Ulcer in the gastric tube for esophageal replacement: a comparison of 12 esophageal cancer patients with or without postoperative radiotherapy

Changes in Acidity Levels in the Gastric Tube After Esophagectomy for Esophageal Cancer

Reflux esophagitis and gastric tube ulcer sometimes cause severe clinical problems in patients undergoing esophagectomy with gastric tube reconstruction. We previously reported that acidity in the gastric tube was decreased for 1 year after esophagectomy, and that lower acidity levels were associated with Helicobacter pylori (H. pylori) infection. However, the long-term changes in gastric acidity remain unknown. We aimed to investigate the long-term changes in gastric acidity after surgery. Eighty-nine patients who underwent esophagectomy with gastric tube reconstruction for esophageal cancer were analyzed. They underwent 24-hour pH monitoring, serum gastrin measurement, and H. pylori infection examination before surgery, at 1 month, 1 year, and 2 years after surgery. The gastric acidity at 1 month and 1 year after surgery was significantly lower than that before surgery (p=0.003, p=0.003). However, there was no difference in gastric acidity before and 2 years after surgery. The gas tric acidity in H. pylori-infected patients was significantly lower in comparison to non-infected patients at each time point (p=0.0003, p<0.0001, p<0.0001, p<0.0001, respectively). In H. pylori-infected patients, gastric acid ity was decreased for 1 year after surgery, and recovered within 2 years after surgery. However, no significant differences were observed in the acidity levels of non-infected patients during the 2-year follow-up period. The serum gastrin level increased after esophagectomy. The acidity levels in the gastric tube recovered within 2 years after surgery. Periodic endoscopy examination is recommended for early detection of acid-related disease, such as reflux esophagitis or gastric tube ulcer, after esophagectomy with gastric tube reconstruction.

Refractory cutaneo-gastric conduit fistula after esophagectomy repaired by a pectoralis major muscle flap and split-thickness skin graft

BACKGROUND

Gastric conduit ulcer after esophagectomy is not uncommon. In cases where a gastric conduit ulcer penetrates the adjacent organs, it is difficult to select a suitable treatment strategy. The treatment depends on the adjacent organs penetrated.

CASE PRESENTATION

We report a case in which a reconstructed gastric conduit ulcer penetrated the precordial skin in a patient who had undergone esophagectomy due to spontaneous esophageal rupture 28 years previously. To treat the cutaneo-gastric conduit fistula, we resected the fistula, covered the site of anastomosis with a major pectoralis muscle flap, and applied a split-thickness skin graft to the skin defect.

CONCLUSIONS

In cases of gastric conduit trouble in patients treated via the antesternal route, a major pectoralis muscle flap is useful because of its rich blood supply and easy mobilization. In addition, a split-thickness skin graft should be applied to the skin defect.

Tracheoesophageal fistula after total resection of gastric conduit for gastro-aortic fistula due to gastric ulcer

Background

Tracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. It has a high mortality rate and often leads to severe aspiration pneumonia. Various types of surgical repair procedures have been reported, but the optimal management of TEF is challenging and controversial. Treatment should be individualized to each patient.

Case presentation

A 66-year-old female underwent transthoracic esophagectomy with gastric tube reconstruction and an intrathoracic anastomosis for esophageal cancer. Three years later, she had hematemesis and was diagnosed with a gastro-aortic fistula due to a gastric ulcer. She underwent endovascular aortic repair urgently at another hospital. Two days later, she underwent total resection of the gastric tube, during which time an injury to the trachea occurred; it was repaired by patching the stump of the esophagus to the injury site. Two months later, descending aortic replacement was performed due to infection of the stent graft. Six months after the first operation, a TEF developed. The patient was referred to our hospital for further treatment. The fistula was ligated and divided via a cervical approach, and a pectoralis major muscle flap was used to cover the defect. Esophageal reconstruction with the pedunculated jejunum was performed via a subcutaneous route. The postoperative course was uneventful. The patient was discharged after 6 months of physical and dysphagia rehabilitation.

Conclusion

A TEF located near the cervicothoracic border was successfully treated with a pectoralis major muscle flap through a cervical approach. Total resection of a gastric conduit in the posterior mediastinum carries a risk of tracheobronchial injury; however, if such an injury occurs, surgeons should be able to repair the injury using a suitable flap depending on the injury site.

Salvage radiotherapy in patients with recurrent esophageal carcinoma

PURPOSE

The feasibility and effectiveness of radiotherapy in the management of recurrent esophageal carcinoma (REC) is reported.

PATIENTS AND METHODS

A consecutive cohort of 54 patients with rcT1-4, rcN0-1, or cM0 recurrent esophageal carcinoma (69% squamous cell carcinoma, 31% adenocarcinoma) was treated between 1988 and 2010. The initial treatment for these patients was definitive radiochemotherapy, surgery alone, or neoadjuvant radiochemotherapy + surgical resection in 8 (15%), 33 (61%), and 13 (24%) patients, respectively. The median time to recurrence from initial treatment was 19 months (range 4-79 months). The site of the recurrence was anastomotic or local, nodal, or both in 63%, 30%, and 7% of patients, respectively. Salvage radio(chemo)therapy was carried out with a median dose of 45 Gy (range 30-68 Gy).

RESULTS

Median follow-up time for surviving patients from the start of R(C)T was 38 months (range 10-105 months). Relief of symptoms was achieved in 19 of 28 symptomatic patients (68%). The median survival time was 12 months (95% confidence interval (CI) 7-17 months) and the median recurrence-free interval was 8 months (95% CI 4-12 months). The survival rates at 1, 2, and 3 years were 55 ± 7%, 29 ± 6%, and 19 ± 5%, respectively. The recurrence-free survival rates at 1, 2, and 3 years were 44 ± 7%, 22 ± 6%, and 15 ± 5%, respectively. A radiation dose ≥ 45 Gy and conformal RT were associated with a better prognosis.

CONCLUSION

RT is feasible and effective in the management of recurrent esophageal carcinoma, especially for relief of symptoms. Toxicity is in an acceptable range. The outcome of REC is poor; however, long-term survival of patients with recurrent esophageal carcinoma after radiochemotherapy might be possible, even with a previous history of radiotherapy in the initial treatment. If re-irradiation of esophageal carcinoma is contemplated, three-dimensional conformal techniques and a minimum total dose of 45 Gy are recommended.

Cerebral air embolism as a complication of peptic ulcer in the gastric tube: case report

Background

The reported incidence of ulcer formation in the gastric tube in esophageal replacement is rare.

Case Presentation

This is the first report of a case of cerebral air embolism as a result of spontaneous perforation of an ulcer in the constructed gastric tube into the pulmonary vein during post-operative follow-up in a patient with esophageal cancer.

Conclusions

Cerebral air embolism is a rare complication of penetrating gastric ulcer, but should be considered in patients with a history of esophagectomy with gastric conduit that present with acute neurologic findings.

[Rare complication following oesophagectomy: early peptic ulcer perforation of the tubal stomach]

CASE REPORT

We report the case of a 45-year-old male patient who developed an acute peptic ulcer perforation of the tubal stomach on the second postoperative day after oesophagectomy. The patient underwent emergency surgery (perforation was closed with a Graham patch) followed by treatment in intensive care, and was finally discharged on the 19th postoperative day.

DISCUSSION

Gastric pull-up is a surgical technique that is widely used to re-establish the continuity of the gastrointestinal tract after oesophagectomy. Various early and late complications of reconstruction with the tubal stomach are well-known, such as gastric necrosis, gastritis, gastric ulcer, as well as benign and malignant tumors. The precise etiology of gastric tube ulceration is not known yet, however, it can develop not only in the late, but also in the early postoperative period, as well.

Gastric tube perforation after esophagectomy for esophageal cancer

We searched for cases of perforation of the gastric tube after esophagectomy for esophageal cancer by reviewing the literature. Only 13 cases were found in the English literature, and serious complications were seen in all cases, especially in cases of posterior mediastinal reconstruction. However, in the Japanese literature serious complications were also frequently seen in retrosternal reconstruction. Gastric tubes are at a higher risk of developing an ulcer than the normal stomach, including an ulcer due to Helicobacter pylori infection, insufficient blood supply, gastric stasis, and bile juice regurgitation. H. pylori eradication and acid-suppressive medications are important preventive therapies for ordinary gastric ulcers, but for gastric tube ulcers the effects of such treatments are still controversial. We tried to determine the most appropriate treatment to avoid serious complications in the gastric tubes, but we could not confirm an optimal route because each had advantages and disadvantages. However, at least in cases with severe atrophic gastritis due to H. pylori infection or a history of frequent peptic ulcer treatment, the antesternal route is clearly the best. Many cases of gastric tube ulcers involve no pain, and vagotomy may be one of the reasons for this absence of pain. Therefore, periodic endoscopic examination may be necessary to rule out the presence of an ulcer.

Therapeutic strategy for the treatment of postoperative recurrence of esophageal squamous cell carcinoma: clinical efficacy of radiotherapy

We investigated the effectiveness of chemoradiotherapy for the treatment of lymph node recurrence and hematogenous metastasis after esophagectomy for esophageal squamous cell carcinoma. Between 2001 and 2006, 216 patients with thoracic esophageal squamous cell carcinoma had curative esophagectomy. Of those, 23 with lymph node recurrence received chemoradiotherapy (50.0-68.8 Gy). In addition, five patients had isolated recurrences in a distant organ and received chemoradiotherapy (50.0-60.0 Gy). We analyzed outcomes from the radiotherapy for recurrent esophageal cancer. The 1-, 2-, and 5-year survival rates after recurrence for the 23 patients whose lymph node recurrence was treated with chemoradiotherapy were 52, 31, and 24%, respectively, and the median survival time was 13 months. Among the five patients with recurrent tumors in a distant organ, chemoradiotherapy produced a complete response in two patients, a partial response in one patient, and stable disease in two patients, giving an effectiveness rate of 60% (complete response + partial response). Chemoradiotherapy has a beneficial prognostic effect in patients with lymph node recurrence of esophageal squamous cell carcinoma. Chemoradiotherapy for a metastatic tumor in a distant organ may be the treatment of choice in cases where systemic chemotherapy has proven ineffective.

Peptic ulcer of the gastric tube after esophagectomy for cancer: clinical implications

The use of the stomach as an esophageal substitute has become a well-established treatment procedure after esophagectomy for cancer. During the procedure, a bilateral truncal vagotomy is performed, which should prevent the occurrence of acid-related diseases in the gastric tube and in the remaining esophagus. We report the case of a man who presented a plugged perforated peptic ulcer that subsequently decompensated following endoscopic examination 1 year after a transthoracic esophagectomy with neoadjuvant chemo-radiation for a middle third squamous cell carcinoma. Resection of the ulcer and suture with a pleural patch was performed. There was no evidence of recurrent malignancy at time of surgery. The pathophysiology of gastric tube ulcer is multifactorial. Long-term treatment with an anti-secretory proton pump inhibitor may decrease esophageal complications of duodeno-gastric-esophageal reflux and could prevent the recurrence of gastric tube ulcers.