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Minimally invasive esophagectomy is safe in patients with previous gastric bypass
Surgery for Obesity and Related Diseases 10 (2014) 95–100
Original article
Minimally invasive esophagectomy is safe in patients with previous gastric bypass Georgios Rossidis, M.D., Robert Browning, M.D., Steven N. Hochwald, M.D., Husain Abbas, M.D., Tad Kim, M.D., Kfir Ben-David, M.D.* Department of Surgery, University of Florida College of Medicine, Gainesville, Florida Received January 15, 2013; accepted March 27, 2013
Abstract
Background: The prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE). Methods: Retrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012. Results: Five patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up. Conclusions: Minimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barrett’s esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery. (Surg Obes Relat Dis 2014;10:95–100.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Minimally invasive esophagectomy; Esophageal cancer; Gastric bypass
The prevalence of morbid obesity in the United States has been steadily increasing [1]. Obesity is an epidemic that has been well described in the literature, and its multifactorial impact on different disease processes and its economic burden has also been well described [2–4]. There is now an *
Correspondence: Kfir Ben-David, M.D., University of Florida College of Medicine, Department of Surgery, 1600 SW Archer Road, P.O. Box 100109, Gainesville, FL 32610-0109. E-mail: kfi[email protected]fl.edu
established relationship between obesity and the risk of developing various cancers, including colon, breast, endometrial, kidney, and esophageal adenocarcinoma [5,6]. Since the introduction of laparoscopy, there has been a marked increase in the number of laparoscopic bariatric procedures performed thanks to low complication rates, reduced morbidity, and reduced length of stay. The incidence of esophageal cancer after bariatric procedures is very low and may be because Roux-en-Y gastric bypass (RYGB)
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.03.015
96
G. Rossidis et al. / Surgery for Obesity and Related Diseases 10 (2014) 95–100
is an excellent antireflux procedure with absence of acid production in the small gastric pouch and absence of bile reflux in the setting of a long Roux limb [7]. The study by Csendes et al. of 557 patients who underwent bariatric surgery further demonstrates this. All study patients had preoperative endoscopy, and 12 patients had Barrett’s esophagus. Postoperative endoscopies showed regression of Barrett’s esophagus in 57% of the patients and complete resolution of clinical symptoms in all of the patients at 2 years [8]. Consequently, patients with a previous gastric bypass and newly diagnosed esophageal cancer represent a new and challenging patient population for minimally invasive esophagectomy because of their altered anatomy. A few case reports in the literature have reported the challenges associated with gastric conduit formation in the setting of a prior RYGB [9–13]. Hence, we present the technique and outcomes of consecutive patients who had prior gastric bypass and underwent minimally invasive esophagectomy for carcinoma. Methods We performed a retrospective review of consecutive patients with a history of gastric bypass and diagnosis of esophageal cancer who underwent a minimally invasive esophagectomy between July 2010 and August 2012. The division’s database was interrogated after internal review board approval, and the patient demographic characteristics, operative details, and postoperative outcomes were collected and analyzed. Results We identified 5 patients from this time period who had a previous open or laparoscopic RYGB and subsequently developed esophageal cancer requiring a minimally invasive esophagectomy. Table 1 shows the patient demographic characteristics. Mean age was 57 years, and average body mass index (BMI) was 33.4 kg/m2. Laparoscopic RYGB was previously performed in 4 patients, and an open gastric bypass was performed in 1 patient. Gastroesophageal reflux disease was present in 2 patients before their bariatric procedures. Two patients received neoadjuvant chemoradiation therapy. Preoperative photon emission tomography (PET) and computed tomography (CT) scans were performed in all patients to rule out metastatic disease. One patient required a colonic interposition as the conduit of choice because of the division of his right gastroepiploic artery at his initial gastric bypass. Perioperative outcomes Mean operative time was 6 hours and 52 minutes. Average blood loss was 170 mL. Negative margins were achieved in all 5 cases. The average number of lymph nodes harvested was 24. The pathologic staging of the 5 patients
Table 1 Patient demographic characteristics Characteristic Gender Male Female Race Caucasian Age (yr) BMI (average kg/m2) Pathology Poorly differentiated adenocarcinoma Moderately differentiated adenocarcinoma Clinical staging T1 N0 M0 T2 N0 M0 T3 N1 M0 Location Mid esophagus Distal esophagus/GE junction Neoadjuvant chemoradiation Yes No
Number of patients* 4 1 5 57.2 33.4 1 4 3 1 1 1 4 2 3
BMI ¼ body mass index; GE ¼ gastroesophageal. * Total number of patients ¼ 5.
was pT1 aN0 M0 (n ¼ 1), pT1 bN0 M0 (n ¼ 3), and pT0 N1 M0 (n ¼ 1) after neoadjuvant chemoradiation therapy. Median length of stay was 7 days. There were no perioperative mortalities. Complications included pneumonia/respiratory failure and prolonged intubation, recurrent laryngeal nerve injury requiring vocal cord medialization, and delayed gastric emptying resulting from pyloric stenosis. The latter patient underwent endoscopic botulin toxin injection to the pylorus but had refractory symptoms and ultimately required laparoscopic pyloroplasty, which resolved her symptoms. Mean follow-up was 9 months. There were no long-term complications or cancer recurrences in this group on a protocol of CT surveillance at regular intervals. Description of procedure Thoracic dissection. Our technique is similar to methods previously described [9]. The patient is intubated with a double-lumen endotracheal tube with plans for deflation of the right lung and isolated left lung ventilation. An 18gauge nasogastric tube is placed to stiffen the esophagus during the dissection and decompress the gastric pouch. The patient is placed in the left lateral decubitus position, and a 5-mm Optiview trocar is placed under direct vision inferior to the tip of the right scapula. The right chest cavity is insufflated with 8 mm Hg of carbon dioxide (CO2) pressure. A 10-mm port is placed in the posterior axillary line along the fifth or sixth intercostal space. A 12-mm port and a 5mm port are placed in tenth intercostal space, just above the diaphragmatic insertion and the seventh intercostal space, respectively. The lung is retracted anteriorly. The inferior
Esophagectomy After Previous Gastric Bypass / Surgery for Obesity and Related Diseases 10 (2014) 95–100
pulmonary ligament is divided. The lower esophagus is widely dissected and encircled with a Penrose drain. The esophagus is mobilized from its distal end to the proximal portion, starting at a point just above the gastroesophageal junction (GEJ). Periesophageal and subcarinal lymph nodes are included with the specimen. The azygous vein is divided with a 6-cm staple cartridge with a vascular load. The esophagus is dissected from underneath the azygous vein. The dissection continues with mobilization of the proximal esophagus away from the trachea up to the thoracic inlet. A 24F Blake drain is placed through the inferior 12-mm port and positioned along the posterior mediastinum [14]. Cervical dissection. In a supine position, a 6-cm incision is made along the anterior border of the sternocleidomastoid muscle (SCM). The SCM is mobilized laterally and the omohyoid muscle is divided. The jugular vein and carotid artery are retracted laterally. The prevertebral fascia plane is entered. The Penrose drain from our previous thoracic dissection is identified and secured. Abdominal dissection. Our most frequent approach includes placement of two 5-mm and two 12-mm trocars as we have previously described. Once metastatic disease is ruled out, we proceed to identify the Roux limb, being in an antecolic or retrocolic position. We then ensure that the patient has adequate stomach as a gastric conduit. Fig. 1 depicts the typical anatomy after a RYGB. The gastrohepatic ligament is divided. The greater curvature of the stomach is mobilized starting at the origin of the right gastroepiploic artery all the way up to the angle of His preserving all of our right gastroepiploic vessel branches. The Roux limb is divided close to the gastrojejunal anastomosis from the previous RYGB. The divided stump of the Roux limb is then used as a handle. We then proceed with mobilization of the duodenum. The right gastric artery is divided with bipolar sealing device. The left gastric vessel is skeletonized and divided right at the origin of the celiac trunk using a vascular load stapler. We reassess the viability of the remnant stomach. If the stomach appears viable, we proceed with creation of the gastric conduit by starting approximately 2 cm proximal to the pylorus along the lesser curvature of the remnant stomach, working our way up to the angle of His with multiple firings of the stapler. In case the patient has had an open gastric bypass with incomplete partitioning of the pouch from the gastric remnant, the gastric conduit is created lateral to the previous gastric bypass staple line. Approximately six to seven 60-mm staple loads are used to create a long gastric conduit, which is approximately 6 to 7 cm in diameter. The junction of the staple lines is inverted using nonabsorbable suture (Fig. 2). A pyloroplasty is not routinely performed. The phrenoesophageal ligament is widely divided, and the esophageal hiatus is dissected. The lower esophagus is widely dissected until the thoracic and abdominal dissections are in continuity. The gastric conduit is sutured to the gastric pouch at 2 points enabling the transfer of the gastric
97
Fig. 1. Anatomy of a Roux-en-Y gastric bypass.
conduit into the posterior mediastinum through the cervical incision (Fig. 3). Feeding jejunostomy. The Roux limb is used for the feeding jejunostomy placement. An enterotomy is performed on the antimesenteric border of the mobilized Roux limb, and through the defect a 16F T-tube is placed. A 2-0 Vicryl purse-string suture is placed to secure the feeding tube in place. The feeding tube is brought through the abdominal wall and the seromuscular layer of the jejunum is fixed to the abdominal wall at 4 points surrounding the Ttube site using nonabsorbable suture with the aid of the Carter-Thomason device. Additional sutures are placed proximal and distal to the T-tube site to prevent kinking or twisting of the small bowel mesentery (Fig. 3). Cervical esophagogastrostomy. The posterior aspect of the gastric tube is placed alongside the medial aspect of the cervical esophagus. A side-to-side 6-cm linear esophagogastrostomy anastomosis is performed. The common defect is reapproximated with the use of a linear stapler (Fig. 4). The staple line is over sewn with a running absorbable suture. The crotch of the gastroesophageal anastomosis is reinforced with 2 nonabsorbable sutures. The completed
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G. Rossidis et al. / Surgery for Obesity and Related Diseases 10 (2014) 95–100
Fig. 2. Creation of the gastric conduit from the remnant stomach.
gastroesophageal anastomosis is reduced back into the posterosuperior mediastinum. In 1 of the 5 patients the right gastroepiploic artery was severed during the original RYGB procedure. In this patient, during laparoscopic exploration, once the left gastric artery was ligated, the gastric conduit was assessed and appeared to be nonviable. Thus we proceeded with conversion to an open procedure, resection of the gastric conduit, and creation of a colonic interposition using the right colon as the conduit. The right colon was passed through the posterior mediastinum in a similar fashion to a gastric conduit and the cervical anastomosis was created between the cecum and the cervical esophagus. The distal part of the colonic conduit was anastomosed to the Roux jejunal limb using a side-to-side stapled anastomosis, and the distal ileum was anastomosed to the transverse colon with a stapled side-to-side anastomosis. The abdominal portion of this procedure was performed in an open fashion, and the thoracic mobilization was performed thoracoscopically. Hence, all patients undergoing an esophagectomy regardless of previous surgeries and technique all have a mechanical bowel preparation in case the right colon is need as a conduit.
Fig. 3. The Roux limb is used as the feeding jejunostomy access.
Discussion The detrimental effects and increased mortality associated with obesity have been described extensively in the literature. Gastroesophageal reflux disease and the subsequent development of esophageal adenocarcinoma are strongly correlated to obesity. Bariatric surgery and its effect of long-term loss of excess weight have been shown to decrease the associated co-morbidities that accompany morbid obesity [15,16]. Despite the fact that RYGB decreases gastroesophageal reflux and even causes regression of Barrett’s esophagus [8], the risk of developing esophageal adenocarcinoma is not negligible. The question then arises, “Do gastric bypass patients still require continued endoscopic surveillance for Barrett’s, high-grade dysplasia, or cancer?” A recent study of routine preoperative endoscopy in 448 consecutive
Esophagectomy After Previous Gastric Bypass / Surgery for Obesity and Related Diseases 10 (2014) 95–100
99
surgery [18]. Hence, we advocate the use of preoperative endoscopy on patients with known Barrett’s esophagus or severe reflux before a bariatric procedure for appropriate diagnosis. In addition, we also are aggressive with postsurgical surveillance in patients who present with symptoms of heartburn or dysphagia after bariatric surgery to ensure that there are no new onset of esophageal mucosal changes, high-grade dysplasia, or esophageal cancer. Conclusions Minimally invasive esophagectomy in patients with previous gastric bypass is a complex gastrointestinal procedure to perform. It often requires the expertise of a bariatric surgeon and esophageal surgeon. However, this procedure is well tolerated, is technically feasible, and has acceptable oncologic outcomes. Adequate lymphadenectomy should be performed, and negative resection margins should be achieved. Our experience with both laparoscopic bariatric surgery and minimally invasive esophagectomy has enabled us to achieve the goals of a minimally invasive procedure with appropriate oncologic outcomes [19,20], especially in the setting of prior gastric bypass. Furthermore, should it be a necessity, the surgeon embarking on these procedures should be well prepared to perform colonic or jejunal interposition in the event that the blood supply to the remnant stomach is insufficient as noted in one of our patients in this case series. References
Fig. 4. Cervical esophagogastrostomy with a stapled-anastomosis through a cervical incision.
bariatric surgery patients found positive findings leading to a change in medical treatment in 18% of patients, but a change involving surgical therapy was needed in only 1% of patients [17]. Thus the need for endoscopic surveillance on asymptomatic patients is questioned. Melstrom et al. highlighted the need for improved surveillance of bariatric surgery patients in their case report of 3 patients who developed esophageal adenocarcinoma after bariatric
[1] Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA 2010;30:235. [2] BenDavid K, Rossidis G. Bariatric surgery: indications, safety and efficacy. Curr Pharm Des 2011;17:1209–17. [3] Finkelstein EA, Trogdon JG, Brown DS, Allaire BT, Dellea PS, Kamal-Bahl SJ. The lifetime medical cost burden of overweight and obesity: implications for obesity prevention. Obesity 2008;16:1843–8. [4] Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet 2011;378:815. [5] Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008;371:569–78. [6] Brown LM, Swanson CA, Schwartz AG, et al. Adenocarcinoma of the esophagus: role of obesity and diet. J Natl Cancer Inst 1995;87: 104–9. [7] Behrns KE, Smith QD, Sarr MG. Prospective evaluation of gastric acid secretion and cobalamin absorption after gastric bypass for clinically severe obesity. Dig Dis Sci 1994;39:315–20. [8] Csendes A, Burgos AM, Smok G, Burdiles P, Henriquez A. Effect of gastric bypass on Barrett’s esophagus and intestinal metaplasia of the cardia in patients with morbid obesity. J Gastrointest Surg 2006;10:259–64. [9] Ben-David K, Sarosi GA, Cendan JC, Hochwald SN. Technique of minimally invasive Ivor Lewis esophagogastrectomy with intrathoracic stapled side-to-side anastomosis. J Gastrointest Surg 2010;14: 1613–8. [10] Allen JW, Leeman MF, Richardson JD. Esophageal carcinoma following bariatric procedures. JSLS 2004;8:372–5.
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[11] Trincado MT, del Olmo JC, Garcia Castano J. Gastric pouch carcinoma after gastric bypass for morbid obesity. Obes Surg 2005;15:1215–7. [12] Babor R, Booth M. Adenocarcinoma of the gastric pouch 26 years after loop gastric bypass. Obes Surg 2006;16:935–938. [13] Nguyen NT, Tran CL, Gelfand DV, et al. Laparoscopic and thoracoscopic Ivor Lewis esophagectomy after Roux-en-Y gastric bypass. Ann Thorac Surg 2006;82:1910–3. [14] Hochwald SN, Ben-David K. Minimally invasive esophagectomy with cervical esophagogastric anastomosis. J Gastrointest Surg 2012;16:1775–81. [15] Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753–61. [16] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery: A systematic review and meta-analysis. JAMA 2004;292:1724–37.
[17] Loewen M, Giovanni J, Barba C. Screening endoscopy before bariatric surgery: a series of 448 patients. Surg Obes Relat Dis 2008;4:709–12. [18] Melstrom LG, Bentrem DJ, Salvino MJ, Blum MG, Talamonti MS, Printen KJ. Adenocarcinoma of the gastroesophageal junction after bariatric surgery. Am J Surg 2008;196:135–8. [19] Ben-David K, Sarosi GA, Cendan JC, Howard D, Rossidis G, Hochwald SN. Decreasing morbidity and mortality in 100 consecutive minimally invasive esophagectomies. Surg Endosc 2012;26: 162–7. [20] Ben-David K, Rossidis G, Zlotecki RA. Minimally invasive esophagectomy is safe and effective following neoadjuvant chemoradiation therapy. Ann Surg Oncol 2011;18:3324–9.
Original article
Minimally invasive esophagectomy is safe in patients with previous gastric bypass Georgios Rossidis, M.D., Robert Browning, M.D., Steven N. Hochwald, M.D., Husain Abbas, M.D., Tad Kim, M.D., Kfir Ben-David, M.D.* Department of Surgery, University of Florida College of Medicine, Gainesville, Florida Received January 15, 2013; accepted March 27, 2013
Abstract
Background: The prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE). Methods: Retrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012. Results: Five patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up. Conclusions: Minimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barrett’s esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery. (Surg Obes Relat Dis 2014;10:95–100.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Minimally invasive esophagectomy; Esophageal cancer; Gastric bypass
The prevalence of morbid obesity in the United States has been steadily increasing [1]. Obesity is an epidemic that has been well described in the literature, and its multifactorial impact on different disease processes and its economic burden has also been well described [2–4]. There is now an *
Correspondence: Kfir Ben-David, M.D., University of Florida College of Medicine, Department of Surgery, 1600 SW Archer Road, P.O. Box 100109, Gainesville, FL 32610-0109. E-mail: kfi[email protected]fl.edu
established relationship between obesity and the risk of developing various cancers, including colon, breast, endometrial, kidney, and esophageal adenocarcinoma [5,6]. Since the introduction of laparoscopy, there has been a marked increase in the number of laparoscopic bariatric procedures performed thanks to low complication rates, reduced morbidity, and reduced length of stay. The incidence of esophageal cancer after bariatric procedures is very low and may be because Roux-en-Y gastric bypass (RYGB)
1550-7289/14/$ – see front matter r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved. http://dx.doi.org/10.1016/j.soard.2013.03.015
96
G. Rossidis et al. / Surgery for Obesity and Related Diseases 10 (2014) 95–100
is an excellent antireflux procedure with absence of acid production in the small gastric pouch and absence of bile reflux in the setting of a long Roux limb [7]. The study by Csendes et al. of 557 patients who underwent bariatric surgery further demonstrates this. All study patients had preoperative endoscopy, and 12 patients had Barrett’s esophagus. Postoperative endoscopies showed regression of Barrett’s esophagus in 57% of the patients and complete resolution of clinical symptoms in all of the patients at 2 years [8]. Consequently, patients with a previous gastric bypass and newly diagnosed esophageal cancer represent a new and challenging patient population for minimally invasive esophagectomy because of their altered anatomy. A few case reports in the literature have reported the challenges associated with gastric conduit formation in the setting of a prior RYGB [9–13]. Hence, we present the technique and outcomes of consecutive patients who had prior gastric bypass and underwent minimally invasive esophagectomy for carcinoma. Methods We performed a retrospective review of consecutive patients with a history of gastric bypass and diagnosis of esophageal cancer who underwent a minimally invasive esophagectomy between July 2010 and August 2012. The division’s database was interrogated after internal review board approval, and the patient demographic characteristics, operative details, and postoperative outcomes were collected and analyzed. Results We identified 5 patients from this time period who had a previous open or laparoscopic RYGB and subsequently developed esophageal cancer requiring a minimally invasive esophagectomy. Table 1 shows the patient demographic characteristics. Mean age was 57 years, and average body mass index (BMI) was 33.4 kg/m2. Laparoscopic RYGB was previously performed in 4 patients, and an open gastric bypass was performed in 1 patient. Gastroesophageal reflux disease was present in 2 patients before their bariatric procedures. Two patients received neoadjuvant chemoradiation therapy. Preoperative photon emission tomography (PET) and computed tomography (CT) scans were performed in all patients to rule out metastatic disease. One patient required a colonic interposition as the conduit of choice because of the division of his right gastroepiploic artery at his initial gastric bypass. Perioperative outcomes Mean operative time was 6 hours and 52 minutes. Average blood loss was 170 mL. Negative margins were achieved in all 5 cases. The average number of lymph nodes harvested was 24. The pathologic staging of the 5 patients
Table 1 Patient demographic characteristics Characteristic Gender Male Female Race Caucasian Age (yr) BMI (average kg/m2) Pathology Poorly differentiated adenocarcinoma Moderately differentiated adenocarcinoma Clinical staging T1 N0 M0 T2 N0 M0 T3 N1 M0 Location Mid esophagus Distal esophagus/GE junction Neoadjuvant chemoradiation Yes No
Number of patients* 4 1 5 57.2 33.4 1 4 3 1 1 1 4 2 3
BMI ¼ body mass index; GE ¼ gastroesophageal. * Total number of patients ¼ 5.
was pT1 aN0 M0 (n ¼ 1), pT1 bN0 M0 (n ¼ 3), and pT0 N1 M0 (n ¼ 1) after neoadjuvant chemoradiation therapy. Median length of stay was 7 days. There were no perioperative mortalities. Complications included pneumonia/respiratory failure and prolonged intubation, recurrent laryngeal nerve injury requiring vocal cord medialization, and delayed gastric emptying resulting from pyloric stenosis. The latter patient underwent endoscopic botulin toxin injection to the pylorus but had refractory symptoms and ultimately required laparoscopic pyloroplasty, which resolved her symptoms. Mean follow-up was 9 months. There were no long-term complications or cancer recurrences in this group on a protocol of CT surveillance at regular intervals. Description of procedure Thoracic dissection. Our technique is similar to methods previously described [9]. The patient is intubated with a double-lumen endotracheal tube with plans for deflation of the right lung and isolated left lung ventilation. An 18gauge nasogastric tube is placed to stiffen the esophagus during the dissection and decompress the gastric pouch. The patient is placed in the left lateral decubitus position, and a 5-mm Optiview trocar is placed under direct vision inferior to the tip of the right scapula. The right chest cavity is insufflated with 8 mm Hg of carbon dioxide (CO2) pressure. A 10-mm port is placed in the posterior axillary line along the fifth or sixth intercostal space. A 12-mm port and a 5mm port are placed in tenth intercostal space, just above the diaphragmatic insertion and the seventh intercostal space, respectively. The lung is retracted anteriorly. The inferior
Esophagectomy After Previous Gastric Bypass / Surgery for Obesity and Related Diseases 10 (2014) 95–100
pulmonary ligament is divided. The lower esophagus is widely dissected and encircled with a Penrose drain. The esophagus is mobilized from its distal end to the proximal portion, starting at a point just above the gastroesophageal junction (GEJ). Periesophageal and subcarinal lymph nodes are included with the specimen. The azygous vein is divided with a 6-cm staple cartridge with a vascular load. The esophagus is dissected from underneath the azygous vein. The dissection continues with mobilization of the proximal esophagus away from the trachea up to the thoracic inlet. A 24F Blake drain is placed through the inferior 12-mm port and positioned along the posterior mediastinum [14]. Cervical dissection. In a supine position, a 6-cm incision is made along the anterior border of the sternocleidomastoid muscle (SCM). The SCM is mobilized laterally and the omohyoid muscle is divided. The jugular vein and carotid artery are retracted laterally. The prevertebral fascia plane is entered. The Penrose drain from our previous thoracic dissection is identified and secured. Abdominal dissection. Our most frequent approach includes placement of two 5-mm and two 12-mm trocars as we have previously described. Once metastatic disease is ruled out, we proceed to identify the Roux limb, being in an antecolic or retrocolic position. We then ensure that the patient has adequate stomach as a gastric conduit. Fig. 1 depicts the typical anatomy after a RYGB. The gastrohepatic ligament is divided. The greater curvature of the stomach is mobilized starting at the origin of the right gastroepiploic artery all the way up to the angle of His preserving all of our right gastroepiploic vessel branches. The Roux limb is divided close to the gastrojejunal anastomosis from the previous RYGB. The divided stump of the Roux limb is then used as a handle. We then proceed with mobilization of the duodenum. The right gastric artery is divided with bipolar sealing device. The left gastric vessel is skeletonized and divided right at the origin of the celiac trunk using a vascular load stapler. We reassess the viability of the remnant stomach. If the stomach appears viable, we proceed with creation of the gastric conduit by starting approximately 2 cm proximal to the pylorus along the lesser curvature of the remnant stomach, working our way up to the angle of His with multiple firings of the stapler. In case the patient has had an open gastric bypass with incomplete partitioning of the pouch from the gastric remnant, the gastric conduit is created lateral to the previous gastric bypass staple line. Approximately six to seven 60-mm staple loads are used to create a long gastric conduit, which is approximately 6 to 7 cm in diameter. The junction of the staple lines is inverted using nonabsorbable suture (Fig. 2). A pyloroplasty is not routinely performed. The phrenoesophageal ligament is widely divided, and the esophageal hiatus is dissected. The lower esophagus is widely dissected until the thoracic and abdominal dissections are in continuity. The gastric conduit is sutured to the gastric pouch at 2 points enabling the transfer of the gastric
97
Fig. 1. Anatomy of a Roux-en-Y gastric bypass.
conduit into the posterior mediastinum through the cervical incision (Fig. 3). Feeding jejunostomy. The Roux limb is used for the feeding jejunostomy placement. An enterotomy is performed on the antimesenteric border of the mobilized Roux limb, and through the defect a 16F T-tube is placed. A 2-0 Vicryl purse-string suture is placed to secure the feeding tube in place. The feeding tube is brought through the abdominal wall and the seromuscular layer of the jejunum is fixed to the abdominal wall at 4 points surrounding the Ttube site using nonabsorbable suture with the aid of the Carter-Thomason device. Additional sutures are placed proximal and distal to the T-tube site to prevent kinking or twisting of the small bowel mesentery (Fig. 3). Cervical esophagogastrostomy. The posterior aspect of the gastric tube is placed alongside the medial aspect of the cervical esophagus. A side-to-side 6-cm linear esophagogastrostomy anastomosis is performed. The common defect is reapproximated with the use of a linear stapler (Fig. 4). The staple line is over sewn with a running absorbable suture. The crotch of the gastroesophageal anastomosis is reinforced with 2 nonabsorbable sutures. The completed
98
G. Rossidis et al. / Surgery for Obesity and Related Diseases 10 (2014) 95–100
Fig. 2. Creation of the gastric conduit from the remnant stomach.
gastroesophageal anastomosis is reduced back into the posterosuperior mediastinum. In 1 of the 5 patients the right gastroepiploic artery was severed during the original RYGB procedure. In this patient, during laparoscopic exploration, once the left gastric artery was ligated, the gastric conduit was assessed and appeared to be nonviable. Thus we proceeded with conversion to an open procedure, resection of the gastric conduit, and creation of a colonic interposition using the right colon as the conduit. The right colon was passed through the posterior mediastinum in a similar fashion to a gastric conduit and the cervical anastomosis was created between the cecum and the cervical esophagus. The distal part of the colonic conduit was anastomosed to the Roux jejunal limb using a side-to-side stapled anastomosis, and the distal ileum was anastomosed to the transverse colon with a stapled side-to-side anastomosis. The abdominal portion of this procedure was performed in an open fashion, and the thoracic mobilization was performed thoracoscopically. Hence, all patients undergoing an esophagectomy regardless of previous surgeries and technique all have a mechanical bowel preparation in case the right colon is need as a conduit.
Fig. 3. The Roux limb is used as the feeding jejunostomy access.
Discussion The detrimental effects and increased mortality associated with obesity have been described extensively in the literature. Gastroesophageal reflux disease and the subsequent development of esophageal adenocarcinoma are strongly correlated to obesity. Bariatric surgery and its effect of long-term loss of excess weight have been shown to decrease the associated co-morbidities that accompany morbid obesity [15,16]. Despite the fact that RYGB decreases gastroesophageal reflux and even causes regression of Barrett’s esophagus [8], the risk of developing esophageal adenocarcinoma is not negligible. The question then arises, “Do gastric bypass patients still require continued endoscopic surveillance for Barrett’s, high-grade dysplasia, or cancer?” A recent study of routine preoperative endoscopy in 448 consecutive
Esophagectomy After Previous Gastric Bypass / Surgery for Obesity and Related Diseases 10 (2014) 95–100
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surgery [18]. Hence, we advocate the use of preoperative endoscopy on patients with known Barrett’s esophagus or severe reflux before a bariatric procedure for appropriate diagnosis. In addition, we also are aggressive with postsurgical surveillance in patients who present with symptoms of heartburn or dysphagia after bariatric surgery to ensure that there are no new onset of esophageal mucosal changes, high-grade dysplasia, or esophageal cancer. Conclusions Minimally invasive esophagectomy in patients with previous gastric bypass is a complex gastrointestinal procedure to perform. It often requires the expertise of a bariatric surgeon and esophageal surgeon. However, this procedure is well tolerated, is technically feasible, and has acceptable oncologic outcomes. Adequate lymphadenectomy should be performed, and negative resection margins should be achieved. Our experience with both laparoscopic bariatric surgery and minimally invasive esophagectomy has enabled us to achieve the goals of a minimally invasive procedure with appropriate oncologic outcomes [19,20], especially in the setting of prior gastric bypass. Furthermore, should it be a necessity, the surgeon embarking on these procedures should be well prepared to perform colonic or jejunal interposition in the event that the blood supply to the remnant stomach is insufficient as noted in one of our patients in this case series. References
Fig. 4. Cervical esophagogastrostomy with a stapled-anastomosis through a cervical incision.
bariatric surgery patients found positive findings leading to a change in medical treatment in 18% of patients, but a change involving surgical therapy was needed in only 1% of patients [17]. Thus the need for endoscopic surveillance on asymptomatic patients is questioned. Melstrom et al. highlighted the need for improved surveillance of bariatric surgery patients in their case report of 3 patients who developed esophageal adenocarcinoma after bariatric
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