Honig Stephanie E, Lundgren Megan P, Kowalski Thomas E, Lavu Harish, Yeo Charles J
Department of Surgery, The Jefferson Pancreas, Biliary and Related Cancer Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
J Pancreat Cancer. 2020 Feb 6;6(1):5-11. doi: 10.1089/pancan.2019.0016. eCollection 2020.
Approximately 4% of patients develop a second upper gastrointestinal cancer after esophagectomy, and nearly 60,000 people are diagnosed with pancreatic cancer in the United States each year. The need for a Whipple procedure after esophagectomy is rarely reported. Post-esophagectomy anatomy, particularly the vascular supply, makes this a complex operation. Herein, we describe the advanced endoscopic rescue of a duodenojejunostomy (DJ) leak after pylorus-preserving pancreaticoduodenectomy (PPPD) in a post-esophagectomy patient. A 72-year-old male with a remote history of esophageal cancer treated with minimally invasive three-hole esophagectomy and chemoradiation presented to our institution for evaluation and management of newly diagnosed pancreatic cancer. The patient had undergone common bile duct (CBD) stent placement by his gastroenterologist 2 weeks earlier after experiencing jaundice, weight loss, and steatorrhea. Endoscopic ultrasound confirmed the presence of a pancreatic head and neck mass, obstructing and dilating the main pancreatic duct and CBD. Fine-needle biopsy revealed a poorly differentiated adenocarcinoma. A PPPD was performed without intraoperative complications. The patient was subsequently readmitted with a DJ leak requiring interventional radiology and advanced endoscopic intervention. PPPD in patients with pancreatic cancer can be performed after previous esophagectomy. Careful dissection is crucial to avoid injury to the remaining right gastric and right gastroepiploic arteries that supply the gastric conduit after esophagectomy. The DJ is at risk after this operation, and access to tertiary care inclusive of interventional radiology and advanced endoscopic teams is critical to the correction and healing of a leak of this anastomosis.
食管癌切除术后约4%的患者会发生第二原发性上消化道癌，在美国每年有近6万人被诊断为胰腺癌。食管癌切除术后进行胰十二指肠切除术的需求鲜有报道。食管癌切除术后的解剖结构，尤其是血管供应，使得这成为一项复杂的手术。在此，我们描述了一例食管癌切除术后患者在保留幽门的胰十二指肠切除术（PPPD）后十二指肠空肠吻合口（DJ）漏的高级内镜挽救治疗。一名72岁男性，有食管癌远期病史，接受了微创三孔食管癌切除术及放化疗，因新诊断的胰腺癌到我院评估和治疗。该患者在出现黄疸、体重减轻和脂肪泻2周后，由其胃肠病医生进行了胆总管（CBD）支架置入术。内镜超声证实胰头和颈部有肿块，阻塞并扩张了主胰管和CBD。细针穿刺活检显示为低分化腺癌。进行了PPPD，术中无并发症。患者随后因DJ漏再次入院，需要介入放射学和高级内镜干预。胰腺癌患者在先前食管癌切除术后可进行PPPD。仔细解剖至关重要，以避免损伤食管癌切除术后供应胃管道的剩余右胃动脉和右胃网膜动脉。此手术后DJ有漏的风险，获得包括介入放射学和高级内镜团队在内的三级医疗护理对于修复和治愈这种吻合口漏至关重要。
