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Gastric necrosis after fundoplication: A novel approach for esophageal preservation
Gastric Necrosis After Fundoplication: A Novel Approach for Esophageal Preservation By Kathryn
D. Bass, David P. Meagher, Jr, and Gerald Denver, Colorado
M. Haase
An II-year-old boy presented moribund, with massive abdominal distension. A Nissen fundoplication and gastrostomy tube had been established at age 2 years. After attempts to pass a nasogastric tube were unsuccessful, the old gastrostomy site was used to gain percutaneous access to the stomach resulting in release of gastric contents and stabilization of blood pressure and perfusion. During operation, massive gastric distention with gastric necrosis was found. Subtotal gastrectomy was performed with stapled closure of the distal intraabdominal esophagus and prepyloric region. Sump suction was placed in the proximal esophagus and the abdomen was drained widely. A distal esophageal perforation was apparent on postoperative day 19 confirmed by imaging and endoscopy. A nasoesophageal tube was passed into the abdomen, tied to a Jackson-Pratt drain, and the compositetube repositioned in the midesopha-
gus allowing controlled proximal and distal drainage. Six months later, a Hunt-Laurence esophagojejunal pouch was created. At age 13, the child is clinically well, and enjoys 50% of his nutritional needs orally, with the remainder delivered overnight via tube feedings. This case describes gastric necrosis after gas bloat syndrome as a late complication of Nissen fundoplication. A novel approach to the management of distal esophageal perforation allowed preservation of a functional, intact native esophagus. J Pediatr Sorg 33:1720-1722. Copyright 6 1998 by W. B. Saunders Company.
ASTRIC NECROSIS after Nissen fundoplication in a child has not been documented in the literature. We report the late complication of gastric necrosis in a child with chronic gas bloat after Nissen fundoplication. A novel approach to preservation of the native esophagus is described that allowed esophageal preservation without division, resection, or cervical diversion.
allowing explosive release of air and gastric contents. The blood pressure and perfusion to the lower extremities improved dramatically. The patient was taken immediately to surgery where abdominal compartment syndrome was confirmed. Gastric perforation had occurred, and contents of the stomach were released explosively at laparotomy. No evidence of gastric volvulus was found; however, the stomach was almost entirely necrotic, with perforation of the posterior wall. The perforation was controlled, and the abdomen irrigated copiously. No other intestinal perforations were present, although patchy areas of ischemia were noted in the proximal jejunum and distal ileum. Subtotal gastrectomy was performed with stapling of the distal intraabdominal esophagus and preservation of the last l-cm of viable prepyloric stomach. A gastrostomy tube was left in the prepyloric region as well as a nasoesophageal tube, and the abdomen was drained widely. Intense peritoneal inflammation and bowel edema demanded a silo construction (Esmark) to achieve temporary abdominal closure. A planned reexploration 24 hours later showed no further progression of ischemic bowel. Serial plication of the silo at the bedside was then performed until fascial closure could be achieved. Bowel perforation on postoperative day 7 was apparent by the presence of succus entericus in the abdominal drains. During exploration, two perforations m areas of previous ischemia were present involving the proximal jejunum and distal ileum. The proximal perforation lay between fourth portion of the duodenum and jejunum and was treated with limited resection and tube enterostomy of both duodenum and jejunum. The distal ileum was treated with an end ileostomy and stapled closure of the distal segment. Four days later the SILASTIC@ (Dow Corning, Midland, MI) silo was removed, a left upper quadrant abscess was drained, the jejunostomy tube was revised to a formal jejunostomy, and the fascia closed. Nineteen days after the initial operation, saliva was noted in the abdominal drains, and breakdown of the distal esophageal staple line was confirmed by contrast study and flexible endoscopy. Drainage of
G
CASE REPORT An 11-year-old boy presented to the emergency department with hypotension, agonal breathing, extreme abdominal distension, and pulseless lower extremities. He had been at a camp for the neurologitally impaired and had been found unresponsive. The only available history was a prior Nissen fundoplication and gastrostomy performed elsewhere at age 2 after a motor vehicle accident. Physical examination confirmed a left upper quadrant incision and a closed gastrostomy site. A radiograph confirmed clear lung fields and a massively distended stomach filling the abdomen. A small amount of free air was present above the liver (Fig 1). Attempts to pass a nasogastric tube to relieve the gastric distension were unsuccessful. Therefore, in the face of persistent respiratory distress, the child’s airway was intubated. The old gastrostomy site was then accessed with a 14-gauge percutaneous catheter
From The Children5 Hospital, University of Colorado Health Science Centel; Denvel; CO. Presented at the 31st Annual Meeting of the Pa@ Association of Pediatric Surgeons, Maui, Hawaii, June 9-13, 1998. Address reprint requests to Gerald M. Haase, MD, 4500 E 9th Ave, Suite 240, Denvec CO 80220. Copyright o I998 by WB. Saunders Company 0022-3468/98/3311-0033$3.00/O 1720
INDEX WORDS: Complications necrosis, esophageal perforation, syndrome.
JournalofPediatric
Surgery,
Vol33,
of
fundoplication, gastric abdominal compartment
No 11 (November),
1998: pp 1720.1722
GASTRIC
NECROSIS
AFTER
FUNDOPLICATION
1721
tion. The child was discharged home 4 months after admission with closed suction esophageal and abdominal drams in place. Six months after his initial illness, the boy was well, weighing more than before his illness. A Hunt-Laurence esophagojejunal pouch was constructed and a duodenojejunostomy created at approximately 30 cm distal to the pouch. The patient recovered well from this procedure and had his ileostomy closed 3 months later, reestablishing gastrointestinal continuity (Fig 3). He is able to swallow, protect his airway, and consumes approximately 50% of his nutritional needs by mouth with the remainder delivered via jejunostomy tube feedings. He is treated with propulsid for reflux into the esophagus demonstrated both by upper gastrointestinal series and by clinical observation of feeds in the oropharnyx during recumbent nightly feedings. This child has resumed normal social activities including eating breakfast and dinner with his family and enjoying lunch and snacks with friends at school. He will relate proudly that he almost died, but survived, and now one of his biggest joys is to eat again.
DISCUSSION
Fig 1. distended
Chest and abdominal radiograph demonstrates abdomen with a small amount of free air (arrow).
massively
the intraabdominal esophagus was achieved by passing the nasoesophageal tube distally into the abdomen. tying a Jackson-Pratt drain onto the distal end, and with retrograde traction, positioning the composrte drain in the mtdesophagus (Fig 2). This allowed controlled proximal and distal drainage of the esophagus without division, resection, or cervical diversion. Tracheostomy for respiratory support and central venous catheter placement for parenteral nutrition were required for rehabilita-
Fig 2. Intraesophageal transabdominal drainage esophageal tube; B, Jackson-Pratt tube; C, duodenal D, duodenal tube-tth portion; E, jejunostomy.
system. tube-1st
A, nasoportion;
Complications of Nissen fundoplication have been well described and include both acute and chronic problems cited at 12% to 15%.1,2 The median time from fundoplication to diagnosis of failure is described at 1.5 years.’ The neurologically impaired are at increased risk for complications including retching and gas bloat, both symptoms of poor gastric emptying.3 The neurologically impaired are also the population most frequently requiring reoperation (5% to 20%) for failure to resolve symptoms. lz4Routine postoperative manometric and contrast studies are not obtained in asymptomatic children. In the neurologically impaired child, however, symptoms may be difficult to ascertain given poor verbal skills. In retrospect, the mother of this child related chronic
Fig 3. Gastrointestinal continuity anastomosis (Hunt-Laurence pouch). pouch; C, duodenojejunostomy with
established by esophagojejunal A, esophagus; B, Hunt-Laurence tube duodenostomy.
1722
BASS
abdominal distension in her son, but noted that the child never complained of abdominal pain and had never vomited since his fundoplication at 2 years of age. It is likely that the boy suffered from chronic gas bloat, but could compensate until the time of his trip to camp. Focal gastric perforation as a complication of fundoplication may occur as a result of poor blood supply after division of the short gastrics, or at the site of fundoplication itself.5*6 Complete gastic necrosis has not been described previously. In this case, the short gastrics had been divided at the initial fundoplication. No early complication related to blood supply occurred. Chronic distension may have begun when the gastrostomy tube was removed or may have simply worsened acutely because of a respiratory or gastrointestinal illness that increased air swallowing or delayed gastric emptying. We postulate that gastric distension reached enormous proportions because a competent wrap precluded burping or
ET AL
vomiting. Abdominal compartment syndrome then ensued. Most likely, venous stasis, and ultimately arterial insufficiency, occurred resulting in the gastric necrosis observed.’ Subtotal gastrectomy followed by breakdown of the distal esophagus was managed in a novel way by intraesophageal, transabdominal drainage creating a controlled fistula that allowed resolution of intraabdominal sepsis. This preserved the entire length of the esophagus and allowed the creation of an intraabdominal jejunal pouch anastomosed to the esophagus. The morbidity of cervical espophagostomy was avoided, keeping the neck clear of esophageal secretions in the presence of a tracheostomy. Although gastric necrosis as a consequence of fundoplication should be a rare event, this method of controlling distal esophageal perforation in the presence of subtotal gastrectomy may be effective and can be considered when appropriate.
REFERENCES 1. Kimber C, Kiely EM, Spitz L: The failure rate of surgery gastro-oesophageal reflux. J Pediatr Surg 33&l-66,1998
for
2. Fonkalsrud EW, Ashcraft KW, Coran AG, et al: Surgical treatment of gastroesophageal reflux in children: A combined hospital study of 7,467 patients. Pediatrics 101:419-442, 1998
3. DeVault K: Gas bloat syndrome: A pre- or postoperative ity syndrome?Am J Gastroenterol90:1536-1537, 1995
dysmotil-
4. Fonkalsrud EW, Ellis DG, Shaw A, et al: A combined hospital experience with fundoplication and gastric emptying procedure
for gastroesophageal
reflux
in children.
J Am Co11 Surg 180449445,
1995
5. Ferguson MK: Pitfalls and complications of antireflux surgery. Nissen and Collis-Nissen techniques (Review). Chest Surg Clin North Am 7:489-509; discussion 510-501, 1997 6. Hunter JG, TNS TL, Branum GD, et al: A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 223:673-685; discussion 685-687, 1996 7. Butch JM, Moore EE, Moore FA, et al: The abdominal compartment syndrome. Surg Clin North Am 76:833-8421996
D. Bass, David P. Meagher, Jr, and Gerald Denver, Colorado
M. Haase
An II-year-old boy presented moribund, with massive abdominal distension. A Nissen fundoplication and gastrostomy tube had been established at age 2 years. After attempts to pass a nasogastric tube were unsuccessful, the old gastrostomy site was used to gain percutaneous access to the stomach resulting in release of gastric contents and stabilization of blood pressure and perfusion. During operation, massive gastric distention with gastric necrosis was found. Subtotal gastrectomy was performed with stapled closure of the distal intraabdominal esophagus and prepyloric region. Sump suction was placed in the proximal esophagus and the abdomen was drained widely. A distal esophageal perforation was apparent on postoperative day 19 confirmed by imaging and endoscopy. A nasoesophageal tube was passed into the abdomen, tied to a Jackson-Pratt drain, and the compositetube repositioned in the midesopha-
gus allowing controlled proximal and distal drainage. Six months later, a Hunt-Laurence esophagojejunal pouch was created. At age 13, the child is clinically well, and enjoys 50% of his nutritional needs orally, with the remainder delivered overnight via tube feedings. This case describes gastric necrosis after gas bloat syndrome as a late complication of Nissen fundoplication. A novel approach to the management of distal esophageal perforation allowed preservation of a functional, intact native esophagus. J Pediatr Sorg 33:1720-1722. Copyright 6 1998 by W. B. Saunders Company.
ASTRIC NECROSIS after Nissen fundoplication in a child has not been documented in the literature. We report the late complication of gastric necrosis in a child with chronic gas bloat after Nissen fundoplication. A novel approach to preservation of the native esophagus is described that allowed esophageal preservation without division, resection, or cervical diversion.
allowing explosive release of air and gastric contents. The blood pressure and perfusion to the lower extremities improved dramatically. The patient was taken immediately to surgery where abdominal compartment syndrome was confirmed. Gastric perforation had occurred, and contents of the stomach were released explosively at laparotomy. No evidence of gastric volvulus was found; however, the stomach was almost entirely necrotic, with perforation of the posterior wall. The perforation was controlled, and the abdomen irrigated copiously. No other intestinal perforations were present, although patchy areas of ischemia were noted in the proximal jejunum and distal ileum. Subtotal gastrectomy was performed with stapling of the distal intraabdominal esophagus and preservation of the last l-cm of viable prepyloric stomach. A gastrostomy tube was left in the prepyloric region as well as a nasoesophageal tube, and the abdomen was drained widely. Intense peritoneal inflammation and bowel edema demanded a silo construction (Esmark) to achieve temporary abdominal closure. A planned reexploration 24 hours later showed no further progression of ischemic bowel. Serial plication of the silo at the bedside was then performed until fascial closure could be achieved. Bowel perforation on postoperative day 7 was apparent by the presence of succus entericus in the abdominal drains. During exploration, two perforations m areas of previous ischemia were present involving the proximal jejunum and distal ileum. The proximal perforation lay between fourth portion of the duodenum and jejunum and was treated with limited resection and tube enterostomy of both duodenum and jejunum. The distal ileum was treated with an end ileostomy and stapled closure of the distal segment. Four days later the SILASTIC@ (Dow Corning, Midland, MI) silo was removed, a left upper quadrant abscess was drained, the jejunostomy tube was revised to a formal jejunostomy, and the fascia closed. Nineteen days after the initial operation, saliva was noted in the abdominal drains, and breakdown of the distal esophageal staple line was confirmed by contrast study and flexible endoscopy. Drainage of
G
CASE REPORT An 11-year-old boy presented to the emergency department with hypotension, agonal breathing, extreme abdominal distension, and pulseless lower extremities. He had been at a camp for the neurologitally impaired and had been found unresponsive. The only available history was a prior Nissen fundoplication and gastrostomy performed elsewhere at age 2 after a motor vehicle accident. Physical examination confirmed a left upper quadrant incision and a closed gastrostomy site. A radiograph confirmed clear lung fields and a massively distended stomach filling the abdomen. A small amount of free air was present above the liver (Fig 1). Attempts to pass a nasogastric tube to relieve the gastric distension were unsuccessful. Therefore, in the face of persistent respiratory distress, the child’s airway was intubated. The old gastrostomy site was then accessed with a 14-gauge percutaneous catheter
From The Children5 Hospital, University of Colorado Health Science Centel; Denvel; CO. Presented at the 31st Annual Meeting of the Pa@ Association of Pediatric Surgeons, Maui, Hawaii, June 9-13, 1998. Address reprint requests to Gerald M. Haase, MD, 4500 E 9th Ave, Suite 240, Denvec CO 80220. Copyright o I998 by WB. Saunders Company 0022-3468/98/3311-0033$3.00/O 1720
INDEX WORDS: Complications necrosis, esophageal perforation, syndrome.
JournalofPediatric
Surgery,
Vol33,
of
fundoplication, gastric abdominal compartment
No 11 (November),
1998: pp 1720.1722
GASTRIC
NECROSIS
AFTER
FUNDOPLICATION
1721
tion. The child was discharged home 4 months after admission with closed suction esophageal and abdominal drams in place. Six months after his initial illness, the boy was well, weighing more than before his illness. A Hunt-Laurence esophagojejunal pouch was constructed and a duodenojejunostomy created at approximately 30 cm distal to the pouch. The patient recovered well from this procedure and had his ileostomy closed 3 months later, reestablishing gastrointestinal continuity (Fig 3). He is able to swallow, protect his airway, and consumes approximately 50% of his nutritional needs by mouth with the remainder delivered via jejunostomy tube feedings. He is treated with propulsid for reflux into the esophagus demonstrated both by upper gastrointestinal series and by clinical observation of feeds in the oropharnyx during recumbent nightly feedings. This child has resumed normal social activities including eating breakfast and dinner with his family and enjoying lunch and snacks with friends at school. He will relate proudly that he almost died, but survived, and now one of his biggest joys is to eat again.
DISCUSSION
Fig 1. distended
Chest and abdominal radiograph demonstrates abdomen with a small amount of free air (arrow).
massively
the intraabdominal esophagus was achieved by passing the nasoesophageal tube distally into the abdomen. tying a Jackson-Pratt drain onto the distal end, and with retrograde traction, positioning the composrte drain in the mtdesophagus (Fig 2). This allowed controlled proximal and distal drainage of the esophagus without division, resection, or cervical diversion. Tracheostomy for respiratory support and central venous catheter placement for parenteral nutrition were required for rehabilita-
Fig 2. Intraesophageal transabdominal drainage esophageal tube; B, Jackson-Pratt tube; C, duodenal D, duodenal tube-tth portion; E, jejunostomy.
system. tube-1st
A, nasoportion;
Complications of Nissen fundoplication have been well described and include both acute and chronic problems cited at 12% to 15%.1,2 The median time from fundoplication to diagnosis of failure is described at 1.5 years.’ The neurologically impaired are at increased risk for complications including retching and gas bloat, both symptoms of poor gastric emptying.3 The neurologically impaired are also the population most frequently requiring reoperation (5% to 20%) for failure to resolve symptoms. lz4Routine postoperative manometric and contrast studies are not obtained in asymptomatic children. In the neurologically impaired child, however, symptoms may be difficult to ascertain given poor verbal skills. In retrospect, the mother of this child related chronic
Fig 3. Gastrointestinal continuity anastomosis (Hunt-Laurence pouch). pouch; C, duodenojejunostomy with
established by esophagojejunal A, esophagus; B, Hunt-Laurence tube duodenostomy.
1722
BASS
abdominal distension in her son, but noted that the child never complained of abdominal pain and had never vomited since his fundoplication at 2 years of age. It is likely that the boy suffered from chronic gas bloat, but could compensate until the time of his trip to camp. Focal gastric perforation as a complication of fundoplication may occur as a result of poor blood supply after division of the short gastrics, or at the site of fundoplication itself.5*6 Complete gastic necrosis has not been described previously. In this case, the short gastrics had been divided at the initial fundoplication. No early complication related to blood supply occurred. Chronic distension may have begun when the gastrostomy tube was removed or may have simply worsened acutely because of a respiratory or gastrointestinal illness that increased air swallowing or delayed gastric emptying. We postulate that gastric distension reached enormous proportions because a competent wrap precluded burping or
ET AL
vomiting. Abdominal compartment syndrome then ensued. Most likely, venous stasis, and ultimately arterial insufficiency, occurred resulting in the gastric necrosis observed.’ Subtotal gastrectomy followed by breakdown of the distal esophagus was managed in a novel way by intraesophageal, transabdominal drainage creating a controlled fistula that allowed resolution of intraabdominal sepsis. This preserved the entire length of the esophagus and allowed the creation of an intraabdominal jejunal pouch anastomosed to the esophagus. The morbidity of cervical espophagostomy was avoided, keeping the neck clear of esophageal secretions in the presence of a tracheostomy. Although gastric necrosis as a consequence of fundoplication should be a rare event, this method of controlling distal esophageal perforation in the presence of subtotal gastrectomy may be effective and can be considered when appropriate.
REFERENCES 1. Kimber C, Kiely EM, Spitz L: The failure rate of surgery gastro-oesophageal reflux. J Pediatr Surg 33&l-66,1998
for
2. Fonkalsrud EW, Ashcraft KW, Coran AG, et al: Surgical treatment of gastroesophageal reflux in children: A combined hospital study of 7,467 patients. Pediatrics 101:419-442, 1998
3. DeVault K: Gas bloat syndrome: A pre- or postoperative ity syndrome?Am J Gastroenterol90:1536-1537, 1995
dysmotil-
4. Fonkalsrud EW, Ellis DG, Shaw A, et al: A combined hospital experience with fundoplication and gastric emptying procedure
for gastroesophageal
reflux
in children.
J Am Co11 Surg 180449445,
1995
5. Ferguson MK: Pitfalls and complications of antireflux surgery. Nissen and Collis-Nissen techniques (Review). Chest Surg Clin North Am 7:489-509; discussion 510-501, 1997 6. Hunter JG, TNS TL, Branum GD, et al: A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 223:673-685; discussion 685-687, 1996 7. Butch JM, Moore EE, Moore FA, et al: The abdominal compartment syndrome. Surg Clin North Am 76:833-8421996