Journal of Surgery

“Damage Control” Esophagogastrectomy in Case of Perforated and Bleeding Gastroesophageal Cancer

Abstract

Bogdan Moldovan, Dumitru Pocreaţă, Dan Teodorescu, Marius Coroş, Viorica Sârbu, Lucian Băilă, Marcel Tanţău, Dragos Grusea, Florentina Pescaru, Andreea Moldovan and Laura Biriş

Introduction: The term “damage control surgery” or “laparotomie écourtée” is not a new concept, but a recent paradigm in the surgery of abdominal trauma, when the ability to maintain homeostasis is impaired due to severe hemorrhage. It can be defined as a surgical method that prevents the trauma triad of death by hemorrhage control and the prevention of peritoneal contamination, while time is an essential factor. Damage control surgery is followed by vigorous resuscitation and definitive reconstruction. The concept of "damage - control” is less reflected in the literature related to surgical oncology.

Case Presentation: A 45-year-old patient, BMI 35, presented to the Emergency Services of the Regional Hospital with abundant hematemesis and shock. The patient had been previously diagnosed with adenocarcinoma of the gastroesophageal junction subsequent to CT scan and endoscopic evaluation and was under the way to complete surgical - oncological balance with scheduled neoadjuvant chemotherapy due to the size and extension of the tumor. Emergency gastroscopy revealed an accumulation of blood in the stomach with ongoing massive hemorrhage while emergency CT scan revealed left hemopneumothorax and hemoperitoneum. Due to the hemorrhagic shock caused by hemodynamic collapse, the patient was performed emergency damage control esophagogastrectomy in the same block with the esophageal hiatus and liver segment 2. Thus the greater curvature of the stomach was preserved, stapled, as well as the intrathoracic esophageal stump and jejunostomy for alimentation were performed. During evolution, several interventions were performed sequentially: hemostasis by packing for hemorrhage control in the hiatal area (day 0), depacking (day 3), left pleural drainage (day 5), left cervicostomy for salivary drainage (day 8), right transthoracic esophagogastric anastomoses by using the Ivor-Lewis technique (day 63) and esophagogastric stenting for the treatment of anastomotic fistula (day 71).

Results: Final evolution after three months of hospitalization, seven surgical interventions, more than 20 units of transfusion, is favorable. The jejunostomy tube was removed on day 95, after resuming in advance oral nutrition in parallel with enteral feeding, cervicotomy closed spontaneously. The esophageal stent was removed 6 months after placement. The pathological examination revealed a G3 poorly differentiated intestinal-type gastric adenocarcinoma (Lauren classification), which infiltrated the last 4 cm of the esophagus and 6 cm of the superior gastric pole towards the lesser curvature of the stomach (pT4N2M0). The patient underwent 6 cycles of adjuvant chemotherapy with DCF, 1 year and 6 months postoperatively becoming disease free and fully reintegrated from the social-professional point of view.

Conclusion: The presented case is a “damage control” type model approach in an imminent life-threatening situation, which successfully implements the principles of traumatology in case of a complex oncology situation and also a multidisciplinary model of approach and collaboration between multiple hospital units for saving a young cancer patient’s life.