Abstract
Background: Historically, the management for recurrent or persistent Gastro-esophageal reflux disease included selective vagotomy and fundoplication. Despite these surgical interventions, the risk of Barrett’s esophagus (BE) and subsequent malignant transformation remains, requiring cancer resection surgery. We present a case of a patient with a gastro-esophageal junction (GEJ) adenocarcinoma, who underwent a pediatric thoracotomy and Belsey Mark IV fundoplication, and was successfully treated by Laparoscopic Ivor-Lewis Esophagectomy (LILE). Case Presentation: This 64-year-old gentleman with BE and GEJ adenocarcinoma was previously deemed unsuitable for curative surgery due to clinical staging indicating a tumor length of 10cm and suspected invasion of the left pleura. Further staging by Endoscopic ultrasound indicated no evidence of pleural invasion with the distal esophageal thickening in keeping with his previous Belsey Mark IV fundoplication. He underwent neo-adjuvant chemotherapy and a subsequent LILE with complete laparoscopic reversion of the gastric fundoplication without injury to the gastroepiploic artery or fundus. There was sufficient preservation of conduit length to enable a tension free hand-sewn anastomosis with an uneventful post-operative recovery. Final histopathology confirmed ypT1 ypN0 moderately differentiated adenocarcinoma with R0 resection margins. The patient has completed 24 months of cancer recurrence free surveillance. Conclusion: We describe the successful management of a patient by LILE on a background of previous hiatal fundoplication surgery, previously refused curative surgery. We highlight the importance of EUS as a staging modality for such cases showing invasive disease to increase the final clinical staging accuracy. We suggest a minimally invasive approach may be utilized for successful re-do hiatal dissection as an alternative to a conventional open surgery.
Highlights
The management for recurrent or persistent Gastro-esophageal reflux disease included selective vagotomy and fundoplication
We present a case of a patient with a gastro-esophageal junction (GEJ) adenocarcinoma, who underwent a pediatric thoracotomy and Belsey Mark IV fundoplication, and was successfully treated by Laparoscopic Ivor-Lewis Esophagectomy (LILE)
Further staging by Endoscopic ultrasound indicated no evidence of pleural invasion with the distal esophageal thickening in keeping with his previous Belsey Mark IV fundoplication
Summary
Symptomatic Gastro-Esophageal Reflux Disease (GERD) is primarily managed by pharmacological intervention with Proton Pump Inhibitors (PPI). The index Computed Tomography (CT) imaging reported two distinct esophageal tumors extending cranio-caudally from mid- to distal esophagus with invasion of the left pleura, deeming him unsuitable for curative surgery at his local hospital (Figures 1 & 2) His past medical history was unremarkable apart from his previous surgery. Our standard oncological resection encompasses partial excision of the right and left crural pillars adjacent to the tumor, excision of the pericardial fat pads, aortic adventitia and the hiatal hernia sac to ensure a clear circumferential resection margin (CRM) All of these steps were undertaken laparoscopically, despite his prior hiatal surgery. Five months post-surgery, the patient complained of symptomatic dysphagia and underwent an EGD with pneumatic dilatation for an anastomotic stricture This procedure was repeated on two further occasions with good effect. At 24 months post-operative follow-up, the patient remains well with no signs of local or distant disease recurrence
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