Robot-Assisted Laparoscopic Reduction of Gastroesophageal Intussusception With Gastropexy

Abstract

We report the rare case of a 71-year-old man with a medical history including dysphagia, gastroesophageal reflux disease, and achalasia with remote open transthoracic Heller myotomy who presented acutely with symptoms of esophageal obstruction. Sustained gastroesophageal intussusception was diagnosed with esophagogastroduodenoscopy and computed tomography. The patient underwent urgent robot-assisted laparoscopic reduction with gastropexy. Intraoperatively, the gastric and esophageal tissue appeared inflamed without evidence of necrosis or perforation. The patient recovered well without complications. This report describes a case of successful surgical treatment of gastroesophageal intussusception by a robotic approach.

Gastroesophageal intussusception (GEI) is a condition in which there is full-thickness telescoping of part or all of the stomach into the distal esophagus. Although transient GEI has been observed endoscopically, commonly in the setting of prolonged forceful retching, sustained GEI resulting in upper gastrointestinal obstruction is extremely rare. Few cases have been reported in humans, although it is more common in canines with congenital megaesophagus. We report the case of a patient with a remote history of achalasia and Heller myotomy who presented acutely with symptoms of esophageal obstruction. He was found to have sustained GEI and underwent successful robot-assisted laparoscopic reduction with diaphragmatic gastropexy.

We report the case of a 71-year-old man with a medical history of recent thyroidectomy for papillary thyroid carcinoma, dysphagia, gastroesophageal reflux disease, Barrett esophagus, and achalasia with remote open transthoracic Heller myotomy. The patient reported long-standing mild dysphagia to solid foods, heartburn (well controlled with medication), and occasional intermittent chest discomfort since his myotomy.

The patient presented with 2 days of acute epigastric pain, nausea, and small-volume hematemesis that began suddenly after straining to defecate. Computed tomography revealed telescoping of the stomach into the distal esophagus with proximal esophageal distention concerning for acute GEI resulting in esophageal obstruction (Figure 1A). The patient was hemodynamically stable and tender to palpation in the epigastrium without peritoneal signs. Laboratory results were notable for mild leukocytosis (14,000 cells/μL) and normal lactate concentration (1.2 mmol/L). Esophagogastroduodenoscopy (EGD) revealed a dilated and fluid-filled esophagus (Figure 1B), with ischemic-appearing gastric mucosa intussuscepting into the distal esophagus (Figure 1C). Informed consent was obtained, and the patient was taken urgently to the operating room.

Figure 1.

Preoperative diagnostic images. (A) Preoperative computed tomography showing telescoping of the stomach into the distal esophagus (purple) with proximal esophageal distention (measured, blue). (B) Preoperative esophagogastroduodenoscopy showing dilated and fluid-filled esophagus. (C) Intussusception of the stomach into the distal esophagus causing esophageal obstruction and ischemic-appearing gastric mucosa.

Four robotic ports and an assistant port were placed in the standard positions using the da Vinci Xi surgical system (Intuitive Surgical). On insufflation, an obvious abnormality of the anterior gastric wall was visualized with telescoping of the fundus into the mediastinum (Figure 2A). The gastrohepatic ligament was incised and the phrenoesophageal ligament was divided circumferentially to identify the right and left crus. The short gastric vessels were ligated, and the fundus was reduced into the abdomen (Figure 2B; Video). After reduction, intraoperative EGD demonstrated a patulous and dilated “sigmoid-shaped” esophagus. The gastric tissue was hyperemic and congested without frank necrosis or perforation when visualized endoscopically (not shown) and laparoscopically (Figure 2C). No significant hiatal hernia was noted. Gastropexy was performed by fixing the fundus to the left crus and diaphragm with a running nonabsorbable barbed suture, reinforced with interrupted silk sutures (Video).

Figure 2.

Intraoperative laparoscopic images. (A) Upper abdominal compartment before reduction, with obvious abnormality of the anterior gastric wall and telescoping of the fundus into the mediastinum (arrow). (B) Reduction of intussuscepted stomach from the mediastinum to the abdomen. (C) Stomach after reduction, with hyperemic and congested gastric tissue without frank necrosis or perforation.

The patient recovered well. A nasogastric tube placed intraoperatively was removed on postoperative day 1. Leukocytosis normalized. Barium swallow study demonstrated esophageal dilation and dysmotility, consistent with achalasia, but free passage of contrast material (Figure 3). He was discharged home on postoperative day 2 tolerating a regular diet. Four months postoperatively, he had continuation of mild baseline symptoms but denied weight loss, regurgitation, or aspiration. There was no radiographic evidence of recurrent GEI.

Figure 3.

Postoperative barium swallow. Barium swallow study on postoperative day 2 showing severe esophageal dilation with associated dysmotility, consistent with achalasia, but free passage of contrast material.

Comment

Our patient’s history is consistent with the few other reported cases of GEI, occurring most frequently in patients with achalasia treated with Heller or peroral endoscopic myotomy.1, 2, 3, 4, 5 His dilated distal esophagus due to chronic dysmotility and iatrogenic lower esophageal sphincter laxity likely predisposed him to spontaneous GEI in the setting of transiently increased intra-abdominal pressure during a Valsalva maneuver. His constipation may have been due to opioid use after recent thyroid surgery. Intra-abdominal hypertension secondary to ascites⁶ or free air⁷ and poor fixation of the stomach from prior surgery or otherwise aberrant anatomy^4,8 are also risk factors. The several decades between our patient’s myotomy and GEI suggests lifelong risk. Risk may also correlate with duration of uncontrolled disease.

Diagnosis of GEI may be challenging because of nonspecific symptoms of epigastric pain, hematemesis, or leukocytosis but should be suspected in patients with risk factors such as history of achalasia and myotomy, with a low threshold for cross-sectional imaging. A target appearance may be visualized, like intussusception elsewhere in the gastrointestinal tract. EGD is crucial but may miss transient GEI, and endoscopic advancement may not be feasible because of concern for iatrogenic perforation of inflamed mucosa. Prompt diagnosis of sustained GEI is essential as risk of ischemic necrosis requiring gastric resection is high.

Endoscopic reduction is a potential minimally invasive option for management of intussusception elsewhere in the gastrointestinal tract but may have higher failure rates for GEI. Moreover, in cases of GEI with features concerning for ischemia, laparoscopic surgery should be considered to evaluate the extent of ischemia and to avoid perforation of inflamed or necrotic tissue with endoscopic manipulation.^1,2 For these reasons, our patient underwent operative management.

Gastric fixation is a key operative step, and the site of gastropexy may be an important factor in preventing GEI recurrence. We chose to fix the fundus and angle of His to the left crus and medial diaphragm as we believed that gastropexy of the previously intussuscepted segment (ie, proximal stomach) would most effectively prevent recurrence. We avoided fixation to the diaphragm’s central tendon to avoid possible suture erosion into the pericardium directly cephalad.

In our patient, we forewent fundoplication because we were concerned that the risks in a patient with significant inflammation and no recent esophageal motility workup (eg, manometry) outweighed the benefits. Our patient reported good postoperative quality of life with continuation of mild baseline symptoms, but elective esophagectomy can be considered in patients with severe preoperative or postoperative symptoms or recurrent GEI.

Robot-assisted laparoscopic surgery is an ever-growing component of thoracic surgery and offers benefits over traditional laparoscopy, including articulated instrument tips, 3-dimensional vision, improved ergonomics, and tremor filtering. This report describes a case of successful surgical reduction and treatment of GEI with use of a surgical robot system.

In conclusion, GEI is more likely to occur in patients with a history of achalasia or esophageal myotomy. Prompt diagnosis is essential, and GEI should be considered in any patient with suggestive history and obstructive symptoms as it may occur decades after myotomy without obvious precipitating factors. Robot-assisted laparoscopic reduction of GEI with gastropexy is a feasible technique for surgical management.