Powerpoint: Sequelae of gastric surgery

SEQUELAE OF GASTRIC SEQUELAE OF GASTRIC SURGERYSURGERY

SEQUELAE OF GASTRIC SURGERYSEQUELAE OF GASTRIC SURGERYA A (sequela, plural sequelæ) is a pathological (sequela, plural sequelæ) is a pathological

condition resulting from a disease, injury, or other condition resulting from a disease, injury, or other traumatrauma

Minor postprandial complaints are Minor postprandial complaints are commonly after gastric operationscommonly after gastric operations

These usually improve with time- dietary These usually improve with time- dietary adjustmentsadjustments

5-20% of gastric surgery patients- severe 5-20% of gastric surgery patients- severe symptoms- altered anatomy and physiology symptoms- altered anatomy and physiology of the upper GI tractof the upper GI tract

SEQUELAE OF GASTRIC SEQUELAE OF GASTRIC SURGERYSURGERY

1. Recurrent ulcer1. Recurrent ulcer2. Dumping symptoms2. Dumping symptoms3. Reactive hypoglycemia3. Reactive hypoglycemia4. Bile vomiting4. Bile vomiting5. Diarrhea5. Diarrhea6. Small stomach syndrome6. Small stomach syndrome7. Mechanical complications7. Mechanical complications8. Other: cholelithiasis, bezoar formation, gastric 8. Other: cholelithiasis, bezoar formation, gastric stump carcinomastump carcinoma

DUMPINGDUMPING

Systemic symptoms:Systemic symptoms:– Weakness, tiredness, dizzinessWeakness, tiredness, dizziness– Headache, fainting, warmth, palpitationsHeadache, fainting, warmth, palpitations– Dyspnea, sweatingDyspnea, sweating

Gastrointestinal symptoms:Gastrointestinal symptoms:– Fullness, epigastric discomfort, heavinessFullness, epigastric discomfort, heaviness– Nausea, vomitingNausea, vomiting– Excessive distension, diarrheaExcessive distension, diarrhea

DUMPINGDUMPING

Dumping syndrome is associated with Dumping syndrome is associated with rapid gastric emptyingrapid gastric emptyingThe systemic symptoms occur within The systemic symptoms occur within minutes of eating- hypovolemia- massive minutes of eating- hypovolemia- massive outpouring of fluid from vessels into the outpouring of fluid from vessels into the bowel lumenbowel lumenHyperosmolar nature of the intestinal Hyperosmolar nature of the intestinal contents secondary to rapid gastric contents secondary to rapid gastric emptying emptying

DumpingDumping

Kinines, enteroglucagon- vasoactive Kinines, enteroglucagon- vasoactive peptides responsible for systemic and peptides responsible for systemic and digestive symptomsdigestive symptoms

Gastrointestinal symptoms occur later Gastrointestinal symptoms occur later during the course of a dumping attackduring the course of a dumping attack

DUMPING- TREATMENTDUMPING- TREATMENT

Small dry meals rich in protein and fat but Small dry meals rich in protein and fat but low in carbohydratelow in carbohydrate

Additive which slow gastric emptying such Additive which slow gastric emptying such as pectin or branas pectin or bran

Remedial gastric surgery for patients with Remedial gastric surgery for patients with severe dumping syndromesevere dumping syndrome

REACTIVE HYPOGLYCEMIAREACTIVE HYPOGLYCEMIA

Rare complication, incidence of 1-6%Rare complication, incidence of 1-6%

Occur 2-3 hours after mealOccur 2-3 hours after meal

Sweating, tremor, difficult concentrationSweating, tremor, difficult concentration

Reactive hypoglycemia may coexist with Reactive hypoglycemia may coexist with vasomotor dumping and diarrheavasomotor dumping and diarrhea

REACTIVE HYPOGLYCEMIAREACTIVE HYPOGLYCEMIA

Diagnosis – oral glucose tolerance testDiagnosis – oral glucose tolerance test

Initial hyperglycemia- exagerated insulin Initial hyperglycemia- exagerated insulin release- elevated plasma insulin and release- elevated plasma insulin and enteroglucagon- hypoglycemiaenteroglucagon- hypoglycemia

It responds to dietary measures, including It responds to dietary measures, including low-carbohydrate and high protein mealslow-carbohydrate and high protein meals

BILE VOMITINGBILE VOMITING

Vomiting of bile or bile-stained fluid before Vomiting of bile or bile-stained fluid before or after meals- common after gastric op.or after meals- common after gastric op.

It may be due to: It may be due to: - recurrent ulcerrecurrent ulcer - enterogastric reflux,enterogastric reflux,- intermittent obstruction of the afferent or intermittent obstruction of the afferent or

efferent loop of gastroenterostomy,efferent loop of gastroenterostomy,- cardioesophageal incompetencecardioesophageal incompetence

ENTEROGASTRIC REFLUXENTEROGASTRIC REFLUX

Causes a reflux erosive Gastritis and bile Causes a reflux erosive Gastritis and bile vomitingvomitingSymptoms: epigastric pain, nausea, bile Symptoms: epigastric pain, nausea, bile vomiting in the early postprandial periodvomiting in the early postprandial periodThe pain- burning in nature, aggravated by food The pain- burning in nature, aggravated by food and not relieved by antacidsand not relieved by antacidsThe attack culminates in the vomiting of bile-The attack culminates in the vomiting of bile-stained fluid 1-2 hours after a mealstained fluid 1-2 hours after a mealThe erosive gastritis leads to chronic blood loss The erosive gastritis leads to chronic blood loss with iron-deficiency anemiawith iron-deficiency anemia

ENTEROGASTRIC REFLUXENTEROGASTRIC REFLUX

Treatment: Treatment: – bile salt-binding agents- cholestiramine,bile salt-binding agents- cholestiramine,– remedial surgical interventionremedial surgical intervention

Prolonged enterogastric reflux can result Prolonged enterogastric reflux can result in atrophic gastritis and intestinal in atrophic gastritis and intestinal metaplasiametaplasia

This is a risk factor for gastric stump This is a risk factor for gastric stump carcinomacarcinoma

EXTRINSIC LOOP EXTRINSIC LOOP OBSTRUCTIONOBSTRUCTION

The causes are: The causes are: - internal herniation,internal herniation,- kinking of the anastomosis,kinking of the anastomosis,- adhesions,adhesions,- volvulus,volvulus,- stenosis,stenosis,- intussusceptionintussusception

Disorders that can develop after resection of the stomach, Disorders that can develop after resection of the stomach, as a result of the technique used to re-establish as a result of the technique used to re-establish

gastrointestinal continuitygastrointestinal continuity

EXTRINSIC LOOP EXTRINSIC LOOP OBSTRUCTIONOBSTRUCTION

Symptoms- upper GI obstructionSymptoms- upper GI obstruction

Diagnosis- rx. contrast study of the GI Diagnosis- rx. contrast study of the GI tracttract

Treatment- surgical correctionTreatment- surgical correction

Complications after Billroth IIComplications after Billroth IIFirst successful gastfrectomy-Theodor First successful gastfrectomy-Theodor

Billroth- 1881Billroth- 1881

DIARRHEADIARRHEA

Severe intractable diarrhea- 2% of pts. after Severe intractable diarrhea- 2% of pts. after truncal vagotomytruncal vagotomy

Characterized by extreme urgency and often Characterized by extreme urgency and often causes incontinence during an acute attackcauses incontinence during an acute attack

Malabsorbtion of bile salts and fatty acids Malabsorbtion of bile salts and fatty acids secondary to intestinal denervation is implicatedsecondary to intestinal denervation is implicated

The sma;ll bowel transit is acceleratedThe sma;ll bowel transit is accelerated

Treatment: low fat diet, codeine phosphate, Treatment: low fat diet, codeine phosphate, imodium, cholestyramineimodium, cholestyramine

SMALL STOMACH SYNDROMESMALL STOMACH SYNDROME

It appears after extensive gastrectomy and It appears after extensive gastrectomy and GI disfunction after truncal vagotomyGI disfunction after truncal vagotomy

The condition leads to gross malnutritionThe condition leads to gross malnutrition

Surgical treatment- reconstruct a gastric Surgical treatment- reconstruct a gastric reservoir and restore duodenal continuityreservoir and restore duodenal continuity

OTHER COMPLICATIONSOTHER COMPLICATIONS

Formation of gall stones and bezoars due Formation of gall stones and bezoars due to:to:– HypoacidityHypoacidity– Impaired proteolytic activityImpaired proteolytic activity– Loss of antral pumpLoss of antral pump

Development of gastric stump carcinoma Development of gastric stump carcinoma after 15-20 years postoperativelyafter 15-20 years postoperatively

BENIGN GASTRIC TUMORSBENIGN GASTRIC TUMORS

Gastric polyps- benign adenomasGastric polyps- benign adenomas– Solitary or multipleSolitary or multiple– Sessile or pedunculatedSessile or pedunculated– Usually asymptomaticUsually asymptomatic– Found incidentally on rx.or endoscopic exam.Found incidentally on rx.or endoscopic exam.– 20% show histological features of dysplasia20% show histological features of dysplasia– Treatment- endoscopic excision biopsy, Treatment- endoscopic excision biopsy,

follow-upfollow-up

BENIGN GASTRIC TUMORSBENIGN GASTRIC TUMORS

Leyomyomas- smooth muscle tumorsLeyomyomas- smooth muscle tumors– May arise anywhere in the muscle wall of GIMay arise anywhere in the muscle wall of GI– Common in the stomach and small bowelCommon in the stomach and small bowel– Discovered incidentally- rx, endoscopyDiscovered incidentally- rx, endoscopy– Large lesions may cause chronic blood loss Large lesions may cause chronic blood loss

or intermittent gastric outlet obstructionor intermittent gastric outlet obstruction– Sessile or pedunculated, covered by normal Sessile or pedunculated, covered by normal

mucosamucosa

MALIGNANT GASTRIC TUMORSMALIGNANT GASTRIC TUMORS

Lymphomas- 10% of gastric malignanciesLymphomas- 10% of gastric malignancies– May present as a bulky ulcerated mass or May present as a bulky ulcerated mass or

diffusely infiltrating the gastric walldiffusely infiltrating the gastric wall– Diagnosis- barium meal, endoscopy with bx.Diagnosis- barium meal, endoscopy with bx.– Treatment- total gastrectomy, Treatment- total gastrectomy,

radio/chemotherapyradio/chemotherapy– Better prognosis than gastric adenocarcinomaBetter prognosis than gastric adenocarcinoma

ENDOSCOPIC VIEW OF ENDOSCOPIC VIEW OF GASTRIC LYMPHOMAGASTRIC LYMPHOMA

GASTRIC LYMPHOMA OF THE GASTRIC LYMPHOMA OF THE GASTRIC FUNDUSGASTRIC FUNDUS

GASTRIC GASTRIC ADENOCARCINOMAADENOCARCINOMA

90% of gastric malignant tumors90% of gastric malignant tumors

Better outcome when diagnosed early Better outcome when diagnosed early

Risk factors:Risk factors:– atrophic gastritis,atrophic gastritis,– pernicious anemia,pernicious anemia,– previous partial gastrectomyprevious partial gastrectomy,,– polypspolyps

ATROPHIC GASTRITISATROPHIC GASTRITIS

GASTRIC CARCINOMAGASTRIC CARCINOMA

Three morphological formsThree morphological forms– Fungating tumorFungating tumor– Ulcerated tumor- necrosis at the centre of the Ulcerated tumor- necrosis at the centre of the

tumor, large, heaped-up indurated margin tumor, large, heaped-up indurated margin with no surrounding mucosal puckeringwith no surrounding mucosal puckering

– Infiltrating tumor- diffusely invades the Infiltrating tumor- diffusely invades the muscular wall of the stomach- wall thickening muscular wall of the stomach- wall thickening and rigidity- linita plastica “lether bottle”and rigidity- linita plastica “lether bottle”

LINITA PLASTICALINITA PLASTICA

EARLY GASTRIC CANCEREARLY GASTRIC CANCER

Cancer limited to the mucosa and Cancer limited to the mucosa and submucosasubmucosaPrognosis with adequte resection excellent Prognosis with adequte resection excellent with 5-year survival rates of more than with 5-year survival rates of more than 80%80%10-15% of early gastric cancers have 10-15% of early gastric cancers have positive regional lymph nodes- this positive regional lymph nodes- this subgroup is referred to as early-simulating subgroup is referred to as early-simulating advanced gastric canceradvanced gastric cancer

EARLY GASTRIC CANCEREARLY GASTRIC CANCER

ADVANCED GASTRIC CANCERADVANCED GASTRIC CANCER

Tumor which has involved the muscular Tumor which has involved the muscular layer of the stomachlayer of the stomach

Positive lymph nodes, peritoneal and Positive lymph nodes, peritoneal and hepatic deposits (secondaries)hepatic deposits (secondaries)

TNM STAGING SYSTEMTNM STAGING SYSTEM

T1- tu.limited to the mucosa, submucosaT1- tu.limited to the mucosa, submucosaT2- tu. involves the muscular layerT2- tu. involves the muscular layerT3- tu. penetrates the serosaT3- tu. penetrates the serosaT4- tu.invades the adjacent structuresT4- tu.invades the adjacent structuresN0- no positive lymph nodesN0- no positive lymph nodesN1- positive perigastric lymph nodes within 3 N1- positive perigastric lymph nodes within 3 cm. of the primary tu.cm. of the primary tu.N2- positive lymph nodes more than 3 cm.N2- positive lymph nodes more than 3 cm.M0- no distant metastasesM0- no distant metastasesM1- evidence of distant metastasesM1- evidence of distant metastases

SPREAD OF GASTRIC CANCERSPREAD OF GASTRIC CANCER

Direct spread through the gastric wallDirect spread through the gastric wall

Extragastric lymphatic spread- perigastric Extragastric lymphatic spread- perigastric and regionaland regional

Vascular spread-distant metastasesVascular spread-distant metastases

Serosal peritoneal spread- carcinomatosis, Serosal peritoneal spread- carcinomatosis, Blummer tu., Krukenberg tu.Blummer tu., Krukenberg tu.

GASRIC CANCERGASRIC CANCER CLINICAL FEATURES CLINICAL FEATURES

Early gastric cancer- asymptomatic or dyspepsia Early gastric cancer- asymptomatic or dyspepsia simulating an gastric ulcersimulating an gastric ulcer

Malaise, postprandial fullness, loss of appetiteMalaise, postprandial fullness, loss of appetite

Cardia cancer-dysphagiaCardia cancer-dysphagia

Antral cancer- obstructive symptomsAntral cancer- obstructive symptoms

Hematemesis/melenaHematemesis/melena

The most frequent reason for the delayed dg. Is a The most frequent reason for the delayed dg. Is a period of symptomatic therapy with antacids period of symptomatic therapy with antacids before referral for endoscopybefore referral for endoscopy

GASTRIC CANCERGASTRIC CANCERCLINICAL FEATURESCLINICAL FEATURES

Anemia- chronic blood lossAnemia- chronic blood loss

Weight loss- persistent skin fold, low Weight loss- persistent skin fold, low serum albuminserum albumin

Enlarged left supraclavicular lymph nodeEnlarged left supraclavicular lymph node

Palpable epigastric massPalpable epigastric mass

Jaundice- liver metastases or biliary Jaundice- liver metastases or biliary compressive lymphadenopathy in the compressive lymphadenopathy in the porta hepatisporta hepatis

GASTRIC CANCERGASTRIC CANCERDIAGNOSISDIAGNOSIS

GI endoscopy with biopsy and brush GI endoscopy with biopsy and brush cytologycytology

Radiological contrast study- barium mealRadiological contrast study- barium meal

Abdo CTAbdo CT

CXRCXR

USS of the abdomenUSS of the abdomen

LaparoscopyLaparoscopy

GASTRIC CANCERGASTRIC CANCERTREATMENTTREATMENT

Only effective treatment which offer a Only effective treatment which offer a chance for cure- adequate surgical chance for cure- adequate surgical resectionresection

A palliative resection whenever feasible is A palliative resection whenever feasible is more effective in relieving sy.than by-pass more effective in relieving sy.than by-pass procedures.procedures.

Radio/chemotherapy uselessRadio/chemotherapy useless


Principles of potentially curative resection:Principles of potentially curative resection:

– Resection with tumor-free marginsResection with tumor-free margins– Lymph node clearance according to the Lymph node clearance according to the

location of the primary tu. in the stomachlocation of the primary tu. in the stomach– Safe and well functioning reconstructionSafe and well functioning reconstruction

GASTRIC CANCER GASTRIC CANCER TREATMENTTREATMENT

Classification of gastric resectionClassification of gastric resection

– R0- complete resection, no microscopic tu.leftR0- complete resection, no microscopic tu.left

– R1- residual microscopic tu.R1- residual microscopic tu.

– R2- residual macroscopic tu.R2- residual macroscopic tu.


Total gastrectomy is necessary:Total gastrectomy is necessary:

– To achieve a safe tumor free marginTo achieve a safe tumor free margin

– When the neoplasm involves 2 or 3 regions of When the neoplasm involves 2 or 3 regions of

the stomachthe stomach

– Diffuse carcinomaDiffuse carcinoma


Omentectomy- the lesser and greater Omentectomy- the lesser and greater omentum removed for a better omentum removed for a better lymphadenectomylymphadenectomyLymph node clearance:Lymph node clearance:– D1 resection- perigastric lymphadenectomyD1 resection- perigastric lymphadenectomy– D2 resection- along left gastric, hepatic, D2 resection- along left gastric, hepatic,

celiac, splenic arteries nodesceliac, splenic arteries nodes– D3 resection- hepatoduodenal, D3 resection- hepatoduodenal,

retropancreatoduodenal, root of the retropancreatoduodenal, root of the mesentery, middle colic, paraaortic nodesmesentery, middle colic, paraaortic nodes

CURATIVE RESECTIONCURATIVE RESECTION

There is no peritoneal or hepatic There is no peritoneal or hepatic metastasesmetastases

The serosa is not involved by the tumorThe serosa is not involved by the tumor

The resection level exceeds the level of The resection level exceeds the level of nodal involvementnodal involvement

RECONSTRUCTIONRECONSTRUCTION

Subtotal gastrectomy with Roux-en Y Subtotal gastrectomy with Roux-en Y procedureprocedure

Total gastrectomy with eso-jejunal Total gastrectomy with eso-jejunal anastomosisanastomosis

PALLIATIVE SURGICAL PALLIATIVE SURGICAL TREATMENTTREATMENT

Gastroenterostomy- by-pass op. for Gastroenterostomy- by-pass op. for obstructing antral carcinoma obstructing antral carcinoma

Intubation for the cardia carcinomaIntubation for the cardia carcinoma

Feeding jejunostomyFeeding jejunostomy

Gastric stump Gastric stump adenocarcinomaadenocarcinoma

Case reportCase report

Gastric stump adenocarcinomaGastric stump adenocarcinoma

Male, MV, 56-year of age, retired brick masonMale, MV, 56-year of age, retired brick mason

2002- 3 months history of epigastric pain, 2002- 3 months history of epigastric pain, vomiting after meals, asthenia, weight lossvomiting after meals, asthenia, weight loss

Habits: smoking, heavy alcohol drinkingHabits: smoking, heavy alcohol drinking

PMH- partial gastric resection for gastric ulcer-PMH- partial gastric resection for gastric ulcer-20 years ago20 years ago

Physical signsPhysical signs

General: underweight, palor, inelastic skin foldGeneral: underweight, palor, inelastic skin fold

Abdominal examinationAbdominal examinationFlat abdomen moving with respirationsFlat abdomen moving with respirationsPost. Op.scar- median xypho- ombilicalPost. Op.scar- median xypho- ombilicalModerate tenderness in epigastriumModerate tenderness in epigastriumSuccusion splashSuccusion splash

NG aspiration- 100o ml. Gastric fluid non-bile NG aspiration- 100o ml. Gastric fluid non-bile stained with undigested foodstained with undigested food

What is the clinical suspicion?What is the clinical suspicion?

Previous partial gastric resection- stump problemPrevious partial gastric resection- stump problem

Frequent vomiting- undigested food- stenosisFrequent vomiting- undigested food- stenosis

Anemia- chronic blood lossAnemia- chronic blood loss

Weight loss- bad nutritionWeight loss- bad nutrition

Succusion splash- stenosisSuccusion splash- stenosis

Clinical diagnosisClinical diagnosis

Cancer of the gastric stump ?Cancer of the gastric stump ?

InvestigationsInvestigations

Lab. Tests- NAD except a moderate anemiaLab. Tests- NAD except a moderate anemia

Barium meal- partial gastric resection Billroth I, Barium meal- partial gastric resection Billroth I, gastric stump dilated, desorganized mucosal foldsgastric stump dilated, desorganized mucosal folds

Endoscopy- stenotic gastro-duodenal Endoscopy- stenotic gastro-duodenal anastomosis , multiple gastro-duodenal polypsanastomosis , multiple gastro-duodenal polyps

Biopsy- adenocarcinoma of the gastric stump of Biopsy- adenocarcinoma of the gastric stump of papillary typepapillary type

Abdominal USS- absent liver MTSAbdominal USS- absent liver MTS

CXR- NADCXR- NAD

Operative findingsOperative findingsGastric stump tumour staring from the Gastric stump tumour staring from the

gastro-duodenal anastomosisgastro-duodenal anastomosis

Invasion of the D1 and D2Invasion of the D1 and D2

Perigastric lymphadenopathyPerigastric lymphadenopathy

Liver and peritoneum intactLiver and peritoneum intact

What to do?What to do?

Frozen section from the a perigastric Frozen section from the a perigastric lymph node negative for tumour cellslymph node negative for tumour cells

Mobile tumour on adjacent planesMobile tumour on adjacent planes

AgeAge

Absent comorbiditiesAbsent comorbidities

Operative decisionOperative decision

Completion gastrectomyCompletion gastrectomy

D2 lymphadenectomy: loco-regionalD2 lymphadenectomy: loco-regional

Tactic splenectomyTactic splenectomy

Cephalic duodenopancreatectomyCephalic duodenopancreatectomy

Digestive continuity:Digestive continuity:– Eso-jejunal anastomosisEso-jejunal anastomosis– 60 cm distal to it- Wirsungo-jejunal anastomosis60 cm distal to it- Wirsungo-jejunal anastomosis– 20 cm distal to it- biliary-jejunal anastomosis20 cm distal to it- biliary-jejunal anastomosis


Operative time- 6 hoursOperative time- 6 hours

Postoperative course- uneventfulPostoperative course- uneventful

Contrast medium eso-jejunal Contrast medium eso-jejunal radiological check-up- intact radiological check-up- intact anastomosis without any leakanastomosis without any leak

Hospital stay- 26 daysHospital stay- 26 days


Operative time- 6 hoursOperative time- 6 hours

Postoperative course- uneventfulPostoperative course- uneventful

Contrast medium eso-jejunal Contrast medium eso-jejunal radiological check-up- intact radiological check-up- intact anastomosis without any leakanastomosis without any leak

Hospital stay- 26 daysHospital stay- 26 days

Pathological report Pathological report of the surgical specimenof the surgical specimen

Polipoyd adenocarcinomaPolipoyd adenocarcinoma

Lymph nodes: perigastric, Lymph nodes: perigastric, retroduodenal, celiac trunk, hilum of retroduodenal, celiac trunk, hilum of the spleen were negative for tumour the spleen were negative for tumour cellscells

pTNM- T2 N0 M0pTNM- T2 N0 M0

2003-1 year post-operatively2003-1 year post-operatively

10 Kg weight gain10 Kg weight gain

Good digestive toleranceGood digestive tolerance

Symptoms-freeSymptoms-free

Normal hematological and Normal hematological and biochemistry testsbiochemistry tests

Next post-operative courseNext post-operative course2005- acute appendicitis- appendectomy2005- acute appendicitis- appendectomy

2007-routine endoscopic check-up2007-routine endoscopic check-up

eso-jejunal anastomotic recurrenceeso-jejunal anastomotic recurrence

2007- further investigations2007- further investigations

Endoscopic biopsy- adenocarcinomaEndoscopic biopsy- adenocarcinoma

CXR- NADCXR- NAD

Abdominal USS-slightly enlarged liver, Abdominal USS-slightly enlarged liver, pneumobilia, normal remnant pancreas, pneumobilia, normal remnant pancreas, no ascites, no lombo-aortic lymph nodesno ascites, no lombo-aortic lymph nodes

Respiratory tests- WNLRespiratory tests- WNL

2007- further investigations2007- further investigations

Barium meal: eso-jejunal Barium meal: eso-jejunal anastomosis T-L, anastomotic anastomosis T-L, anastomotic lacunar image- 2cm in sizelacunar image- 2cm in size

Abdominal CT- thickening at the level Abdominal CT- thickening at the level of the anastomosis with esophageal of the anastomosis with esophageal extentextent

What to do?What to do?

Surgical options:Surgical options:

– Partial esophagectomy with intrathoracic Partial esophagectomy with intrathoracic graft interpositiongraft interposition

– Esophageal stripping with colic graftEsophageal stripping with colic graft

Small eso-jejunal tumourSmall eso-jejunal tumour

Absence of mediastinal lymph nodes-Absence of mediastinal lymph nodes-CTCT

Avoidance of left thoracotomyAvoidance of left thoracotomy

DecisionsDecisionsSurgical resectionSurgical resection– Esophageal strippingEsophageal stripping– Proximal jejunostomyProximal jejunostomy

Digestive reconstructionDigestive reconstruction– Left colon graftLeft colon graft– Colo-jejunal anastomosisColo-jejunal anastomosis– Colo-colic anastomosisColo-colic anastomosis– Cervical eso-colic anastomosisCervical eso-colic anastomosis

NutritionNutrition– TPNTPN– Jejunostomy tubeJejunostomy tube

Pathology reportPathology report

Colloid adenocarcinoma invading the Colloid adenocarcinoma invading the digestive wall thickness till subserosadigestive wall thickness till subserosa

3 out of 4 jejunal mesentry limph nodes 3 out of 4 jejunal mesentry limph nodes positivepositive

Periesophageal lymph nodes negativePeriesophageal lymph nodes negative

Early morbidityEarly morbidity

Cervical eso-colic fistulaCervical eso-colic fistula– Small outputSmall output– Conservative treatmentConservative treatment– Oral hygeneOral hygene– Spontaneous closure in 2 weeksSpontaneous closure in 2 weeks– Radiological check-up before oral intakeRadiological check-up before oral intake

Eso-colic fistula-jan.2008Eso-colic fistula-jan.2008

Late morbidityLate morbidity

Colic fistula due to forcibly coughing episodes Colic fistula due to forcibly coughing episodes after quit smokingafter quit smoking

Relaparotomy-transverse colon fistulaRelaparotomy-transverse colon fistula– Colo-jejunal and colo-colic anastomoses intactColo-jejunal and colo-colic anastomoses intact– Coloraphy and abdominal drainageColoraphy and abdominal drainage– Good recoveryGood recovery– Discharged after 9 daysDischarged after 9 days

Patent eso-colic anastomosis, Patent eso-colic anastomosis, may 2008may 2008

Intact colo-jejunal anastomoses, Intact colo-jejunal anastomoses, may 2008may 2008

20092009

Multiple pulmonary metastasesMultiple pulmonary metastases

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Powerpoint: Sequelae of gastric surgery