Roux-en-Y Diversion for Intractable Reflux After Esophagectomy

Marked improvement of severe reflux esophagitis following proximal gastrectomy with esophagogastrostomy by the right gastroepiploic vessels-preserving antrectomy and Roux-en-Y biliary diversion

Duodenogastroesophageal reflux (DGER) following esophagectomy or gastrectomy can cause severe esophagitis, which impairs patients' quality of life and increases the risk of esophageal carcinogenesis. It is sometimes resistant to medical treatment, and surgical treatment is considered effective in such cases. However, an optimal operative procedure for medical treatment-resistant reflux esophagitis (RE) after proximal gastrectomy (PG) with esophagogastrostomy (EG) has not yet been established. We performed the right gastroepiploic vessels-preserving antrectomy and Roux-en-Y biliary diversion in a 70-year-old man with medical treatment-resistant severe esophagitis caused by DGER following PG with EG for esophagogastric junction cancer. The postoperative course was uneventful, and esophagogastroduodenoscopy performed on the 19th postoperative day showed marked improvement in the esophageal erosions. The patient reported symptomatic relief. The right gastroepiploic vessels-preserving antrectomy and Roux-en-Y biliary diversion were considered safe and feasible for medical treatment-resistant RE following PG with EG.

Randomized Comparison of Gastric Tube Reconstruction With and Without Duodenal Diversion Plus Roux-en-Y Anastomosis After Esophagectomy

OBJECTIVE

This prospective randomized phase-II trial examined whether gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis(RY) minimized gastroduodenal reflux and delayed gastric emptying compared with standard gastric reconstruction.

SUMMARY BACKGROUND DATA

There is no established standard surgical procedure to prevent both gastroduodenal reflux and delayed gastric emptying simultaneously.

METHODS

Sixty patients with thoracic esophageal cancer scheduled to undergo esophagectomy with retrosternal gastric tube reconstruction were randomly allocated to standard gastric reconstruction (non-RY, n = 31) or gastric reconstruction with duodenal diversion plus RY (n = 29) groups. Primary endpoint was quality of life assessed by DAUGS-32 score 1 year after surgery. Secondary endpoints were the extent of postoperative duodenal juice reflux into the gastric tube, postoperative morbidity, endoscopic findings, body weight changes, and nutritional status.

RESULTS

Preoperative clinicopathological characteristics and postoperative morbidity did not differ significantly between groups. However, operation time and blood loss volume were significantly higher in the RY group. Pancreatic amylase concentrations in the gastric conduit on postoperative days 2, 3, and 7 were higher in the non-RY group. Postoperative endoscopic examination showed residual gastric content in 7 of 17 patients in the non-RY group but in none in the RY group (P = 0.012). Quality of life was significantly favorable in the RY group with regard to reflux symptoms and food passage dysfunction. Postoperative body weight changes, serum albumin levels, and peripheral blood lymphocyte counts were not significantly different between groups.

CONCLUSION

Gastric reconstruction with duodenal diversion plus RY is effective in improving both gastroduodenal reflux and delayed gastric emptying.

Complications After Esophagectomy

Esophagectomy is the mainstay for treating esophageal cancers and other pathology. Even with refinements in surgical techniques and the introduction of minimally invasive approaches, the overall morbidity remains formidable. Complications, if not quickly recognized, can lead to significant long-term sequelae and even death. Vigilance with a high degree of suspicion remains the surgeon's greatest ally when caring for a patient who has recently undergone an esophagectomy. In this review, we highlight different approaches in dealing with anastomotic leaks, chyle leaks, cardiopulmonary complications, and later functional issues after esophagectomy.

Management of gastric conduit retention following hybrid and minimally invasive esophagectomy for esophageal cancer: Two retrospective case series

INTRODUCTION

Following esophagectomy about 5% of patients experience long-term gastric conduit retention. We report two patients with surgical correction for this problematic condition. This case series is a retrospective, non-consecutive single center report.

PRESENTATION OF CASES

A slender female aged 76 (patient 1) and an obese man aged 69 (patient 2) with esophageal cancer, underwent hybrid and total minimally invasive Ivor-Lewis esophagectomy, respectively. The conduit was tubularized, and the stapled anastomosis located above carina. The crura were divided in patient 1. Contrast enema revealed a straight (patient 1) or redundant (patient 2) thoracic conduit. Conduit retention in patient 1 began after 47 months. After 61 months reoperation was performed with open thoracoabdominal access for mobilization, abdominal reduction and diaphragmatic suture fixation of the herniated conduit. Symptoms improved and oral nutrition is still sufficient after 8 months.Patient 2 had clinically significant retention after 15 months, despite using pyloric Botox injection and expandable metal stenting. At laparoscopic reoperation after 27 months a partial conduit mobilization and refixation were unsuccessful, but an accidental colonic hiatal hernia was taken down. After 28 months a second reoperation was performed, similar to patient 1. Fifteen months afterwards the patient still ate sufficiently, but a limited double reherniation had occurred.

DISCUSSION

Long-term retention post-esophagectomy often start with an initial redundant conduit, that can increase from food-induced stretching and declive emptying against gravity. A wide hiatal opening probably also predispose to conduital herniation.

CONCLUSIONS

Conduit retention improved after mobilization, reduction and its hiatal fixation. A too wide or narrow hiatal opening must be avoided to prevent herniation.

Ivor-Lewis oesophagogastrectomy with Roux-en-Y duodenal bypass

Oesophagectomies and gastrectomies are performed predominantly for the treatment of malignant disease. However, in this case series, we describe three patients with benign disease who had a laparoscopic oesophagogastrectomy with gastroduodenal detachment and Roux-en-Y biliary diversion, and discuss the operative feasibility and consequent patient outcomes. Our aim was to modify the procedure using an established reconstruction already practised in gastric and bariatric surgery, thereby preventing operative sequelae that lead to a poor quality of life (eg reflux oesophagitis and vomiting). During the first postoperative year, our first two patients experienced weight loss, indigestion and lower bowel symptoms with no apparent improvement in gastric function compared with a standard gastric tube pull-up reconstruction. In the longer term, in both patients, the gastric tube interpositions appeared to function well and there was no evidence of gastro-oesophageal reflux disease, delayed gastric emptying or troublesome indigestion. Our third patient, who had lifelong severe reflux symptoms, was eating normally three months after the operation with no need for antacid medication. We therefore conclude that laparoscopic Ivor-Lewis oesophagogastrectomy with Roux-en-Y bypass is a more complex reconstruction with added risks but may in the long term result in better overall outcomes and satisfaction for patients, particularly those with benign disease.

End-stage achalasia

Despite symptom improvement offered to achalasia patients by either pneumatic dilation or surgical myotomy, 10% to 15% of those so treated will present progressive deterioration of their esophageal function and up to 5% may eventually require an esophagectomy. The natural evolution of achalasia to its end stage as well as the timing of esophagectomy in these patients form the basis of this review. The optimal reconstruction for the decompensated resected esophagus will also be explored: gastric interposition, colon interposition, and jejunal interposition all have their respective advantages and disadvantages. Their use is examined in the exclusive context of resection for achalasia.

The Kagoshima consensus on esophageal achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and a lower esophageal sphincter that fails to relax appropriately in response to swallowing. This article summarizes the most salient issues in the diagnosis and management of achalasia as discussed in a symposium that took place in Kagoshima, Japan, in September 2010 under the auspices of the International Society for Diseases of the Esophagus.

Prevention of gastroduodenal content reflux and delayed gastric emptying after esophagectomy: gastric tube reconstruction with duodenal diversion plus Roux-en-Y anastomosis

Reflux of gastroduodenal contents and delayed gastric emptying are the most common and serious problems after esophagectomy with gastric reconstruction. However, attempts to reduce the above symptoms, surgically as well as non-surgically, had no or limited effect. To address this issue, we performed retrosternal gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis (RY) in eight patients with thoracic esophageal cancer and compared the outcomes with control patients who underwent standard reconstruction. The procedure is simple, safe, and not associated with any postoperative complications. The pancreatic amylase concentrations in the gastric juice samples on postoperative day 2 were slightly lower in the non-RY group than in the RY group (1884 ± 2152 vs. 25,790 ± 23,542IU/mL, respectively, P= 0.07). Postoperative endoscopic examination showed neither reflux esophagitis nor residual gastric content in the RY group. Quality of life assessed by the Dysfunction After Upper Gastrointestinal Surgery-32 questionnaire postoperatively was significantly better in the RY group than in the non-RY group for 'decreased physical activity,''symptoms of reflux,''nausea and vomiting,' and 'pain.' The results of this pilot study suggest that gastric reconstruction with duodenal diversion plus RY seems effective in improving both the reflux and delayed gastric emptying. The benefits of this procedure need to be further assessed in a large-scale, randomized controlled trial.

Functional disorders and quality of life after esophagectomy and gastric tube reconstruction for cancer

Functional disorders such as delayed gastric emptying, dumping syndrome or duodeno-gastro-esophageal reflux occur in half of the patients who undergo esophagectomy and gastric tube reconstruction for cancer. The potential role for pyloroplasty in the prevention of functional disorders is still debated. Antireflux fundoplication during esophagectomy can apparently reduce the reflux but at the cost of increasing the complexity of the operation; it is not widely used. The treatment of functional disorders arising after esophagectomy and gastroplasty for cancer is based mainly on dietary measures. Proton pump inhibitors have well documented efficiency and should be given routinely to prevent reflux complications. Erythromycin may prevent delayed gastric emptying, but it should be used with caution in patients with cardiovascular disorders. In the event of anastomotic stricture, endoscopic dilatation is usually efficient. Problems related to gastrointestinal functional disorders after esophageal resection and gastric tube reconstruction do not significantly impair long-term quality of life, which is mainly influenced by tumor recurrence.