Minimally invasive redo esophagojejunostomy for postoperative dehiscence after laparoscopic total gastrectomy for gastric cancer
Epublication WebSurg.com, Jan 2014;14(01). URL: http://websurg.com/doi/vd01en4156
This is the case of an 87-year-old man receiving dual antiplatelet therapy, with aortic steno-insufficiency, chronic heart and renal failure, admitted to our service for anemia due to lesser curvature gastric cancer. The patient underwent an uneventuful laparoscopic total gastrectomy with D1 lymph node dissection with Roux-en-Y reconstruction. Pathological findings were consistent with a poorly differentiated pT4bN2M0 adenocarcinoma (TNM classification, 7th edition). A fifth postoperative day gastrografin swallow revealed a large anastomotic leak at the esophagojejunostomy. A conservative approach was considered to treat this complication with a multispecialty approach. However, this approach was rejected for two reasons: - Firstly, the occurrence of a broad anastomotic leakage in the early postoperative period is often due to necrosis of perianastomotic tissues; - Secondly, the patient’s age, the poor nutritional status and the early signs of hemodynamic instability - hypertension and tachycardia - called for a more timely and potentially resolutive approach. Additionally, in our experience, the use of self-expandable metallic stents is associated with a high rate of stent migration in the setting of end-to-side anastomoses. As a result, a decision was made to perform an emergency explorative laparoscopy with a minimally invasive redo esophagojejunostomy. The procedure was performed using 5 trocars through the same incisions as the first surgery. Operative time was 180 minutes, with minimal blood loss and no intraoperative transfusion. Results: After surgery, the patient required admission to the postoperative intensive care unit for 9 days because of respiratory failure, hemodynamic instability, and the development of a subdiaphragmatic collection, treated by percutaneous drainage. An upper gastrointestinal gastrografin swallow on postoperative day 10 showed a patent esophagojejunostomy without any leak. The patient was started on a clear fluid diet, and advanced to a solid diet as tolerated, until discharge on postoperative day 14.