McKeown esophagectomy with concomitant median arcuate ligament release in a case of esophageal cancer with celiac artery stenosis

Background The celiac artery stenosis due to compression by median arcuate ligament (MAL) has been reported in many cases of pancreaticoduodenectomy, but not in cases of esophagectomy. Recently, the celiac artery stenosis due to MAL or arteriosclerosis has been reported to be associated with the gastric tube necrosis or anastomotic leakage following Ivor–Lewis esophagectomy. Herein, we present the first reported case of esophageal cancer with celiac artery stenosis due to compression by the MAL successfully treated by McKeown esophagectomy and gastric tube reconstruction following prophylactic MAL release. Case presentation A 72-year-old female patient was referred to our department for esophagectomy. The patient had received two courses of neoadjuvant chemotherapy with 5-FU and cisplatin for T2N0M0 squamous cell carcinoma of the middle esophagus. Preoperative contrast-enhanced computed tomography (CECT) showed celiac artery stenosis due to compression by the MAL. The development of collateral arteries around the pancreatic head was observed without evidence of aneurysm formation. The patient reported no abdominal symptoms. After robot-assisted esophagectomy with mediastinal lymphadenectomy, gastric mobilization, supra-pancreatic lymphadenectomy, and preparation of the gastric tube were performed under laparotomy. Subsequently, the MAL was cut, and released to expose the celiac artery. Improved celiac artery blood flow was confirmed by decreased pulsatility index on intraoperative Doppler sonography. The operation was completed with the cervical esophagogastric anastomosis following cervical lymphadenectomy. Postoperative CECT on postoperative day 7 demonstrated increased celiac artery patency. The patient had an uncomplicated postoperative course thereafter. Conclusions Prophylactic MAL release may be considered in patients with celiac artery stenosis due to compression by the MAL on preoperative CECT for esophagectomy.

The effect of early oral feeding after subtotal esophagectomy with immediate esophageal reconstruction on the patients’ nutritional status: randomized single-center study.

Background: The efficiency of early oral feeding (EOF) in the postoperative period is well known. Though in the esophagus surgery doctors still prefer another types of nutritional support after esophagectomy (EE) with immediate gastric tube reconstruction. Aims: to improve the results of patients treatment after EE with gastric tube reconstruction by choosing the method of nutritional support and to evaluate nutritional status of the patients with EOF. Materials and methods: weve conducted prospective single-center randomized study. Subtotal esophagectomy with immediate gastric tube reconstruction was performed to 60 patients. In the postoperative period we evaluated the results of treatment, the frequency and severity of complications, as well as anthropometric and laboratory indicators of the nutritional status before the operation, on 1, 3 and 6 postoperative day (POD). Results: Patients without high risk of malnutrition were randomly divided in 2 groups: main group (n=30) starting EOF on the 1 POD and control group (n=30) that remained nil by mouth and got parenteral feeding within 4 POD. The patients of EOF group had statistically significant earlier gas discharge (2[2;3] POD vs 4[3;6] POD, р = 0,000042) and stool appearance (3[2;4] POD vs 5[4;7] POD, р = 0,000004). There is a tendency of reduction of the duration of postoperative hospitalization in EOF group (8[7;9] POD vs 9[8;9] POD, р=0,13). EOF does not affect on frequency (46,6% vs 53,3%, р=0,66) and character of postoperative complications. After evaluation of the parameters of nutritional status we found statistically significant decrease of prealbumin level on 3 POD in EOF group (0,17 [0,13;0,21] vs 0,2 [0,16;0,34], р=0,03) of due to inability to compensate daily calorie needs in the first days after the operation. At 6 POD prealbumin became the same in both groups. There were no other significant differences between the groups. Conclusions: EOF after EE with immediate gastric tube reconstruction is safe and effective. EOF doesnt increase the frequency of anastomotic insufficiency and other complications.

Three-step operation for esophago-left bronchial fistula with respiratory failure after esophagectomy: a case report with literature review

Background The development of esophago-bronchial fistula after esophagectomy and reconstruction using a posterior mediastinal gastric tube remains a rare complication associated with a high rate of mortality. Case presentation A 63-year-old man with esophageal cancer underwent a thoracoscopic esophagectomy with two-field lymph node dissection and reconstruction via a gastric tube through the posterior mediastinal route. Postoperatively, the patient developed extensive pyothorax in the right lung due to port site bleeding and hematoma infection. Four months after surgery, he developed an esophago-left bronchial fistula due to ischemia of the cervical esophagus and severe reflux esophagitis at the site of the anastomosis. Because of respiratory failure due to the esophago-bronchial fistula and the history of extensive right pyothorax, right thoracotomy and left one-lung ventilation were thought to be impossible, so we decided to perform the surgery in three-step systematically. First, we inserted a decompression catheter and feeding tube into the gastric tube as a gastrostomy and expected neovascularization to develop from the wall of the gastric tube through the anastomosis after this procedure. Second, 14 months after esophagectomy, we constructed an esophagostomy after confirming blood flow in the distal side of the cervical esophagus via gastric tube using intraoperative indocyanine green-guided blood flow evaluation. In the final step, we closed the esophagostomy and performed a cervical esophago-jejunal anastomosis to restore esophageal continuity using a pedicle jejunum in a Roux-en-Y anastomosis via a subcutaneous route. Conclusion This three-step operation can be an effective procedure for patients with esophago-left bronchial fistula after esophagectomy, especially those with respiratory failure and difficulty in undergoing right thoracotomy with left one-lung ventilation.

Distal gastric tube resection with preservation of the right gastroepiploic artery for gastric tube cancer: a case report

Background The incidence of gastric tube cancer is increasing because of improved survival rates in patients with esophageal cancer treated by esophagectomy. Total resection of the gastric tube is expected to be highly curative, but it is associated with a higher risk of severe postoperative complications. Herein we report a case of early gastric tube cancer that was successfully treated by distal gastric tube resection with preservation of the right gastroepiploic artery (RGEA). Case presentation An 82-year-old man was diagnosed as having gastric tube cancer, B-12-O, Type 0-IIc, T1b, N0, M0, cStage IA (Japanese Classification of Gastric Carcinoma). Upper gastrointestinal endoscopy showed a Type 0-IIc lesion measuring 30 mm in length in the lower part of the gastric tube, and histopathological examination of biopsy specimens revealed the features of poorly differentiated adenocarcinoma. The primary lesion could not be identified by computed tomography, and there was no obvious lymph node metastasis or distant metastasis. Considering that total resection of the gastric tube would have been highly invasive and that the gastric tube cancer was at a relatively early stage, we performed distal gastric tube resection with preservation of the RGEA. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. There has been no recurrence during the 17 months of follow-up. Conclusion We successfully treated a patient with gastric tube cancer by distal gastric tube resection with preservation of the RGEA. This treatment strategy may be acceptable for patients with early gastric tube cancer without lymph node metastasis, considering the balance between the surgical invasiveness and curability of the tumor.

Application of Modified Gastric Tube Placement in Patients with Indwelling Gastric Tube

Objective: To explore the effect of modified nasogastric tube placement and Rehabilitation New Liquid Spray in patients with indwelling gastric tube. Methods: Eighty-six cases with indwelling gastric tube in our hospital from January 2020 to May 2021 were randomly selected and divided into the reference group and the research group. The reference group was treated by modified gastric tube placement, and the research group was given the Rehabilitation New Liquid Spray intervention. The effect of the interventions on two groups was observed. Results: The incidence of nasal mucosal injury in the research group was lower than that in the reference group, and the incidence of pharyngeal mucosal injury in the research group was lower than that in the reference group (P < 0.05). The pain score of the study group was lower than that of the reference group at 8 h, 12 h and 24 h after replacement, and the incidence of hoarseness, swallowing discomfort and dry oropharynx was lower than that of the reference group (P < 0.05). Conclusion: The application of modified gastric tube placement and Rehabilitation New Liquid Spray intervention in patients with indwelling gastric tube can effectively reduce the nasopharyngeal injury and improve the pain of catheterization.

Treating Early Delayed Gastric Tube Emptying after Esophagectomy with Pneumatic Pyloric Dilation

<b><i>Introduction:</i></b> Endoscopic pneumatic pyloric balloon dilation is a treatment option for early postoperative delayed gastric tube emptying following esophageal resection. This study aimed to determine the safety and effectiveness of endoscopic balloon dilation. <b><i>Methods:</i></b> Between 2015 and 2018, patients with delayed gastric emptying 8–10 days after esophageal resection with gastric tube reconstruction due to esophageal carcinoma were considered for inclusion. Inclusion criteria were ≥1 of the following: nasogastric tube production ≥500 mL/24 h, ≥300 mL gastric retention, ≥50% gastric tube dilatation on X-ray, or nasogastric tube replacement. Patients were excluded on evidence of anastomotic leakage or reintervention. Success was defined as the ability to expand intake without needing to replace the nasogastric tube. Dilation was performed using a 30-mm Rigiflex balloon. <b><i>Results:</i></b> Fifteen patients underwent pyloric dilation, 12 according to the study protocol. Treatment was performed at a median of 12 days (IQR 9–15) postoperatively. Success was achieved in 58%. At 3 months, 8 patients progressed to exclusively oral intake. The remaining 4 patients had supplementary nightly enteral tube feeding. There were no adverse events. <b><i>Conclusion:</i></b> Endoscopic balloon dilation of the pylorus is a safe, feasible therapy for early postoperative delayed gastric emptying. With a success rate of 58%, a clinical trial is a necessary next step.