Two patients with debilitating reflux after esophagectomy are reported. Complete relief of symptoms after creation of a Roux-en-Y limb to the gastric conduit is described.
MEDICALLY REFRACTORY duodcnogastric reflux after esophagectomy, though relatively rare, can be extremely debilitating. Surgical options are limited and historically have involved resection of the gastric conduit with colonie or jejunal reconstruction, a major undertaking with significant morbidity. The following cases describe the creation of a Roux-en-Y limb to the gastric conduit, which is a less demanding operation and can safely and effectively relieve severe duodenogastric reflux after esophagectomy.
Case 1
The patient is a 41-year-old white female with a history of severe gastroesophageal reflux disease. She had failed maximal medical therapy and underwent a Nissen fundoplication. Despite this, she continued with disabling reflux and multiple admissions for aspiration pneumonia and ultimately underwent transhiatal esophagectomy. She developed an anastomotic stricture requiring serial dilatations roughly 4 weeks later. At each dilatation, bile was noted in the stomach, and biopsies showed severe esophagitis. Her stricture was ultimately relieved after multiple dilatations, however she then developed disabling bile reflux. Despite a variety of maneuvers including diet modification, strict attention to posture including sleeping in a recliner, and promotility agents, she continued with severe bile reflux causing chest pain, nocturnal biliary emesis, worsening of her asthma requiring use of four inhalers as well as occasional steroids, and multiple admissions for aspiration pneumonia. She ultimately was referred to our institution for evaluation.
She was taken to the operating room for creation of a Roux-en-Y limb to the gastric conduit. The gastric pull-up and duodenum were identified and the pyloroduodenal junction just below the hiatus identified. The pyloroduodenal junction was encircled along its serosal layer with care taken to preserve the mesenteric blood supply and was divided using a stapler just distal to the pylorus. The jejunum was then divided approximately 15 cm distal to the ligament of Treitz and brought in a retrocolic fashion to the pylorus. An endto-end two-layer handsewn anastomosis was then constructed between the pylorus and the jejunum. Gastrointestinal continuity was then restored by creating a side-to-side functional end-to-end stapled anastomosis between the cut end of proximal jejunum and the Roux limb approximately 45 cm distal to the divided pyloroduodenal junction (Figs. 1-3).
She did well postoperatively and continues to do well now 5 years later. She swallows normally without reflux symptoms and takes no medications. Additionally, her asthma has improved markedly with only occasional use of an albuterol inhaler.
Case 2
The patient is a 56-year-old white male with a history of severe gastroesophageal reflux disease. His symptoms were refractory to medical therapy, and biopsies showed Barrett changes. He underwent a laparoscopic Nissen fundoplication, and his symptoms, although not fully relieved, were able to be medically managed. He continued to undergo surveillance endoscopy, and ultimately biopsies revealed Barrett with high-grade dysplasia. He therefore underwent transhiatal esophagectomy. Approximately 8 weeks postoperatively, he developed dysphagia, and endoscopy revealed an anastomotic stricture. There were a large amount of bile-stained secretions in the esophagus and stomach, and biopsies revealed severe esophagitis. Despite weekly dilatations over the course of several months, he would restricture rapidly, and he ultimately underwent placement of an esophageal stent across the anastomosis, which relieved his dysphagia. Unfortunately, he then developed disabling reflux resulting in chest pain, frequent biliary emesis, and aspiration. The stent was removed, however, he restrictured within 10 days prompting reinsertion of the stent and referral for consideration of colon interposition. He was offered a Roux-en-Y as an alternative.
FIG. 1. Postesophagectomy.
FIG. 2. Creation of Roux-en-Y limb.
FIG. 3. Completion of Roux-en-Y limb.
He was taken to the operating room for creation of a Roux-en-Y limb to the gastric conduit. The procedure was identical to case 1 except that the pylorojejunal anastomosis was constructed with a GIA stapler for the back wall and the anterior defect closed in two layers as described by Orringer et al. for esophagogastric anastomosis.1
He has since recovered well and is swallowing without difficulty and without reflux symptoms now 18 months later. His esophageal stent remains in place.
Comment
Esophagectomy is the standard therapy for esophageal cancer and is occasionally required in benign conditions as well. Although there will always be disagreement as to the optimal approach to esophagectomy (transhiatal vs Ivor-Lewis) and the need for pyloric drainage (pyloromyotomy or pyloroplasty vs no drainage), the majority of studies have shown essentially equivalent results regardless of approach.2, 3 One common feature of esophagectomy, regardless of technique used, is that it promotes the development of reflux. The combination of truncal vagotomy, impaired motility of the esophageal remnant and gastric conduit, elimination of the lower esophageal sphincter, and placement of the stomach in the thorax in which it is exposed to negative intrathoracic pressure predisposes to duodenogastric reflux. The presence of duodenogastric reflux after esophagectomy is 60 per cent to 80 per cent.4, 5 Although its occurrence is common, its symptoms, including regurgitation, cough, aspiration, and “cervical heartburn” are usually easily controlled with a combination of medicines and lifestyle modification. In rare instances, however, as in the two cases described above, this reflux can be lifestyle limiting and refractory to treatment. In these situations of medical failure, options are limited and often revolve around resection of the conduit with reconstruction using colon or jejunum. Due to the magnitude of this operation and its significant morbidity profile, it is often avoided and the patient unfortunately is obligated to continue with debilitating symptoms.
The creation of a Roux-en-Y gastrojejunostomy is well described and widely used for the correction of severe symptomatic duodenogastric reflux after gastricsurgery. Overall, long-term results have been favorable using this remedial operation with the majority of patients reporting relief of symptoms.6, 7 Given this success, it would stand to reason that its application to the problem of debilitating duodenogastric reflux after esophagectomy would be physiologically sound. In fact, it could be postulated that it may meet with higher success, as its main problem after gastrectomy is poor motility of the denervated stomach and development of the “Roux stasis syndrome,” and its use in the setting of previous esophagectomy with a “tubularized” stomach may actually allow better drainage and avoidance of this problem.
Both patients described above had complete relief of symptoms with this procedure. Additionally, we have recently had the opportunity to perform this procedure on another similar patient who although early in his postoperative course (approximately 2 months) appears to have complete resolution of symptoms. A review of the literature reveals that this procedure has only once before been described in a 1975 report by Smith and Payne.8 Their patient underwent similar reconstruction and also had complete relief of symptoms. Whether the reason this procedure has not been more universally adopted is due to the relative infrequency of this problem or due to this option being overlooked is unclear, although it is the author’s opinion that it is more likely the latter.
The technical aspects of this procedure are relatively straightforward and are described in case 1 and outlined in Figs. 1- 3. The main tenets are to accurately dissect out the pyloroduodenal junction along its serosal layer with care taken to preserve the gastric blood supply (the right gastroepiploic artery and the right gastric artery). The junction is divided on the duodenal side to avoid any potential for retained stomach/antrum. The biliary limb should be divided approximately 15 cm distal to the ligament of Treitz and anastomosed approximately 45 cm distal to the pyloric division.
Conclusion
Severe medically refractory duodenogastric reflux is fortunately relatively rare after esophagectomy. When encountered, however, it is extremely debilitating for the patient, and surgical options have centered on resection of the conduit with colonie or jejunal reconstruction, a major undertaking with a significant morbidity profile. The cases described show that construction of a Roux-en- Υ limb to the gastric conduit, a much simpler operation with lower potential morbidity, can safely and effectively relieve severe duodenogastric reflux after esophagectomy.
REFERENCES
1. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119:277-88.
2. Hulscher JB, van Sandick \JW, de Boer AG, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002;347: 1662-9.
3. Rentz J, Bull D, Harpole D, et al. Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients. J Thorac Cardiovasc Surg 2003; 125:1114-20.
4. Aly A, Jamieson GG. Reflux after oesophagectomy. Br J Surg 2004;91:137-41.
5. Shibuya S, Fukudo S, Shineha R, et al. High incidence of reflux esophagitis observed by routine endoscopic examination after gastric pull-up esophagectomy. World J Surg 2003;27:580-3.
6. Sawyers JL, Herrington JL Jr, Buckspan GS. Remedial operation for alkaline reflux gastritis and associated postgastrectomy syndromes. Arch Surg 1980;115:519-24.
7. Kelly KA, Becker JM, van Heerden JA. Reconstructive gastric surgery. Br J Surg 1981;68:687-91.
8. Smith J, Payne WP. Surgical technique for management of reflux esophagitis after esophagogastrectomy for malignancy. Further application of Roux-en-Y principle. May Clin Proc 1975;50: 588-90.
MARIO G. GASPARRI, M.D., WILLIAM B. TISOL, M.D., GEORGE B. HAASLER, M.D.
From the Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
Address correspondence and reprint requests to Mario G. Gasparri, M.D., Division of Cardiothoracic Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226.
Copyright The Southeastern Surgical Congress Aug 2005
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