Severe Gastroparesis After Ivor-Lewis Esophagectomy in a Patient With Type II Achalasia

22 Nov 2021 05:00 07:00
Bordeaux

Patient Profile & Clinical History

  • Patient: 48-year-old female

  • History: Heartburn and episodes of dysphagia for 30 years.

  • Weight / Height: 46 kg, 160 cm (BMI 17 kg/m2).

  • High-Resolution Manometry (HRM): Type II achalasia (July 2015).

Initial Treatment & Diagnosis

  • Endoscopic Dilation: Two sessions of endoscopic dilation with improvement of symptoms and a 5 kg weight gain.

  • Endoscopic Finding: During the last session, a superficial 18 mm lesion was identified in the mid-third of the esophagus.

  • Pre-operative Workup: T1 squamous cell tumor.

  • Endoscopic Treatment: Endoscopic removal planned in June 2015, but failed due to submucosal fibrosis precluding submucosal dissection.

Surgical Treatment

  • Procedure: Ivor Lewis procedure performed in July 2016 by laparoscopy and thoracoscopy approach.

  • Pathology: T1 N0 R0 squamous cell cancer.

  • Postoperative Course: Complicated by gastroparesis which delayed oral feeding.

  • Discharge: Patient discharged on postoperative day 17.

Postoperative Course & Management

October 2016

  • Repeated vomiting necessitating a naso-gastric tube.

  • Endoscopy: Large gastric ulcer at the site of the staple line.

  • Intervention: Endoscopic dilation of the pylorus.

  • Oral feeding stopped and replaced by enteral nutrition by jejunostomy, which fell 2 months later.

January 2017

  • Weight: 45 kg (+2 kg).

  • Endoscopy: Persistent ulcer with negative biopsies.

  • Oral feeding remained very difficult.

  • Endoscopic Treatment: Endoscopic submucosal pylorotomy performed with poor clinical results.

March 2017

  • Weight: 34 kg.

  • Naso gastro-duodenal tube placed for nutrition.

  • Enteral feeding associated with clinical improvement.

May 2017

  • Weight: 45 kg.

  • Oral feeding possible but still uncomfortable.

  • Patient complained of vomiting, reflux and coughing at night.

  • Endoscopy: Healing of gastric ulcer.

March 2018

  • Procedure: Duodenal diversion performed with an uneventful postoperative course.

Two Months Later

  • Weight: Stable at 44 kg.

  • Oral feeding possible and sufficient.

  • Still experiencing regurgitations and episodes of vomiting.

  • Nutritional status did not improve due to persistent difficulties with feeding.

June 2020

  • Jejunostomy: 1 liter of enteral nutrition each night, together with 3 meals per day.

July 2021

  • Weight: 49 kg.

  • Normal oral feeding.

  • Removal of the jejunostomy planned for December 2021.

Conclusion

Severe gastroparesis after Ivor Lewis procedure in a patient who suffered from Type II achalasia.

Duodenal diversion was performed by our team in similar, but less severe situations in 9 patients. This time, duodenal diversion did not meet our expectations.

Our indications and results will be discussed during the session.

Presentation of the Case

Denis Collet (Bordeaux) | Caroline Gronnier (Bordeaux)

Panel of Experts for Discussion

George Triadafilopoulos (Stanford) | Guillaume Piessen (Lille) | Richard McCallum (El Paso) | Bruno Zilberstein (São Paulo)