Management of gastric conduit dehiscence with self-expanding metal stents: a case report on salvaging the gastric conduit
© The Author(s). 2017
Received: 25 May 2016
Accepted: 19 January 2017
Published: 25 January 2017
Three-hole minimally invasive esophagectomy (3HMIE) is one of the most radical procedures in gastrointestinal surgery. It involves thoracoscopic dissection of the esophagus followed by creation of a gastric conduit in the abdomen with anastomosis in the neck, and is associated with significant morbidity. Gastric conduit dehiscence is one of the most morbid complications following esophagectomy. Historically, the standard of care in this situation has been conduit diversion with delayed esophageal reconstruction.
Here, we report two patients with a timely diagnosis of gastric conduit dehiscence of staple line after 3HMIE who were salvaged successfully with endoscopic placement of self-expanding metal stents.
Endoscopic stents may be used in selected cases of gastric conduit dehiscence after 3HMIE to salvage the conduit.
KeywordsEsophageal stents Esophageal surgery Operations
Three-hole minimally invasive esophagectomy (3HMIE) is used to treat patients with esophageal cancer and benign end-stage esophageal disease. Gastric conduit necrosis and dehiscence remains a rare, but catastrophic, complication after any esophagectomy . Traditionally, such complications have necessitated conduit removal and esophageal diversion with esophagostomy followed by delayed reconstruction with either jejunum or colon . Here, we present two patients with partial gastric conduit necrosis and/or dehiscence with thoracic contamination after 3HMIE that were successfully managed with self-expanding metal stents (SEMS) with concomitant chest decortication.
Case presentation #1
Case presentation #2
In the setting of 3HMIE with primary anastomosis at the cervical region, placement of esophageal stents has been anecdotally viewed as intolerable and technically difficult. Here, we report two patients with gastric conduit dehiscence after 3HMIE who were successfully managed endoscopically with temporary SEMS placement with concomitant chest washout that allowed gastric conduit salvage. Although both patients developed a post-operative stricture that required dilations, we believe that they were related to the original dehiscence and not the stent themselves.
Careful postoperative monitoring of all esophagectomy patients with high suspicion for anastomotic leakage is crucial in optimizing postoperative outcome. Typically, patients with conduit loss have an initial insidious course prior to clinical deterioration, and early identification of conduit ischemia is critical in decreasing the morbidity and mortality. Both of our patients underwent prompt evaluation for anastomotic leak prior to clinical deterioration and were found to have conduit dehiscence. Of note, neither of these two patients required vasopressors intra-operatively or post-operatively that could have resulted in conduit compromise and neither of them had any evidence of conduit malperfusion/ significant necrosis.
In review of the literature, there is one previous report of successful management of cervical esophago-gastric conduit disruption with SEMS . However, to the best of our knowledge, using SEMS in the setting of conduit dehiscence and contamination of the thoracic cavity after 3HMIE with high anastomosis has never been reported.
We therefore recommend the use of endoscopic stents in selected cases of gastric conduit dehiscence after 3HMIE in an effort to salvage the conduit, based on the clinical status of the patient, expertise of the surgeon, and experience of intensive care units that can manage such critically-ill patients. Albeit, we are not suggesting that if significant conduit necrosis is found or ischemia is suspected, that a stent be utilized as a salvage strategy; as those patients would need to have their conduit taken down with delayed reconstruction.
Three-hole minimally invasive esophagectomy
Partially-covered self-expanding metal stent
Self-expanding metal stent
Availability of data and materials
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
MPK and PGK performed the operation. PGK conceived the report. DHL wrote the first draft with input from all authors. All authors read, revised, and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Both patients included in the study consented to participate in research and consent to publish.
Ethics approval and consent to participate
Approval for the study was obtained from the Institutional Review Board of the Houston Methodist Hospital (IRB0407-0516, Pro00000561).
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