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Laparoscopic transhiatal esophagectomy after biliopancreatic diversion with duodenal switch
Surgery for Obesity and Related Diseases 14 (2018) 123–124
Case report
Laparoscopic transhiatal esophagectomy after biliopancreatic diversion with duodenal switch Deepali H. Jain, M.D.a,b,*, Tedi S. Vlahu, M.D.a,b, Paul R. Kemmeter, M.D.a,b,c, Jill K. Onesti, M.D.a,b,d a
Grand Rapids Medical Education Partners, Department of Surgery, Grand Rapids, Michigan b Michigan State University, College of Human Medicine, Grand Rapids, Michigan c Grand Health Partners, Grand Rapids, Michigan d Mercy Health Saint Mary’s, Grand Rapids, Michigan Received July 20, 2017; accepted October 10, 2017
The incidence of esophageal adenocarcinoma has steadily risen paralleling the global rise in obesity [1]. There appears to be a strong association between increasing body mass index and incidence of esophageal adenocarcinoma. There is insufficient data to indicate that this risk abates after weight loss surgery [2]. Additionally, previous bariatric surgery, particularly sleeve gastrectomy (SG), poses significant technical challenges in reconstruction after esophageal resection. Primarily, the right gastroepiploic artery feeds the gastric conduit in transhiatal esophagectomy after the left gastric artery is divided. However, after SG, the branches of the right gastroepiploic artery are ligated. Furthermore, as the SG is based off the lesser curvature of the stomach it limits the available length of the conduit especially when considering adequate margins and a cervical anastomosis. We present a novel surgical technique of laparoscopic transhiatal esophagectomy after previous biliopancreatic diversion with duodenal switch (BPD/DS) operation. Case presentation Our patient is a 61-year-old male, 4-years postlaparoscopic BPD/DS performed for super morbid obesity. He had done well without complication and now had a body mass index of 25 kg/m2. He was undergoing annual surveillance for Barrett’s esophagus and had progression *
Correspondence: Deepali Jain, M.D., 1414 N 6th St, Tacoma, WA 98403. E-mail: [email protected]
to adenocarcinoma with a clinical stage T1 b, N0, M0. On endoscopic ultrasound he was found to have a nodular mass arising from a 4-cm segment of Barrett’s esophagus. His positron emission tomography scan did not demonstrate any regional or distant disease. He was recommended for surgical resection. We planned a reversal of his BPD/DS and esophageal resection with a gastric versus colonic interposition conduit.
Management He was taken to the operating room in a joint effort with surgical oncology and bariatric surgery. We first identified and dissected the left gastric vessels. We clamped the left gastric vessels while we completed the reversal of the BPD/ DS and planned to use the stomach as the conduit if it remained viable after adequate clamp time. If the stomach did not remain well perfused, we planned on performing a colonic interposition. We then dissected the esophagus circumferentially well into the mediastinum. Next, we proceeded with reversal of the BPD/DS. We evaluated the biliopancreatic and digestive limbs and created a new, stapled side-to-side jejunojejunostomy. This was performed at a point 20-cm distal to the Ligament of Trietz and 60 cm along the Roux limb to create an additional 200 cm of common channel. At this point, after approximately 60 minutes of clamp time on the left gastric pedicle, the gastric conduit remained viable both on gross inspection and endoscopic evaluation. We determined that the stomach would serve as an
http://dx.doi.org/10.1016/j.soard.2017.10.006 1550-7289/r 2018 American Society for Metabolic and Bariatric Surgery. All rights reserved.
124
D. H. Jain et al. / Surgery for Obesity and Related Diseases 14 (2018) 123–124
acceptable conduit. We performed a pyloroplasty for emptying. We also placed a feeding jejunostomy tube 20-cm distal to the new anastomosis. After approximately 2 hours of clamping the left gastric pedicle, it was divided with a vascular staple load. The proximal stomach was divided ensuring at least a 5-cm margin from the tumor location in the distal esophagus. The esophageal dissection was then completed connecting the blunt cervical dissection in the mediastinum. The proximal esophagus was transected and the specimen was extracted. The conduit was passed into the neck and a handsewn end-to-end anastomosis was created. Postoperatively, the patient did have a chyle leak, which resolved with drainage and total parenteral nutrition. He developed an anastomotic stricture in the neck, which improved with serial dilations. Tumor pathology demonstrated stage II disease and he has not required adjuvant treatment. Discussion With rising rates of bariatric surgery as well as certain gastrointestinal malignancies, these situations will become more frequent. While our case is quite rare considering the number of BPD/DS currently performed in the United States, the rising popularity of SG poses a similar difficulty with reconstruction options for esophageal cancer resection. The 2 primary issues in using a gastric conduit after vertical SG are the blood supply to the conduit and the length. In transhiatal esophagectomy, the gastric conduit is supplied primarily by the right gastroepiploic artery after ligation of the left gastric artery. In vertical SG, especially when done as part of a BPD/DS, the branches of the right gastroepiploic artery are ligated and the main branch may be as well. We determined viability of the conduit by gross inspection and endoscopic evaluation with the left gastric artery clamped. Many other options for evaluating perfusion exist, including Doppler ultrasound, fluorescent dye, transmural oxygen saturation, laser Doppler flowmetry, and others. Recently, there has also been increased use of and interest in the SPY system (Fluorescence Imaging System; Novadaq Technologies Inc, USA) to gauge perfusion, though the data are currently insufficient to detect a clinically significant difference in anastomotic integrity [3,4]. This technology is not currently employed at our institution. Any of these techniques to evaluate perfusion could be used as an adjunct to sound clinical evaluation. Because the SG is based on the lesser curvature, the length of the conduit is significantly shorter than when
using native stomach. This makes a cervical anastomosis difficult as it risks excess tension. In our patient’s case, we could bring up adequate length for a hand-sewn anastomosis; however, an Ivor-Lewis esophagectomy with thoracic anastomosis would be an alternative for an amenable tumor. Conclusion Situations like this will continue to arise as rates of bariatric surgery increase. Several case reports describe esophagectomy after Roux-en-Y gastric bypass using the remnant stomach as conduit [5]. To our knowledge, this is the first described case of esophagectomy after BPD/DS. While the number of patients in the United States with BPD/DS anatomy remains relatively low, with the rapid increase in patients with SG anatomy, reconstruction options after esophageal resection will be of increasing interest. Our case demonstrates feasibility of using a gastric conduit when appropriate considerations of perfusion and length are employed. Disclosure Dr. Kemmeter receives educational stipends from W.L Gore, Medtronic, and Richard Wolf. Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. soard.2017.10.006.
References [1] Blot WJ, McLaughlin JK. The changing epidemiology of esophageal cancer. Semin Orthod 1999;26(5Suppl15):2–8. [2] Murray L, Romero Y. Role of obesity in Barrett’s esophagus and cancer. Surg Oncol Clin N Am 2009;18(3):439–52. [3] Pacheco PE, Hill SM, Henriques SM, Paulsen JK, Anderson RC. The novel use of intraoperative laser-induced fluorescence of indocyanine green tissue angiography for evaluation of the gastric conduit in esophageal reconstructive surgery. Am J of Surg 2013;205(3):349–53. [4] Dickinson KJ, Blackmon SH. Management of conduit necrosis following esophagectomy. Thorac Surg Clin 2015;25(4):461–70. [5] Kuruba R, Jawad M, Karl R, Murr M. Technique of resection of esophageal adenocarcinoma after Roux-en-Y gastric bypass and literature review of esophagogastric tumors after bariatric procedures. Surg Obes Rel Dis 2009;5(5):576–81.
Case report
Laparoscopic transhiatal esophagectomy after biliopancreatic diversion with duodenal switch Deepali H. Jain, M.D.a,b,*, Tedi S. Vlahu, M.D.a,b, Paul R. Kemmeter, M.D.a,b,c, Jill K. Onesti, M.D.a,b,d a
Grand Rapids Medical Education Partners, Department of Surgery, Grand Rapids, Michigan b Michigan State University, College of Human Medicine, Grand Rapids, Michigan c Grand Health Partners, Grand Rapids, Michigan d Mercy Health Saint Mary’s, Grand Rapids, Michigan Received July 20, 2017; accepted October 10, 2017
The incidence of esophageal adenocarcinoma has steadily risen paralleling the global rise in obesity [1]. There appears to be a strong association between increasing body mass index and incidence of esophageal adenocarcinoma. There is insufficient data to indicate that this risk abates after weight loss surgery [2]. Additionally, previous bariatric surgery, particularly sleeve gastrectomy (SG), poses significant technical challenges in reconstruction after esophageal resection. Primarily, the right gastroepiploic artery feeds the gastric conduit in transhiatal esophagectomy after the left gastric artery is divided. However, after SG, the branches of the right gastroepiploic artery are ligated. Furthermore, as the SG is based off the lesser curvature of the stomach it limits the available length of the conduit especially when considering adequate margins and a cervical anastomosis. We present a novel surgical technique of laparoscopic transhiatal esophagectomy after previous biliopancreatic diversion with duodenal switch (BPD/DS) operation. Case presentation Our patient is a 61-year-old male, 4-years postlaparoscopic BPD/DS performed for super morbid obesity. He had done well without complication and now had a body mass index of 25 kg/m2. He was undergoing annual surveillance for Barrett’s esophagus and had progression *
Correspondence: Deepali Jain, M.D., 1414 N 6th St, Tacoma, WA 98403. E-mail: [email protected]
to adenocarcinoma with a clinical stage T1 b, N0, M0. On endoscopic ultrasound he was found to have a nodular mass arising from a 4-cm segment of Barrett’s esophagus. His positron emission tomography scan did not demonstrate any regional or distant disease. He was recommended for surgical resection. We planned a reversal of his BPD/DS and esophageal resection with a gastric versus colonic interposition conduit.
Management He was taken to the operating room in a joint effort with surgical oncology and bariatric surgery. We first identified and dissected the left gastric vessels. We clamped the left gastric vessels while we completed the reversal of the BPD/ DS and planned to use the stomach as the conduit if it remained viable after adequate clamp time. If the stomach did not remain well perfused, we planned on performing a colonic interposition. We then dissected the esophagus circumferentially well into the mediastinum. Next, we proceeded with reversal of the BPD/DS. We evaluated the biliopancreatic and digestive limbs and created a new, stapled side-to-side jejunojejunostomy. This was performed at a point 20-cm distal to the Ligament of Trietz and 60 cm along the Roux limb to create an additional 200 cm of common channel. At this point, after approximately 60 minutes of clamp time on the left gastric pedicle, the gastric conduit remained viable both on gross inspection and endoscopic evaluation. We determined that the stomach would serve as an
http://dx.doi.org/10.1016/j.soard.2017.10.006 1550-7289/r 2018 American Society for Metabolic and Bariatric Surgery. All rights reserved.
124
D. H. Jain et al. / Surgery for Obesity and Related Diseases 14 (2018) 123–124
acceptable conduit. We performed a pyloroplasty for emptying. We also placed a feeding jejunostomy tube 20-cm distal to the new anastomosis. After approximately 2 hours of clamping the left gastric pedicle, it was divided with a vascular staple load. The proximal stomach was divided ensuring at least a 5-cm margin from the tumor location in the distal esophagus. The esophageal dissection was then completed connecting the blunt cervical dissection in the mediastinum. The proximal esophagus was transected and the specimen was extracted. The conduit was passed into the neck and a handsewn end-to-end anastomosis was created. Postoperatively, the patient did have a chyle leak, which resolved with drainage and total parenteral nutrition. He developed an anastomotic stricture in the neck, which improved with serial dilations. Tumor pathology demonstrated stage II disease and he has not required adjuvant treatment. Discussion With rising rates of bariatric surgery as well as certain gastrointestinal malignancies, these situations will become more frequent. While our case is quite rare considering the number of BPD/DS currently performed in the United States, the rising popularity of SG poses a similar difficulty with reconstruction options for esophageal cancer resection. The 2 primary issues in using a gastric conduit after vertical SG are the blood supply to the conduit and the length. In transhiatal esophagectomy, the gastric conduit is supplied primarily by the right gastroepiploic artery after ligation of the left gastric artery. In vertical SG, especially when done as part of a BPD/DS, the branches of the right gastroepiploic artery are ligated and the main branch may be as well. We determined viability of the conduit by gross inspection and endoscopic evaluation with the left gastric artery clamped. Many other options for evaluating perfusion exist, including Doppler ultrasound, fluorescent dye, transmural oxygen saturation, laser Doppler flowmetry, and others. Recently, there has also been increased use of and interest in the SPY system (Fluorescence Imaging System; Novadaq Technologies Inc, USA) to gauge perfusion, though the data are currently insufficient to detect a clinically significant difference in anastomotic integrity [3,4]. This technology is not currently employed at our institution. Any of these techniques to evaluate perfusion could be used as an adjunct to sound clinical evaluation. Because the SG is based on the lesser curvature, the length of the conduit is significantly shorter than when
using native stomach. This makes a cervical anastomosis difficult as it risks excess tension. In our patient’s case, we could bring up adequate length for a hand-sewn anastomosis; however, an Ivor-Lewis esophagectomy with thoracic anastomosis would be an alternative for an amenable tumor. Conclusion Situations like this will continue to arise as rates of bariatric surgery increase. Several case reports describe esophagectomy after Roux-en-Y gastric bypass using the remnant stomach as conduit [5]. To our knowledge, this is the first described case of esophagectomy after BPD/DS. While the number of patients in the United States with BPD/DS anatomy remains relatively low, with the rapid increase in patients with SG anatomy, reconstruction options after esophageal resection will be of increasing interest. Our case demonstrates feasibility of using a gastric conduit when appropriate considerations of perfusion and length are employed. Disclosure Dr. Kemmeter receives educational stipends from W.L Gore, Medtronic, and Richard Wolf. Appendix Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. soard.2017.10.006.
References [1] Blot WJ, McLaughlin JK. The changing epidemiology of esophageal cancer. Semin Orthod 1999;26(5Suppl15):2–8. [2] Murray L, Romero Y. Role of obesity in Barrett’s esophagus and cancer. Surg Oncol Clin N Am 2009;18(3):439–52. [3] Pacheco PE, Hill SM, Henriques SM, Paulsen JK, Anderson RC. The novel use of intraoperative laser-induced fluorescence of indocyanine green tissue angiography for evaluation of the gastric conduit in esophageal reconstructive surgery. Am J of Surg 2013;205(3):349–53. [4] Dickinson KJ, Blackmon SH. Management of conduit necrosis following esophagectomy. Thorac Surg Clin 2015;25(4):461–70. [5] Kuruba R, Jawad M, Karl R, Murr M. Technique of resection of esophageal adenocarcinoma after Roux-en-Y gastric bypass and literature review of esophagogastric tumors after bariatric procedures. Surg Obes Rel Dis 2009;5(5):576–81.