Minimally Invasive Esophagectomy After Pediatric Nissen Fundoplication for Esophageal Adenocarcinoma

The authors present a case of successful minimally invasive esophagectomy after prior open Nissen fundoplication and gastrostomy, not previously described in the literature.

A 43-year-old man presented with dysphagia to solids only. He had a past medical history of reactive airway disease and known Barrett’s esophagus, for which he was getting endoscopy surveillance every three years. He had a past surgical history of open Nissen and G-tube as an infant for severe reflux. CT chest showed an intraluminal lesion in the distal esophagus that was hypermetabolic on PET-CT, which did not show any signs of metastatic disease.

Esophagogastroduodenoscopy demonstrated an ulcerated intraluminal mass starting at 40 cm from the incisors. Endoscopic ultrasound revealed that the mass extended into but not through the muscularis propria, without evidence of nodal disease. Biopsy from the EGD returned as adenocarcinoma, resulting in a diagnosis of clinical stage IB (T2N0M0) esophageal adenocarcinoma at the gastroesophageal junction within his previous Nissen wrap. The patient was referred for neoadjuvant tx and completed chemoradiation per the CROSS trial regimen before surgery.

The authors typically perform esophagectomies totally minimally invasively via a laparoscopic-thoracoscopic Ivor Lewis approach. They placed the ports in their usual configuration. In order to access the lesion and bring the stomach into the thoracic cavity, the previous Nissen wrap was dissected and taken down. Once the wrap was dissected, the right gastroepiploic artery was identified and protected in order to preserve the blood supply to the gastric conduit. Due to scarring and thickening of the tissues from his previous Nissen wrap and fibrosis from the neoadjuvant chemoradiation, the hiatus had to be widened to allow passage of the stomach into the thoracic cavity. The patient’s previous gastrostomy site was stapled off using purple load staples and was eventually completely resected with the final specimen. The dissection was laborious but ultimately the esophagus was fully encircled and the hiatus cleared. The left gastric artery pedicle was transected with a purple load stapler as there are often thickened vasculature in this area. Afterward, adhesions between the colon and the stomach were taken down carefully. Additional mobilization maneuvers were performed, including Kocherization of the duodenum and dissection of additional posterior adhesions and attachments to the pancreas. After the stomach was fully mobilized, tubularization was performed.

The stomach was then carefully brought into the thoracic cavity. Once the stomach was intrathoracic, a 28 mm end-to-end anastomotic stapler was used to create the esophagogastric anastomosis in standard fashion. In this case, the authors paid extra attention to preserving as many proximal esophageal vessels as possible in order to maintain adequate perfusion to the anastomosis. This can be seen with the help of indocyanin green. The authors have found that indocyanine green can be an additional tool to ensure conduit and anastomotic viability and used it in this case due to the patient’s previous surgical history. The authors felt it necessary to resect the fundoplication due to its proximity to the cancer, neoadjuvant irradiation, and poor tissue quality secondary to scarring and extensive dissection. After the specimen, including the wrap, was removed, indocyanine green was used to confirm adequate perfusion in the gastric conduit and anastomosis. Exparel intercostal nerve blockades were performed thoracoscopically and one 28Fr chest tube and one 24Fr Blake drain was placed in the L chest. Estimated blood loss was 100 ml and the operation time was five hours. Final surgical pathology demonstrated complete pathologic response of the tumor. The patient’s postoperative course was benign, complicated only by a chyle leak that was managed nonoperatively. His conduit survived and his postoperative upper endoscopy showed no leak.

He was discharged on postoperative day four. From the authors’ review of the literature, this is a rare and novel case because previous publications have only discussed open esophagectomies after Nissen fundoplication. They were able to perform his esophagectomy completely laparoscopically, using the no touch stomach technique, and were able to preserve the stomach in order to use a gastric conduit. In addition, the patient required no subsequent operations. The rates of surgical treatment for GERD in infants has increased from 4/100,000 in 1996 to 10/100,000 in 2003, with increasing numbers of laparoscopic surgery. Current incidence of esophageal cancer is 3.9/100,000. Patients with Barrett’s esophagus are at least 10 times more likely to develop esophageal adenocarcinoma, with an annual conversion rate of about 0.1%. GERD is a known risk factor for esophageal cancer (it has not been shown to be successful to be used as a risk stratification tool) and its incidence is rising. With rising numbers of pediatric anti-reflux surgeries and rising incidence of GERD, situations similar to this case report are likely to recur. The authors present this case as an example that a minimally invasive esophagectomy can be successfully completed in patients with a history of open Nissen fundoplication.

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