powerpoint: sequelae of gastric surgery
TRANSCRIPT
SEQUELAE OF GASTRIC SEQUELAE OF GASTRIC SURGERYSURGERY
SEQUELAE OF GASTRIC SURGERYSEQUELAE OF GASTRIC SURGERYA A (sequela, plural sequelæ) is a pathological (sequela, plural sequelæ) is a pathological
condition resulting from a disease, injury, or other condition resulting from a disease, injury, or other traumatrauma
Minor postprandial complaints are Minor postprandial complaints are commonly after gastric operationscommonly after gastric operations
These usually improve with time- dietary These usually improve with time- dietary adjustmentsadjustments
5-20% of gastric surgery patients- severe 5-20% of gastric surgery patients- severe symptoms- altered anatomy and physiology symptoms- altered anatomy and physiology of the upper GI tractof the upper GI tract
SEQUELAE OF GASTRIC SEQUELAE OF GASTRIC SURGERYSURGERY
1. Recurrent ulcer1. Recurrent ulcer2. Dumping symptoms2. Dumping symptoms3. Reactive hypoglycemia3. Reactive hypoglycemia4. Bile vomiting4. Bile vomiting5. Diarrhea5. Diarrhea6. Small stomach syndrome6. Small stomach syndrome7. Mechanical complications7. Mechanical complications8. Other: cholelithiasis, bezoar formation, gastric 8. Other: cholelithiasis, bezoar formation, gastric stump carcinomastump carcinoma
DUMPINGDUMPING
Systemic symptoms:Systemic symptoms:– Weakness, tiredness, dizzinessWeakness, tiredness, dizziness– Headache, fainting, warmth, palpitationsHeadache, fainting, warmth, palpitations– Dyspnea, sweatingDyspnea, sweating
Gastrointestinal symptoms:Gastrointestinal symptoms:– Fullness, epigastric discomfort, heavinessFullness, epigastric discomfort, heaviness– Nausea, vomitingNausea, vomiting– Excessive distension, diarrheaExcessive distension, diarrhea
DUMPINGDUMPING
Dumping syndrome is associated with Dumping syndrome is associated with rapid gastric emptyingrapid gastric emptyingThe systemic symptoms occur within The systemic symptoms occur within minutes of eating- hypovolemia- massive minutes of eating- hypovolemia- massive outpouring of fluid from vessels into the outpouring of fluid from vessels into the bowel lumenbowel lumenHyperosmolar nature of the intestinal Hyperosmolar nature of the intestinal contents secondary to rapid gastric contents secondary to rapid gastric emptying emptying
DumpingDumping
Kinines, enteroglucagon- vasoactive Kinines, enteroglucagon- vasoactive peptides responsible for systemic and peptides responsible for systemic and digestive symptomsdigestive symptoms
Gastrointestinal symptoms occur later Gastrointestinal symptoms occur later during the course of a dumping attackduring the course of a dumping attack
DUMPING- TREATMENTDUMPING- TREATMENT
Small dry meals rich in protein and fat but Small dry meals rich in protein and fat but low in carbohydratelow in carbohydrate
Additive which slow gastric emptying such Additive which slow gastric emptying such as pectin or branas pectin or bran
Remedial gastric surgery for patients with Remedial gastric surgery for patients with severe dumping syndromesevere dumping syndrome
REACTIVE HYPOGLYCEMIAREACTIVE HYPOGLYCEMIA
Rare complication, incidence of 1-6%Rare complication, incidence of 1-6%
Occur 2-3 hours after mealOccur 2-3 hours after meal
Sweating, tremor, difficult concentrationSweating, tremor, difficult concentration
Reactive hypoglycemia may coexist with Reactive hypoglycemia may coexist with vasomotor dumping and diarrheavasomotor dumping and diarrhea
REACTIVE HYPOGLYCEMIAREACTIVE HYPOGLYCEMIA
Diagnosis – oral glucose tolerance testDiagnosis – oral glucose tolerance test
Initial hyperglycemia- exagerated insulin Initial hyperglycemia- exagerated insulin release- elevated plasma insulin and release- elevated plasma insulin and enteroglucagon- hypoglycemiaenteroglucagon- hypoglycemia
It responds to dietary measures, including It responds to dietary measures, including low-carbohydrate and high protein mealslow-carbohydrate and high protein meals
BILE VOMITINGBILE VOMITING
Vomiting of bile or bile-stained fluid before Vomiting of bile or bile-stained fluid before or after meals- common after gastric op.or after meals- common after gastric op.
It may be due to: It may be due to: - recurrent ulcerrecurrent ulcer - enterogastric reflux,enterogastric reflux,- intermittent obstruction of the afferent or intermittent obstruction of the afferent or
efferent loop of gastroenterostomy,efferent loop of gastroenterostomy,- cardioesophageal incompetencecardioesophageal incompetence
ENTEROGASTRIC REFLUXENTEROGASTRIC REFLUX
Causes a reflux erosive Gastritis and bile Causes a reflux erosive Gastritis and bile vomitingvomitingSymptoms: epigastric pain, nausea, bile Symptoms: epigastric pain, nausea, bile vomiting in the early postprandial periodvomiting in the early postprandial periodThe pain- burning in nature, aggravated by food The pain- burning in nature, aggravated by food and not relieved by antacidsand not relieved by antacidsThe attack culminates in the vomiting of bile-The attack culminates in the vomiting of bile-stained fluid 1-2 hours after a mealstained fluid 1-2 hours after a mealThe erosive gastritis leads to chronic blood loss The erosive gastritis leads to chronic blood loss with iron-deficiency anemiawith iron-deficiency anemia
ENTEROGASTRIC REFLUXENTEROGASTRIC REFLUX
Treatment: Treatment: – bile salt-binding agents- cholestiramine,bile salt-binding agents- cholestiramine,– remedial surgical interventionremedial surgical intervention
Prolonged enterogastric reflux can result Prolonged enterogastric reflux can result in atrophic gastritis and intestinal in atrophic gastritis and intestinal metaplasiametaplasia
This is a risk factor for gastric stump This is a risk factor for gastric stump carcinomacarcinoma
EXTRINSIC LOOP EXTRINSIC LOOP OBSTRUCTIONOBSTRUCTION
The causes are: The causes are: - internal herniation,internal herniation,- kinking of the anastomosis,kinking of the anastomosis,- adhesions,adhesions,- volvulus,volvulus,- stenosis,stenosis,- intussusceptionintussusception
Disorders that can develop after resection of the stomach, Disorders that can develop after resection of the stomach, as a result of the technique used to re-establish as a result of the technique used to re-establish
gastrointestinal continuitygastrointestinal continuity
EXTRINSIC LOOP EXTRINSIC LOOP OBSTRUCTIONOBSTRUCTION
Symptoms- upper GI obstructionSymptoms- upper GI obstruction
Diagnosis- rx. contrast study of the GI Diagnosis- rx. contrast study of the GI tracttract
Treatment- surgical correctionTreatment- surgical correction
Complications after Billroth IIComplications after Billroth IIFirst successful gastfrectomy-Theodor First successful gastfrectomy-Theodor
Billroth- 1881Billroth- 1881
DIARRHEADIARRHEA
Severe intractable diarrhea- 2% of pts. after Severe intractable diarrhea- 2% of pts. after truncal vagotomytruncal vagotomy
Characterized by extreme urgency and often Characterized by extreme urgency and often causes incontinence during an acute attackcauses incontinence during an acute attack
Malabsorbtion of bile salts and fatty acids Malabsorbtion of bile salts and fatty acids secondary to intestinal denervation is implicatedsecondary to intestinal denervation is implicated
The sma;ll bowel transit is acceleratedThe sma;ll bowel transit is accelerated
Treatment: low fat diet, codeine phosphate, Treatment: low fat diet, codeine phosphate, imodium, cholestyramineimodium, cholestyramine
SMALL STOMACH SYNDROMESMALL STOMACH SYNDROME
It appears after extensive gastrectomy and It appears after extensive gastrectomy and GI disfunction after truncal vagotomyGI disfunction after truncal vagotomy
The condition leads to gross malnutritionThe condition leads to gross malnutrition
Surgical treatment- reconstruct a gastric Surgical treatment- reconstruct a gastric reservoir and restore duodenal continuityreservoir and restore duodenal continuity
OTHER COMPLICATIONSOTHER COMPLICATIONS
Formation of gall stones and bezoars due Formation of gall stones and bezoars due to:to:– HypoacidityHypoacidity– Impaired proteolytic activityImpaired proteolytic activity– Loss of antral pumpLoss of antral pump
Development of gastric stump carcinoma Development of gastric stump carcinoma after 15-20 years postoperativelyafter 15-20 years postoperatively
BENIGN GASTRIC TUMORSBENIGN GASTRIC TUMORS
Gastric polyps- benign adenomasGastric polyps- benign adenomas– Solitary or multipleSolitary or multiple– Sessile or pedunculatedSessile or pedunculated– Usually asymptomaticUsually asymptomatic– Found incidentally on rx.or endoscopic exam.Found incidentally on rx.or endoscopic exam.– 20% show histological features of dysplasia20% show histological features of dysplasia– Treatment- endoscopic excision biopsy, Treatment- endoscopic excision biopsy,
follow-upfollow-up
BENIGN GASTRIC TUMORSBENIGN GASTRIC TUMORS
Leyomyomas- smooth muscle tumorsLeyomyomas- smooth muscle tumors– May arise anywhere in the muscle wall of GIMay arise anywhere in the muscle wall of GI– Common in the stomach and small bowelCommon in the stomach and small bowel– Discovered incidentally- rx, endoscopyDiscovered incidentally- rx, endoscopy– Large lesions may cause chronic blood loss Large lesions may cause chronic blood loss
or intermittent gastric outlet obstructionor intermittent gastric outlet obstruction– Sessile or pedunculated, covered by normal Sessile or pedunculated, covered by normal
mucosamucosa
MALIGNANT GASTRIC TUMORSMALIGNANT GASTRIC TUMORS
Lymphomas- 10% of gastric malignanciesLymphomas- 10% of gastric malignancies– May present as a bulky ulcerated mass or May present as a bulky ulcerated mass or
diffusely infiltrating the gastric walldiffusely infiltrating the gastric wall– Diagnosis- barium meal, endoscopy with bx.Diagnosis- barium meal, endoscopy with bx.– Treatment- total gastrectomy, Treatment- total gastrectomy,
radio/chemotherapyradio/chemotherapy– Better prognosis than gastric adenocarcinomaBetter prognosis than gastric adenocarcinoma
ENDOSCOPIC VIEW OF ENDOSCOPIC VIEW OF GASTRIC LYMPHOMAGASTRIC LYMPHOMA
GASTRIC LYMPHOMA OF THE GASTRIC LYMPHOMA OF THE GASTRIC FUNDUSGASTRIC FUNDUS
GASTRIC GASTRIC ADENOCARCINOMAADENOCARCINOMA
90% of gastric malignant tumors90% of gastric malignant tumors
Better outcome when diagnosed early Better outcome when diagnosed early
Risk factors:Risk factors:– atrophic gastritis,atrophic gastritis,– pernicious anemia,pernicious anemia,– previous partial gastrectomyprevious partial gastrectomy,,– polypspolyps
ATROPHIC GASTRITISATROPHIC GASTRITIS
GASTRIC CARCINOMAGASTRIC CARCINOMA
Three morphological formsThree morphological forms– Fungating tumorFungating tumor– Ulcerated tumor- necrosis at the centre of the Ulcerated tumor- necrosis at the centre of the
tumor, large, heaped-up indurated margin tumor, large, heaped-up indurated margin with no surrounding mucosal puckeringwith no surrounding mucosal puckering
– Infiltrating tumor- diffusely invades the Infiltrating tumor- diffusely invades the muscular wall of the stomach- wall thickening muscular wall of the stomach- wall thickening and rigidity- linita plastica “lether bottle”and rigidity- linita plastica “lether bottle”
LINITA PLASTICALINITA PLASTICA
EARLY GASTRIC CANCEREARLY GASTRIC CANCER
Cancer limited to the mucosa and Cancer limited to the mucosa and submucosasubmucosaPrognosis with adequte resection excellent Prognosis with adequte resection excellent with 5-year survival rates of more than with 5-year survival rates of more than 80%80%10-15% of early gastric cancers have 10-15% of early gastric cancers have positive regional lymph nodes- this positive regional lymph nodes- this subgroup is referred to as early-simulating subgroup is referred to as early-simulating advanced gastric canceradvanced gastric cancer
EARLY GASTRIC CANCEREARLY GASTRIC CANCER
ADVANCED GASTRIC CANCERADVANCED GASTRIC CANCER
Tumor which has involved the muscular Tumor which has involved the muscular layer of the stomachlayer of the stomach
Positive lymph nodes, peritoneal and Positive lymph nodes, peritoneal and hepatic deposits (secondaries)hepatic deposits (secondaries)
TNM STAGING SYSTEMTNM STAGING SYSTEM
T1- tu.limited to the mucosa, submucosaT1- tu.limited to the mucosa, submucosaT2- tu. involves the muscular layerT2- tu. involves the muscular layerT3- tu. penetrates the serosaT3- tu. penetrates the serosaT4- tu.invades the adjacent structuresT4- tu.invades the adjacent structuresN0- no positive lymph nodesN0- no positive lymph nodesN1- positive perigastric lymph nodes within 3 N1- positive perigastric lymph nodes within 3 cm. of the primary tu.cm. of the primary tu.N2- positive lymph nodes more than 3 cm.N2- positive lymph nodes more than 3 cm.M0- no distant metastasesM0- no distant metastasesM1- evidence of distant metastasesM1- evidence of distant metastases
SPREAD OF GASTRIC CANCERSPREAD OF GASTRIC CANCER
Direct spread through the gastric wallDirect spread through the gastric wall
Extragastric lymphatic spread- perigastric Extragastric lymphatic spread- perigastric and regionaland regional
Vascular spread-distant metastasesVascular spread-distant metastases
Serosal peritoneal spread- carcinomatosis, Serosal peritoneal spread- carcinomatosis, Blummer tu., Krukenberg tu.Blummer tu., Krukenberg tu.
GASRIC CANCERGASRIC CANCER CLINICAL FEATURES CLINICAL FEATURES
Early gastric cancer- asymptomatic or dyspepsia Early gastric cancer- asymptomatic or dyspepsia simulating an gastric ulcersimulating an gastric ulcer
Malaise, postprandial fullness, loss of appetiteMalaise, postprandial fullness, loss of appetite
Cardia cancer-dysphagiaCardia cancer-dysphagia
Antral cancer- obstructive symptomsAntral cancer- obstructive symptoms
Hematemesis/melenaHematemesis/melena
The most frequent reason for the delayed dg. Is a The most frequent reason for the delayed dg. Is a period of symptomatic therapy with antacids period of symptomatic therapy with antacids before referral for endoscopybefore referral for endoscopy
GASTRIC CANCERGASTRIC CANCERCLINICAL FEATURESCLINICAL FEATURES
Anemia- chronic blood lossAnemia- chronic blood loss
Weight loss- persistent skin fold, low Weight loss- persistent skin fold, low serum albuminserum albumin
Enlarged left supraclavicular lymph nodeEnlarged left supraclavicular lymph node
Palpable epigastric massPalpable epigastric mass
Jaundice- liver metastases or biliary Jaundice- liver metastases or biliary compressive lymphadenopathy in the compressive lymphadenopathy in the porta hepatisporta hepatis
GASTRIC CANCERGASTRIC CANCERDIAGNOSISDIAGNOSIS
GI endoscopy with biopsy and brush GI endoscopy with biopsy and brush cytologycytology
Radiological contrast study- barium mealRadiological contrast study- barium meal
Abdo CTAbdo CT
CXRCXR
USS of the abdomenUSS of the abdomen
LaparoscopyLaparoscopy
GASTRIC CANCERGASTRIC CANCERTREATMENTTREATMENT
Only effective treatment which offer a Only effective treatment which offer a chance for cure- adequate surgical chance for cure- adequate surgical resectionresection
A palliative resection whenever feasible is A palliative resection whenever feasible is more effective in relieving sy.than by-pass more effective in relieving sy.than by-pass procedures.procedures.
Radio/chemotherapy uselessRadio/chemotherapy useless
GASTRIC CANCERGASTRIC CANCERTREATMENTTREATMENT
Principles of potentially curative resection:Principles of potentially curative resection:
– Resection with tumor-free marginsResection with tumor-free margins– Lymph node clearance according to the Lymph node clearance according to the
location of the primary tu. in the stomachlocation of the primary tu. in the stomach– Safe and well functioning reconstructionSafe and well functioning reconstruction
GASTRIC CANCER GASTRIC CANCER TREATMENTTREATMENT
Classification of gastric resectionClassification of gastric resection
– R0- complete resection, no microscopic tu.leftR0- complete resection, no microscopic tu.left
– R1- residual microscopic tu.R1- residual microscopic tu.
– R2- residual macroscopic tu.R2- residual macroscopic tu.
GASTRIC CANCERGASTRIC CANCERTREATMENTTREATMENT
Total gastrectomy is necessary:Total gastrectomy is necessary:
– To achieve a safe tumor free marginTo achieve a safe tumor free margin
– When the neoplasm involves 2 or 3 regions of When the neoplasm involves 2 or 3 regions of
the stomachthe stomach
– Diffuse carcinomaDiffuse carcinoma
GASTRIC CANCERGASTRIC CANCERTREATMENTTREATMENT
Omentectomy- the lesser and greater Omentectomy- the lesser and greater omentum removed for a better omentum removed for a better lymphadenectomylymphadenectomyLymph node clearance:Lymph node clearance:– D1 resection- perigastric lymphadenectomyD1 resection- perigastric lymphadenectomy– D2 resection- along left gastric, hepatic, D2 resection- along left gastric, hepatic,
celiac, splenic arteries nodesceliac, splenic arteries nodes– D3 resection- hepatoduodenal, D3 resection- hepatoduodenal,
retropancreatoduodenal, root of the retropancreatoduodenal, root of the mesentery, middle colic, paraaortic nodesmesentery, middle colic, paraaortic nodes
CURATIVE RESECTIONCURATIVE RESECTION
There is no peritoneal or hepatic There is no peritoneal or hepatic metastasesmetastases
The serosa is not involved by the tumorThe serosa is not involved by the tumor
The resection level exceeds the level of The resection level exceeds the level of nodal involvementnodal involvement
RECONSTRUCTIONRECONSTRUCTION
Subtotal gastrectomy with Roux-en Y Subtotal gastrectomy with Roux-en Y procedureprocedure
Total gastrectomy with eso-jejunal Total gastrectomy with eso-jejunal anastomosisanastomosis
PALLIATIVE SURGICAL PALLIATIVE SURGICAL TREATMENTTREATMENT
Gastroenterostomy- by-pass op. for Gastroenterostomy- by-pass op. for obstructing antral carcinoma obstructing antral carcinoma
Intubation for the cardia carcinomaIntubation for the cardia carcinoma
Feeding jejunostomyFeeding jejunostomy
Gastric stump Gastric stump adenocarcinomaadenocarcinoma
Case reportCase report
Gastric stump adenocarcinomaGastric stump adenocarcinoma
Male, MV, 56-year of age, retired brick masonMale, MV, 56-year of age, retired brick mason
2002- 3 months history of epigastric pain, 2002- 3 months history of epigastric pain, vomiting after meals, asthenia, weight lossvomiting after meals, asthenia, weight loss
Habits: smoking, heavy alcohol drinkingHabits: smoking, heavy alcohol drinking
PMH- partial gastric resection for gastric ulcer-PMH- partial gastric resection for gastric ulcer-20 years ago20 years ago
Physical signsPhysical signs
General: underweight, palor, inelastic skin foldGeneral: underweight, palor, inelastic skin fold
Abdominal examinationAbdominal examinationFlat abdomen moving with respirationsFlat abdomen moving with respirationsPost. Op.scar- median xypho- ombilicalPost. Op.scar- median xypho- ombilicalModerate tenderness in epigastriumModerate tenderness in epigastriumSuccusion splashSuccusion splash
NG aspiration- 100o ml. Gastric fluid non-bile NG aspiration- 100o ml. Gastric fluid non-bile stained with undigested foodstained with undigested food
What is the clinical suspicion?What is the clinical suspicion?
Previous partial gastric resection- stump problemPrevious partial gastric resection- stump problem
Frequent vomiting- undigested food- stenosisFrequent vomiting- undigested food- stenosis
Anemia- chronic blood lossAnemia- chronic blood loss
Weight loss- bad nutritionWeight loss- bad nutrition
Succusion splash- stenosisSuccusion splash- stenosis
Clinical diagnosisClinical diagnosis
Cancer of the gastric stump ?Cancer of the gastric stump ?
InvestigationsInvestigations
Lab. Tests- NAD except a moderate anemiaLab. Tests- NAD except a moderate anemia
Barium meal- partial gastric resection Billroth I, Barium meal- partial gastric resection Billroth I, gastric stump dilated, desorganized mucosal foldsgastric stump dilated, desorganized mucosal folds
Endoscopy- stenotic gastro-duodenal Endoscopy- stenotic gastro-duodenal anastomosis , multiple gastro-duodenal polypsanastomosis , multiple gastro-duodenal polyps
Biopsy- adenocarcinoma of the gastric stump of Biopsy- adenocarcinoma of the gastric stump of papillary typepapillary type
Abdominal USS- absent liver MTSAbdominal USS- absent liver MTS
CXR- NADCXR- NAD
Operative findingsOperative findingsGastric stump tumour staring from the Gastric stump tumour staring from the
gastro-duodenal anastomosisgastro-duodenal anastomosis
Invasion of the D1 and D2Invasion of the D1 and D2
Perigastric lymphadenopathyPerigastric lymphadenopathy
Liver and peritoneum intactLiver and peritoneum intact
What to do?What to do?
Frozen section from the a perigastric Frozen section from the a perigastric lymph node negative for tumour cellslymph node negative for tumour cells
Mobile tumour on adjacent planesMobile tumour on adjacent planes
AgeAge
Absent comorbiditiesAbsent comorbidities
Operative decisionOperative decision
Completion gastrectomyCompletion gastrectomy
D2 lymphadenectomy: loco-regionalD2 lymphadenectomy: loco-regional
Tactic splenectomyTactic splenectomy
Cephalic duodenopancreatectomyCephalic duodenopancreatectomy
Digestive continuity:Digestive continuity:– Eso-jejunal anastomosisEso-jejunal anastomosis– 60 cm distal to it- Wirsungo-jejunal anastomosis60 cm distal to it- Wirsungo-jejunal anastomosis– 20 cm distal to it- biliary-jejunal anastomosis20 cm distal to it- biliary-jejunal anastomosis
Case reportCase report
Operative time- 6 hoursOperative time- 6 hours
Postoperative course- uneventfulPostoperative course- uneventful
Contrast medium eso-jejunal Contrast medium eso-jejunal radiological check-up- intact radiological check-up- intact anastomosis without any leakanastomosis without any leak
Hospital stay- 26 daysHospital stay- 26 days
Case reportCase report
Operative time- 6 hoursOperative time- 6 hours
Postoperative course- uneventfulPostoperative course- uneventful
Contrast medium eso-jejunal Contrast medium eso-jejunal radiological check-up- intact radiological check-up- intact anastomosis without any leakanastomosis without any leak
Hospital stay- 26 daysHospital stay- 26 days
Pathological report Pathological report of the surgical specimenof the surgical specimen
Polipoyd adenocarcinomaPolipoyd adenocarcinoma
Lymph nodes: perigastric, Lymph nodes: perigastric, retroduodenal, celiac trunk, hilum of retroduodenal, celiac trunk, hilum of the spleen were negative for tumour the spleen were negative for tumour cellscells
pTNM- T2 N0 M0pTNM- T2 N0 M0
2003-1 year post-operatively2003-1 year post-operatively
10 Kg weight gain10 Kg weight gain
Good digestive toleranceGood digestive tolerance
Symptoms-freeSymptoms-free
Normal hematological and Normal hematological and biochemistry testsbiochemistry tests
Next post-operative courseNext post-operative course2005- acute appendicitis- appendectomy2005- acute appendicitis- appendectomy
2007-routine endoscopic check-up2007-routine endoscopic check-up
eso-jejunal anastomotic recurrenceeso-jejunal anastomotic recurrence
2007- further investigations2007- further investigations
Endoscopic biopsy- adenocarcinomaEndoscopic biopsy- adenocarcinoma
CXR- NADCXR- NAD
Abdominal USS-slightly enlarged liver, Abdominal USS-slightly enlarged liver, pneumobilia, normal remnant pancreas, pneumobilia, normal remnant pancreas, no ascites, no lombo-aortic lymph nodesno ascites, no lombo-aortic lymph nodes
Respiratory tests- WNLRespiratory tests- WNL
2007- further investigations2007- further investigations
Barium meal: eso-jejunal Barium meal: eso-jejunal anastomosis T-L, anastomotic anastomosis T-L, anastomotic lacunar image- 2cm in sizelacunar image- 2cm in size
Abdominal CT- thickening at the level Abdominal CT- thickening at the level of the anastomosis with esophageal of the anastomosis with esophageal extentextent
What to do?What to do?
Surgical options:Surgical options:
– Partial esophagectomy with intrathoracic Partial esophagectomy with intrathoracic graft interpositiongraft interposition
– Esophageal stripping with colic graftEsophageal stripping with colic graft
Small eso-jejunal tumourSmall eso-jejunal tumour
Absence of mediastinal lymph nodes-Absence of mediastinal lymph nodes-CTCT
Avoidance of left thoracotomyAvoidance of left thoracotomy
DecisionsDecisionsSurgical resectionSurgical resection– Esophageal strippingEsophageal stripping– Proximal jejunostomyProximal jejunostomy
Digestive reconstructionDigestive reconstruction– Left colon graftLeft colon graft– Colo-jejunal anastomosisColo-jejunal anastomosis– Colo-colic anastomosisColo-colic anastomosis– Cervical eso-colic anastomosisCervical eso-colic anastomosis
NutritionNutrition– TPNTPN– Jejunostomy tubeJejunostomy tube
Pathology reportPathology report
Colloid adenocarcinoma invading the Colloid adenocarcinoma invading the digestive wall thickness till subserosadigestive wall thickness till subserosa
3 out of 4 jejunal mesentry limph nodes 3 out of 4 jejunal mesentry limph nodes positivepositive
Periesophageal lymph nodes negativePeriesophageal lymph nodes negative
Early morbidityEarly morbidity
Cervical eso-colic fistulaCervical eso-colic fistula– Small outputSmall output– Conservative treatmentConservative treatment– Oral hygeneOral hygene– Spontaneous closure in 2 weeksSpontaneous closure in 2 weeks– Radiological check-up before oral intakeRadiological check-up before oral intake
Eso-colic fistula-jan.2008Eso-colic fistula-jan.2008
Late morbidityLate morbidity
Colic fistula due to forcibly coughing episodes Colic fistula due to forcibly coughing episodes after quit smokingafter quit smoking
Relaparotomy-transverse colon fistulaRelaparotomy-transverse colon fistula– Colo-jejunal and colo-colic anastomoses intactColo-jejunal and colo-colic anastomoses intact– Coloraphy and abdominal drainageColoraphy and abdominal drainage– Good recoveryGood recovery– Discharged after 9 daysDischarged after 9 days
Patent eso-colic anastomosis, Patent eso-colic anastomosis, may 2008may 2008
Intact colo-jejunal anastomoses, Intact colo-jejunal anastomoses, may 2008may 2008
20092009
Multiple pulmonary metastasesMultiple pulmonary metastases