Beware of gastric tube in esophagectomy after gastric radiotherapy:A case report

lNTRODUCTlON

Esophagectomy,combined with neoadjuvant chemo(radio)therapy in the locally advanced situation,is considered standard treatment with curative intention for carcinomas of the esophagus and the esophagogastric junction[1].Most commonly,anastomosis of the remnant esophagus to a gastric tube is performed[2].Whether prior chemoradiotherapy for gastric mucosa-associated lymphoid tissue lymphoma limits the stomach’s suitability for reconstruction is unknown.With this case report we provide first evidence for pretreated stomach usage for esophagogastrostomy in esophagectomy.

CASE PRESENTATlON

Chief complaints

Due to asymptomatic gastro-esophageal reflux disease with Long Segment Barrett’s esophagus C9M13 according to Prague Classification,a 64-year-old patient underwent repetitive esophagogastroduodenoscopy.

History of present illness

In 2020,biopsy of the distal esophagus 34 cm from row of teeth revealed invasive moderately differentiated(G2)adenocarcinoma.Moreover,erythema and atrophy of the gastric mucosa were detected.However,the patient had no disease-specific complaints when he first presented to our department.Oral intake of standard western-diet was unrestricted and body weight was constant at a BMI of 29.1 kg/m².

At length, as the last day of the seven years dawned, he went once more out on to the heath, and seated himself beneath the circle of trees. It was not long before the wind whistled,28 and the Devil stood before him and looked angrily at him; then he threw Bearskin his old coat, and asked for his own green one back. We have not got so far as that yet, answered Bearskin, thou must first make me clean. Whether the Devil liked it or not, he was forced to fetch water, and wash Bearskin, comb his hair, and cut his nails. After this, he looked like a brave soldier, and was much handsomer29 than he had ever been before.

History of past illness

In 2012,the 57-year-old man was diagnosed with diffuse large B-cell lymphoma(DLBCL)of the stomach in the course of endoscopic treatment of gastric bleeding(2a according to the Forrest Classification of gastrointestinal bleedings).Although there was no detection of

,eradication therapy was performed.Endosonography proved localization at the posterior gastric wall without infiltration of neighboring tissues,whereas computed tomography(CT)scan and bone marrow biopsy were without evidence of disease equivalent to stage IE according to the Ann Arbor staging system.Following four courses of rituximab,cyclophosphamide,doxorubicin hydrochloride(hydroxydaunorubicin),vincristine sulfate(Oncovin),and prednisone(R-CHOP)with curative intention percutaneous normofractionated radiotherapy of the stomach with a total of 39.6 Gray(Gy)in 20 fractions weekly was performed as consolidating therapy.Both systemic and radiation therapy were well tolerated.Due to herpes zoster of the left thorax antiviral therapy with aciclovir was introduced.

The patient had a history of herniated vertebral disc,struma nodosa,chronic-venous insufficiency and endoscopic resection of a low-grade adenoma of the sigmoid colon and regularly took metformin,thyroxine and sitagliptin for type 2 diabetes mellitus and hypothyroidism respectively.Hepatic and renal function were not impaired.Follow-up examinations up to five years were without any peculiarities or evidence of tumor recurrence.The patient had skipped drinking and smoking after intake of 60 pack-years.

Personal and family history

Family history was unremarkable and not related to the present case.

Physical examination

The patient was in a normal general state without any evidence of disease or restriction of normal activities.

The authors thank Margreiter MH for her kind contribution to preparation of the manuscript.

Laboratory examinations

Preoperative blood examinations were unremarkable.Tumor markers CEA,CA19-9 and CA72-4 were within reference range.

What can be the reason for such a crowd close by the pigsty? said theEmperor, who happened just then to step out on the balcony; he rubbed hiseyes, and put on his spectacles. They are the ladies of the court; I must godown and see what they are about! So he pulled up his slippers at the heel,for he had trodden them down.

Imaging examinations

Whereas CT scan showed no signs of distant metastases or involvement of locoregional lymph nodes,endosonography described uT1(sm2)uN+according to TNM classification of malignant tumors,8

edition.Positron emission tomography-CT was performed for further clarification,which ruled out involvement of locoregional lymph nodes.

Despite expectable poor outcome following resection of the necrotic gastric tube with diversion[12],creation of a cervical fistula and secondary colonic interposition,our patient fully recovered,has sufficient oral intake capacity and to date remains without signs of any tumor recurrence.

Material and methods

We therefore recommend that stomachs pretreated by radiotherapy should not be utilized for reconstruction in esophagectomy.Although this case report provides little evidence from a single patient only without proven causality,further investigations as to whether stomachs pretreated by radiotherapy in general should not be utilized for reconstruction in esophagectomy are required.

Emergency thoracotomy was necessary for resection of the necrotic gastric tube,hemithyroidectomy and creation of the salivary glandula.A jejunal feeding tube was inserted after laparotomy.Continuous intestinal passage was reconstructed by colonic interposition.Following laparotomy,the transverse colon was prepared for retrosternal pull-up and formation of an end-to-end esophagocolostomy and an end-to-side colojejunostomy.A side-to-side ascendodescendostomy was created.

At first Miles couldn t believe that it was really a gift from his hero. As he comprehended that it was not a dream or a joke, he beamed a wide eternal smile. It was as if any discomfort7 he was having just disappeared.

Endoscopy was performed with a standard gastroscope with 9.8-mm outer caliber and 3.2-mm working channel(PENTAX Medical,Tokyo,Japan).A thin open-pore film wrapped around a drain(Medicoplast,Illingen,Germany)and fixed with a suture was constructed prior to endoscopically controlled insertion and positioning of the device.Negative pressure of -125 mmHg was established with the use of a vacuum therapy system(KCI medical,Wiesbaden,Germany).

FlNAL DlAGNOSlS

Moderately differentiated adenocarcinoma of the distal esophagus with infiltration of the submucosal layer without locoregional lymph node metastases[TNM: pT1b,pN0(0/17)L0,V0,Pn0,R0,Grading: G2].

TREATMENT

The multidisciplinary tumor board consequently recommended surgical resection without neoadjuvant treatment.Thoracoscopic and laparoscopic abdominal right thoracic esophagectomy with two-field lymphadenectomy(Ivor Lewis)and stapled end-to-side esophagogastrostomy was performed.Histopathological examination confirmed the diagnosis and staging results and complete resection of a moderately differentiated adenocarcinoma of the distal esophagus.The gastric mucosa showed signs of erosive gastritis with denuded surface epithelium,subepithelial and interstitial hemorrhage,but no recurrent lymphoma infiltrates.The initial postoperative course was regular and without any pathologic findings.Following extubation immediately after surgery,the patient was monitored at the intermediate care unit for one day without requiring cardiocirculatory or respiratory support before transfer to the general ward.Low-dose anticoagulation with unfractionated heparin was initiated six hours after surgery.Amount and quality of drain output were unsuspicious.Seven days after surgery the patient’s general state was seen to deteriorate and elevated leukocytes and C-reactive protein were observed,which required endoscopic assessment of the esophagogastrostomy to rule out anastomotic leakage.The gastric interposition showed compromised perfusion without evidence of anastomotic insufficiency.Endoscopic negative-pressure therapy was therefore introduced.After vomiting with aspiration during anaesthetization the patient was transferred to the intensive care unit.Despite initiation of calculated antibiotic therapy with meropenem,vancomycin and anidulafungin there was no observable improvement.On day 12 postoperative,endoscopy revealed necrosis of the gastric interposition with a pronounced anastomotic insufficiency prompting surgical resection of the gastric tube interposition,creation of a cervical fistula and insertion of a jejunal feeding catheter(Figure 1).Histopathology confirmed ischemic necrosis of the proximal gastric tube with anastomotic leakage.There was no evidence of residual adenocarcinoma or recurrent lymphoma in the resected esophagogastrostomy or gastric tube.Postoperative pleural effusion was treated with a thoracic drain and central venous lineassociated blood-stream infection,while paroxysmal tachycardia and delirium necessitated respective therapy.The patient slowly recovered until he was discharged 40 d after esophageal resection.Followup care was recommended by the multidisciplinary tumor board.

OUTCOME AND FOLLOW-UP

Six months later,the patient underwent colonoscopy and CT scan in preparation for colonic interposition without any contraindications or signs of tumor recurrence.Retrosternal interposition of the transverse colon creating an end-to-end esophagotransversostomy,end-to-side transversojejunostomy and a side-to-side ascendotransversostomy was performed.Postoperative course was normal.Oral intake of food and liquids was without difficulty.Supportive enteral feeding was continued.The patient was discharged home on day 12 postoperative.Nine weeks later,the patient was in an unrestricted general condition with stable body weight so that the jejunal feeding catheter was removed.Table 1 shows information from this case report organized in a time table.

DlSCUSSlON

When the patient first presented to our out-patient clinic,the suitability of the pretreated stomach for construction of an esophagogastrostomy was uncertain because evidence was missing.In the literature,complications of esophagogastrostomy in general are reported to occur in 12% and mortality in 4% of all cases[3].According to the present literature,small bowel or colonic interposition may be considered alternative grafts.Compared to the colon,small bowel grafts require fewer anastomoses,are rarely affected by malignancies and have good peristalsis,but provide no reservoir function.Colonic interposition is complicated by the need for three to four anastomoses and potential metachronous development of adenoma and carcinoma.Nevertheless,longer grafts are available offering reservoirlike function and less reflux[4,5].However,a retrospective cohort study comparing complex esophageal reconstruction including 44.7% of patients with other than gastric tube formation to non-complex esophagectomy with direct gastric pull-up reported higher morbidity and longer length of stay for patients in the complex therapy group[6].Jejunal grafts are described as suitable primary alternatives for any scope of esophageal replacement,but are accompanied by up to 36% anastomotic leakage and 10% mortality[7].In colonic interposition,higher overall morbidity of 45.0%-64.0% and increased risk of anastomotic leakage occurring in 13.0%-30.0% of patients is shown[8-11].Alternatively,construction of a cervical salivary fistula with secondary gastric tube formation could be an option,but especially patients with cancer were shown to have poor outcome after primary diversion and secondary reconstruction in esophagectomy[12].Considering our experience with gastric tubes and the lower complication rates as compared to small bowel and colonic interposition,the decision for esophagogastrostomy was therefore made together with the patient.

All, that is, except for a few irreplaceable bulbs. For years, Arnoldus had been trying to cultivate a black tulip, something no gardener had ever been able to do. He was now very close. By careful selection, he had created a dark-purple tulip. These few bulbs he guarded vigorously to prevent people from stealing them for food. He did not even give them to his family to eat, because they would make just one meager4（） meal, and eating them would destroy his chance of restarting his business and restoring his village after the war.

The Tsar had a walled garden, so rich and beautiful that in no kingdom of the world was there a more splendid one. Many rare trees grew in it whose fruits were precious jewels, and the rarest of all was an apple tree whose apples were of pure gold, and this the Tsar loved best of all.

CONCLUSlON

Surgery was performed in minimally invasive technique of Ivor Lewis esophagectomy.Access to the abdominal cavity and capnoperitoneum was established with the help of a Veress needle.An optic trocar was introduced under vision with a 30° camera(KARL STORZ SE &Co.KG,Tuttlingen,Germany).The abdominal cavity was inspected to rule out injuries during access and also peritoneal or hepatic metastases.Then,gastric mobilization was performed with an electrosurgical vessel sealer,left gastric artery was clipped whereas the right gastric artery as well as the right gastroepiploic arcade were preserved.Complete D2-lymphadenectomy was performed followed by stapled gastric tube formation of approximately 5 cm in diameter.Esophagectomy including mediastinal lymphadenectomy was operated thoracoscopically with four right-sided intercostal trocars.The resection was completed with formation of a stapled circular end-toside-esophagogastrostomy.

Neoadjuvant radiochemotherapy prior to esophagectomy has been shown to improve overall survival compared to surgery alone with a very favourable toxicity profile.In particular,no increase in anastomotic leakage was reported in the CROSS trial[13],whereas in-field creation of anastomosis following neoadjuvant radiochemotherapy and esophagectomy was identified as a risk factor foranastomotic leakage in a retrospective analysis of 285 patients treated for esophageal cancer[14].Especially in distal esophageal cancer the celiac lymph nodes and the ones at the lesser gastric curvature are frequently irradiated in the preoperative setting with doses that are comparable to the dose given in the current case presentation resulting in a considerable dose burden to the stomach without causing an excessive rate of anastomotic leakage.A major difference however between preoperative radiotherapy for esophageal cancer and the previous treatment with radiotherapy in the current case is the interval between radiotherapy and surgery.While surgery after planned neoadjuvant therapy is commonly scheduled within a couple of weeks,the interval was seven years in the present case.One can hypothesize that the tissue turned less“flexible”over the time due to fibrosis which might have contributed to anastomotic leakage.However,in the present case radiotherapy was applied to the specimen employed for reconstruction and not to the resected organ.

ACKNOWLEDGEMENTS

Then came the Devil, who was always seeking to injure the good Queen, and exchanged the letter for another, in which was written that the Queen had brought a monster into the world

FOOTNOTES

The authors have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

For all clinical data and personal images written consent for publication was obtained from the patient.

The authors have no competing interests to declare in the context of the current case.

Yurttas C,Thiel K and Koenigsrainer A conceived and wrote the manuscript;Thiel K and Koenigsrainer A were responsible for overall treatment;Endoscopic treatment was performed by Wichmann D;Yurttas C and Bongers MN prepared the figures;Yurttas C,Thiel K,Gani C,Thiel C,Singer S and Koenigsrainer A revised the manuscript;all authors read and approved the final version of the manuscript.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

Germany

Can Yurttas 0000-0001-9720-8243;Doerte Wichmann 0000-0002-8832-5031;Cihan Gani 0000-0003-0242-9428;Malte N Bongers 0000-0003-2852-0270;Stephan Singer 0000-0003-4775-6609;Christian Thiel 0000-0001-8880-4860;Alfred Koenigsrainer 0000-0002-2301-4080;Karolin Thiel 0000-0002-7328-7589.

The tune2 stopped suddenly. Granddad said, It s a fine girl your father s going to marry. He ll be feeling young again with a pretty wife like that. And what would an old fellow like me be doing around their house, getting in the way? An old nuisance（）, what with my talks of aches and pains. It s best that I go away, like I m doing. One more tune or two, and then we ll be going to sleep. I ll pack up my blanket in the morning.

I went there and sat with other quiet, anxious strangers. I spotted9 a phone on the wall, and I fished for quarters in my pocketbook. The first call was to Mike s parents. They d come home right away, but it would take a while. I called my mother, wishing she wasn t so far away. Then I called my daughter, Kate. I didn t want to worry her. But she d always been a rock for me. It helped a little just to hear her voice. When I hung up, however, I choked back the tears.

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