospital , Madrid , Spain
e-mail: jlgsabrido@gmail.com, jlgsabrido@ciriii.hggm.es
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_12,
© Springer International Publishing Switzerland 2014
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Fig. 12.1 End-to-side
esophagojejunostomy
anastomosis by means of
circular stapler
J.L.G. Sabrido and W.V. Jimenez
Pathology
The pathological stage was pT3N1M0.
Postoperative Course: Identifi cation and Treatment
of the Complication
On the 6th postoperative day, after taking oral liquids, the patient achieved fever,
pain in the upper left abdomen, and an increase in the amount of left drain volume,
which was opalescent, with an amylase level of 800 UI/L. White cell count showed
leukocytosis of 20,000 with left deviation of 95 %.
First a swallow X-ray (Fig. 12.2 ) and after a CT scan with double contrast
showed leakage at the level of the esophagojejunal anastomosis with a perianastomotic fl uid collection of 4 cm in diameter, communicating with the left drain.
12 Case on Esophagojejunostomy Leakage Following Extended Total Gastrectomy
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Fig. 12.2 Leakage of
contrast from the
esophagojejunostomy
Oral intake was stopped, and administration of IV fl uids and iv broad spectrum
antibiotics was initiated. At the 8th postoperative day, the patient improved; however, the volume of the drainage remained high (approximately, 500 mL/day). An
expandable endoprosthesis was then inserted at the level of the esophagojejunostomy that immediately sealed the anastomotic leakage (Illustration 12.1 ,
Fig. 12.3 ).
The patient continued to evolve favorably; oral ingestion started again at the 12th
postoperative day. The patient was discharged on the 18th postoperative day. She
was scheduled to complete her adjuvant systemic chemotherapy.
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Second Patient
Diagnosis and Indication for Surgery
A 69-year-old man diagnosed with a proximal gastric adenocarcinoma was found
elsewhere unresectable at explorative laparotomy because of lymph nodes metastases along the celiac trunk. The tumor seemed attached to the aorta at the level of the
hiatus, and the surgeon preferred not to resect the tumor at this stage. The patient
was referred to our hospital and treated by neoadjuvant chemotherapy (MAGIC
protocol scheme [1]), three sessions, and at the new CT scan, it appeared that the
tumor had regressed and could be resected.
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J.L.G. Sabrido and W.V. Jimenez
Leakage
Drain
Drain
Illustration 12.1 Leakage of the esophagojejunostomy is showed with perianastomotic leakage.
Stent is placed by esophagoscopy and the abscess has been drained percutaneously. If there is
general peritonitis, like in the second patient, a laparotomy should be done with rinsing of the
abdomen, stent at the anastomosis, and drains
Stent
Fig. 12.3 Control of the
leakage of the
esophagojejunostomy with
the placement of an
endoprosthesis
12 Case on Esophagojejunostomy Leakage Following Extended Total Gastrectomy
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Fig. 12.4 CT scan of
anastomotic leakage of
esophagojejunostomy with
general peritonitis
Operation
69
A new laparotomy showed that a total gastrectomy could be performed, extended to the
distal 7 cm of the esophagus, splenectomy, and lymphadenectomy of the celiac trunk.
An esophagojejunostomy was performed transhiatally with a Roux-en-Y long loop
through the transverse mesocolon in an end-to-side fashion (circular stapler 25 mm).
Pathology
The pathological study showed an adenocarcinoma pT3N1M0, radical resected
with a resection margin of 1 cm, and metastases in 3 of the 15 studied lymph nodes.
Postoperative Course: Identifi cation and Treatment
of the Complication
The postoperative course was complicated, at day 8 by a leakage of the
esophagojejunostomy, necessitating an exploratory laparotomy. An abscess was
found around of the anastomosis in the upper abdomen and lower mediastinum, but
a clear anastomotic leakage could not be identifi ed. Drains were left at the mediastinum and hiatus area, draining pus. Five days later a CT scan (Fig. 12.4 ) was
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performed because of continuing sepsis and clinical deterioration showing multiple
abscesses around the anastomosis. A new relaparotomy showed a leakage at the
anastomosis and a stent was placed by esophagoscopy at the level of the anastomosis after draining the abscesses and rinsing the abdomen. Leakage was no longer
seen following this procedure, and patient could be taken off the mechanical ventilation. Finally, the patient was discharged. Four years later, the patient developed a
local recurrence around the anastomosis well responding to chemotherapy. He is
now 1 year after detection of the recurrent disease and doing well.
J.L.G. Sabrido and W.V. Jimenez
Discussion
Esophago-jejunostomy leakage is a much-feared postoperative complication, occurring in 4–27 % of cases after total gastrectomy and being associated with a mortality
of 60 %. Moreover, 30–50 % of patients with leakage of an esophago-jejunal anastomosis will later develop a stenosis at that level [ 2 ].
Factors involved in the prevention include: (a) optimization of the nutritional
status before surgery, patients with an esophageal and gastric cancer usually have a
poor oral intake, and enteral nutrition should be given through a nasojejunal tube;
(b) a perfect surgical technique, distal esophageal margins should be well perfused
and free of cancer by intra-operative frozen-section evaluation [ 3 , 4 ]. The jejunal
loop to be anastomosed needs to have enough length and a good perfusion. The best
way to reach the esophagus, without any tension of the jejunal loop, is the transmesocolic route. The esophago-jejunal Roux-Y anastomosis is usually performed in an
end-to-side fashion by means of a 25-mm circular stapler. Placement of a drain does
not diminish the incidence of anastomotic leak, but may decrease the immediate
clinical impact of such a complication and may allow the possibility of a less invasive treatment such as the placement of a stent [ 5 ]. Diagnosis of this complication is
based on clinical signs, usually between the seventh and tenth postoperative day; the
use of a CT scan of thorax and abdomen with double contrast will provide suffi cient
information about the anastomotic leakage and the presence of peri-anastomotic
abscesses, mediastinitis, or general peritonitis and the use of the gastroscopy in
those cases without a clear diagnosis after clinical and radiological evaluation, or in
a case whereby the possibility of treatment by means of a stent is being considered.
In most of the cases during endoscopic evaluation, a stent should be placed.
Concerning the treatment, patient should be admitted to Intensive Care or
Medium Care. Resuscitation measures are very important to achieve an optimal
circulation and urinary fl ow; a broad-spectrum IV antibiotics should, according to
protocol, be started immediately after diagnosis and an adequate control of anastomotic leakage: (1) In case a hemodynamically unstable patient is in critical septic
condition despite resuscitation measures, the patient should be operated on urgently,
including either closure of the distal esophageal stump plus cervical esophagostomy
and jejunostomy for feeding or esophago-jejunal dismantling and placement of
drains in the distal esophagus and in the jejunum and (2) In case of a
12 Case on Esophagojejunostomy Leakage Following Extended Total Gastrectomy
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71
hemodynamically stable patient, time is available to perform a quick study of anastomotic leakage. If the leakage is <30 % of the circumference, treatment may be
conservative, including: sepsis control, adequate local drainage of fl uid-collections,
stent placement, and enteral feeding by microtube through the anastomosis or TPN
[ 6 , 7 ]. If the leakage is >30 %, then the esophago-jejunostomy should be dismantled
and adequately drained [ 8 ]. A reconstruction may be performed 6–12 weeks later in
order to redo the anastomosis.
References
1. Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery
alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355:11–20.
2. Garcia Sabrido JL, Vasquez Jimenez W. How to prevent, early diagnose, and treat major post-
operative complications after gastric surgery. In: Cuesta MA, Bonjer HJ, editors. Treatment of
complications after digestive surgery, chapter 9. London: Springer; 2013.
3. Deguchi Y, Fukagawa T, Morita S. Identifi cation of risk factors for esophagojejunal anasto-
motic leakage after gastric surgery. World J Surg. 2012;36(7):1617–22.
4. Kight CE. Nutrition considerations in esophagectomy patients. Nutr Clin Pract.
2008;23:521–8.
5. Takeyoshi I, Ohwada S, Ogawa T, et al. Esophageal anastomosis following gastrectomy for
gastric cancer: comparison of hand-sewn and stapling technique. Hepatogastroenterology.
2000;47:1026–9.
6. Dai YY, Gretschel S, Dudeck O, et al. Treatment of oesophageal anastomotic leaks by tempo-
rary stenting with self-expanding plastic stents. Br J Surg. 2009;96:887–91.
7. Blackmon SH, Santora R, Schwarz P, et al. Utility of removable esophageal covered self-
expanding metal stents for leak and fi stula management. Ann Thorac Surg. 2010;89:931–6.
8. Lang H, Piso P, Stukenborg C, et al. Management and results of proximal anastomotic leaks in
a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol. 2000;26:168–71.
Chapter 13
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Case on Leakage of the Duodenal Stump
Following Gastrectomy
Jose L. Garcia Sabrido and Wenceslao Vasquez Jimenez
Keywords Gastrectomy • Antrectomy • Vagotomy • Gastrojejunostomy • Pyloric
obstruction • Peptic stenosis • Duodenal leakage
Diagnosis and Indication for Surgery
In view is a 60-year-old male patient with a long-standing history of a peptic ulcer,
treated with ranitidine, proton pump inhibitors, and eradication of Helicobacter
pylori with antibiotics. He had been referred to the emergency room due to an
obstruction of the upper gastrointestinal tract lasting several days. He had been
vomiting after meals for 3 weeks, resulting in a 7 kg weight loss.
After clinical assessment, an abdominal CT scan showed a gastric dilatation. The
follow-up gastroscopy revealed a stenosis of the duodenal bulb due to severe antroduodenal fi brosis. The biopsies were compatible with a chronic infl ammation without signs of cancer.
Diagnosis was a pyloric obstruction due to peptic stenosis.
Operation
A laparoscopic antrectomy, truncular vagotomy, and gastrojejunostomy by means
of Roux-en-Y reconstruction was performed.
Two vacuum drainages (Jackson-Pratt) were placed: one at the duodenal stump
and another close to the gastric stump.
J. L. G. Sabrido , M.D. (*) • W. V. Jimenez , M.D., Ph.D.
Department of Surgery , Gregorio Marañon Hospital , Madrid , Spain
e-mail: jlgsabrido@gmail.com, jlgsabrido@ciriii.hggm.es
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_13,
© Springer International Publishing Switzerland 2014
73
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J.L.G. Sabrido and W.V. Jimenez
Pathology
The pathologic evaluation showed an antral peptic ulcer with intense antro- duodenal
infl ammatory response, without malignant disease.
Postoperative Course: Identifi cation and Treatment
of the Complication
The postoperative course was favorable until the fourth day. Biliary fl uid was then
seen in the duodenal stump drain having an initial production of 400 mL/24 h. The
patient complained of abdominal pain, but he was hemodinamically stable without
signs of sepsis. The performed abdominal CT scan revealed abundant intraabdominal fl uid and pneumoperitoneum.
A laparoscopic surgical exploration was then performed. This located a free biliary collection in the abdominal cavity and fi brin depositions, but its origin could not
be determined. Conversion to laparotomy followed, in which a diffuse biliary peritonitis and dehiscence of the duodenal stump was seen. After aspiration and washing of the cavity, a terminal duodenostomy was performed by means of a 22F Foley
catheter, using a purse string suture, and placing an omental patch around the closure. The suture was tested with an instillation of 50 mL of saline into the catheter.
The Foley catheter was exteriorized through the right upper abdomen (Figs. 13.1
and 13.2 , Illustration 13.1 ). In addition, a Jackson-Pratt vacuum drainage was
placed close to the duodenal stump. The postoperative evolution was good, with
Fig. 13.1 Leakage of the
duodenal stump with
subhepatic fl uid collection
and air
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