Thoracoscopic management of volvulus of the gastric conduit following minimally invasive Ivor-Lewis esophagectomy

Jeremy M Linson, MD, Bestoun Ahmed, MD, Ziad Awad, MD, FACS. UF COM Jacksonville, FL

We present a case of emergent thoracoscopic management of volvulus of the gastric conduit following minimally invasive Ivor-Lewis esophagectomy. The patient is a 69 year old caucasian male with a history of adenocarcinoma of the lower third of the esophagus. Initial presentation was dysphagia with solid foods, which progressed in severity until he was unable to swallow anything. EUS demonstrated a partially obstructing mass at 33cm, biopsy revealed poorly differentiated adenocarcinoma, stage T3N2Mx. PET scan did not reveal any metastatic disease. Pre-operative management included neoadjuvant chemoradiation therapy (5-FU and Cisplatin) and early placement of a jejunal feeding tube. Post-operatively, the patient progressed without difficulty to POD4, when prior to beginning a PO diet, an upper-GI swallow study was obtained which demonstrated a lack of transit of contrast through the distal neo-esophagus. Follow-up endoscopy revealed volvulus of the gastric conduit with obliteration of the lumen. We immediately took the patient to the OR for thoracoscopic detorsion, which we accomplished successfully using blunt dissection. Upon entering the thoracic cavity, the staple line that had been oriented anteriorly was now posterior. Attachments were gently teased away from the chest wall and the conduit was detorsed and anchored to the chest wall in the correct orientation with silk suture. Intra-operative endoscopy demonstrated a patent conduit, and post-operative upper-GI fluoroscopy now showed good transit of contrast. The patient continued to improve, and was eventually advanced to mechanical soft diet and discharged on POD9.

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