ORIGINAL ARTICLE
Minimally Invasive Management of Postoperative Esophagojejunal Anastomotic Leak Olivier Facy, MD,* Martine Goergen, MD,* Virginie Poulain, MD,* Frank Heieck, MD,* Vincent Lens, MD,w and Juan-Santiago Azagra, MD*
Purpose: Postoperative esophagojejunal fistula induces morbidity and mortality after total gastrectomy and affects the long-term survival rate. Methods: Between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy and 2 developed an esophagojejunal fistula. Results: The diagnosis was established by a computed tomography scan with contrast ingestion. The absence of complete dehiscence and the vitality of the alimentary loop were checked during laparoscopic exploration, associated with effective drainage. During the endoscopy, dehiscence was assessed and a covered stent and nasojejunal tube were inserted for enteral feeding. The leaks healed progressively, oral feeding was resumed and the drains removed within 3 weeks. The stent was removed 6 weeks. Three months later, the patients were able to eat without dysphagia. Conclusions: Early diagnosis allows successful conservative management. The objectives are effective drainage, covering by an endoscopic stent and renutrition. Management by a multidisciplinary team is essential. Key Words: esophagojejunal fistula, stent, laparoscopy, total gastrectomy
(Surg Laparosc Endosc Percutan Tech 2014;24:183–186)
T
otal gastrectomy associated with perioperative chemotherapy is the curative treatment of choice for cancer of the upper and middle third of the stomach.1 Despite progress in preoperative renutrition and the intraoperative techniques of esophagojejunostomy, the risk of postoperative fistula varies from 5% to 10%.2–5 This complication and leak of the duodenal stump are the main factors of postoperative morbidity and mortality. They also affect the long-term prognosis of locally advanced tumors.4 The management of the esophagojejunal fistula (EJF) is not perfectly codified and varies from one team to another. We present here the minimally invasive successful management of 2 patients in our department.
METHODS In our department between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy for cancer. Of these, 2 patients were managed for subsequent EJF. The data Received for publication July 17, 2012; accepted November 27, 2012. From the *Unite´ des Maladies de l’Appareil Digestif et Endocrine (UMADE); and wDepartment of Radiology, Centre Hospitalier de Luxembourg, Luxembourg, UK. The authors declare no conflicts of interest. Reprints: Olivier Facy, MD, Unite´ des Maladies de l’Appareil Digestif et Endocrine (UMADE), Centre Hospitalier de Luxembourg, 4 rue Barble´, L-1210 Luxembourg, UK (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
concerning the preoperative and intraoperative period were recorded: age, sex, tumor, percentage of weight loss, albumin, preoperative treatment, blood loss, operative time, and type of anastomosis. The data about the fistula included the clinical symptoms (fever, hemodynamic tolerance, aspect of drainage), the delay, and the radiologic workup. The data about the management and the outcomes included the repeat intervention, the endoscopy, the time to closure of the fistula, the hospital stay, and the functional results.
RESULTS Preoperative and Intraoperative Period Two patients presented with EJF after laparoscopic total gastrectomy between 2003 and 2011. They were 2 men of 74 and 70 years old, with a medical history of prostate disease and coronary angioplasty. They had lost 13% and 9% of their weight before the intervention and their albumin was 31 and 32 g/L. Their American Society of Anesthesiology (ASA) score was II. Both patients had an adenocarcinoma classified as T3N1M0. They had received 4 cycles of preoperative chemotherapy (FOLFOX). The intervention lasted 5 hours, with
Minimally Invasive Management of Postoperative Esophagojejunal Anastomotic Leak Olivier Facy, MD,* Martine Goergen, MD,* Virginie Poulain, MD,* Frank Heieck, MD,* Vincent Lens, MD,w and Juan-Santiago Azagra, MD*
Purpose: Postoperative esophagojejunal fistula induces morbidity and mortality after total gastrectomy and affects the long-term survival rate. Methods: Between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy and 2 developed an esophagojejunal fistula. Results: The diagnosis was established by a computed tomography scan with contrast ingestion. The absence of complete dehiscence and the vitality of the alimentary loop were checked during laparoscopic exploration, associated with effective drainage. During the endoscopy, dehiscence was assessed and a covered stent and nasojejunal tube were inserted for enteral feeding. The leaks healed progressively, oral feeding was resumed and the drains removed within 3 weeks. The stent was removed 6 weeks. Three months later, the patients were able to eat without dysphagia. Conclusions: Early diagnosis allows successful conservative management. The objectives are effective drainage, covering by an endoscopic stent and renutrition. Management by a multidisciplinary team is essential. Key Words: esophagojejunal fistula, stent, laparoscopy, total gastrectomy
(Surg Laparosc Endosc Percutan Tech 2014;24:183–186)
T
otal gastrectomy associated with perioperative chemotherapy is the curative treatment of choice for cancer of the upper and middle third of the stomach.1 Despite progress in preoperative renutrition and the intraoperative techniques of esophagojejunostomy, the risk of postoperative fistula varies from 5% to 10%.2–5 This complication and leak of the duodenal stump are the main factors of postoperative morbidity and mortality. They also affect the long-term prognosis of locally advanced tumors.4 The management of the esophagojejunal fistula (EJF) is not perfectly codified and varies from one team to another. We present here the minimally invasive successful management of 2 patients in our department.
METHODS In our department between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy for cancer. Of these, 2 patients were managed for subsequent EJF. The data Received for publication July 17, 2012; accepted November 27, 2012. From the *Unite´ des Maladies de l’Appareil Digestif et Endocrine (UMADE); and wDepartment of Radiology, Centre Hospitalier de Luxembourg, Luxembourg, UK. The authors declare no conflicts of interest. Reprints: Olivier Facy, MD, Unite´ des Maladies de l’Appareil Digestif et Endocrine (UMADE), Centre Hospitalier de Luxembourg, 4 rue Barble´, L-1210 Luxembourg, UK (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
concerning the preoperative and intraoperative period were recorded: age, sex, tumor, percentage of weight loss, albumin, preoperative treatment, blood loss, operative time, and type of anastomosis. The data about the fistula included the clinical symptoms (fever, hemodynamic tolerance, aspect of drainage), the delay, and the radiologic workup. The data about the management and the outcomes included the repeat intervention, the endoscopy, the time to closure of the fistula, the hospital stay, and the functional results.
RESULTS Preoperative and Intraoperative Period Two patients presented with EJF after laparoscopic total gastrectomy between 2003 and 2011. They were 2 men of 74 and 70 years old, with a medical history of prostate disease and coronary angioplasty. They had lost 13% and 9% of their weight before the intervention and their albumin was 31 and 32 g/L. Their American Society of Anesthesiology (ASA) score was II. Both patients had an adenocarcinoma classified as T3N1M0. They had received 4 cycles of preoperative chemotherapy (FOLFOX). The intervention lasted 5 hours, with
