Succesful Medical Management of Gastric After Minimally Invasive Three Fields Esofagectomy by Achalasia Megaesophagus

Evelyn Dorado, DR, Andres Romero, DR. Fundacion Clinica Valle Del Lili Cali Colombia.

Achalasia is a disease that affects men and women equally, although it is not yet clear etiology, progression to a megaesophagus is evident in the terminal stages of the disease. In advanced cases esophagectomy is the best option for these patients. Since the advent of laparoscopic procedure has shown superiority over open esophagectomy with fewer complications and faster recovery.

A case of a 50 year old patient with progressive dysphagia during six years of evolution with endoscopy, intestinal transit and manometry indicating megaesophagus for achalasia. He has lost 6 kg in 2 months, nutritional recovery starts before surgery per 10 days with nasoenteral feeding, and is scheduled for three fields minimally invasive esophagectomy . Procedure starts with a prone thoracoscopy evidenced , followed laparoscopy greater curve of the stomach tubulizarion and finally ascent of the stomach and cervical with blue carthrigde laterolateral anastomosis of the esophagus with the stomach. The patient had an incidental finding of zencker diverticulum was resected with mechanical suture. we left a right thoracostomy and nasoenteral feeding tube and 6 hours after procedure started nutrition. the patient was early extube and he didnt need vasopresor drugs.


The patient is transferred to ICU, fourth days left we ordered esophagogram showing no leaks and delayed gastric transit. per rutine we dont perform pyloromiotomy . At seven postoperative day the patient shows change in the characteristics of tohoracis drainage and elevated acute phase reactants.
we scheduale an emergency thoracoscopy with evidence of empyema handled successfully with drainage and leave anterior and posterior thoracostomy, we didnt see a perforation, by accident nasoenteral tube was move for nurse and we need a endoscopy for pass a new tube, During the passage of tube, air insufflation permit dehiscence of the suture line 1 cm opening which was not evident at the start of endoscopyI,
the patient was managed with thoracostomy, enteral nutrition and New Whey protein. No infectious complications occurred after the empyema dranaige and, 60 days after the first surgery decreased production of intrathoracic tube, methylene blue test and negative esophagogram filtration test we started liquefied diet with good tolerance. level of Albumin at time of dehiscence was 1.7 and 3.0 at discharge,

Esophagectomy for minimal invasion is a safe and well tolerated procedure . 11% may have leaks, especially in the cervical anastomosis. Conservative management with drainage of fsitula and and optimizing the nutritional requirements allowed rapid recovery and sealing of the fistula on a record time of 60 days . The advantages of minimal invasion are shown in the short stay in ICU, reduced opioid analgesic requirement and early mobilization.

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