A 71-year-old woman underwent gastrostomy due to malnutrition resulting from impaired esophageal peristalsis due to scleroderma. However, the gastrostomy tube was removed due to worsening of difficult-to-treat dermatitis around the gastrostomy. An intractable gastrocutaneous fistula with persistent gastric juice leakage and peri-gastrostomy dermatitis was treated with fistulotomy and local negative pressure closure therapy under local anesthesia. Spontaneous closure of an intractable fistula after gastrostomy removal can be difficult due to underlying malnutrition and exposure to leaking gastric juice, among other factors. The present case suggests that fistulectomy followed by local negative pressure closure therapy for an intractable fistula after gastrostomy removal can enable oral intake in the early postoperative period and also facilitate wound management.

PURPOSE: Postoperative pancreatic fistula is a serious and fatal complication of gastrectomy for gastric cancer. Blunt trauma to the parenchyma of the pancreas can result from an assistant's forceps compressing and retracting the pancreas, which in turn may result in pancreatic juice leakage. However, no published studies have focused on blunt trauma to the pancreas during laparoscopic surgery. Our aim was to investigate the relationship between compression of the pancreas and pancreatic juice leakage in a swine model. MATERIALS AND METHODS: Three female pigs were used in this study. The pancreas was gently compressed dorsally for 15 minutes laparoscopically with gauze grasped with forceps. Pancreatic juice leakage was visualized by fluorescence imaging after topical administration of chymotrypsin-activatable fluorophore in real time. Amylase concentrations in ascites collected at specified times was measured. In addition, pancreatic tissue was fixed with formalin, and the histology of the compressed sites was evaluated. RESULTS: Fluorescence imaging enabled visualization of pancreatic juice leaking into ascites around the pancreas. Median concentrations of pancreatic amylase in ascites increased from 46 U/L preoperatively to 12,509 U/L 4 hours after compression. Histological examination of tissues obtained 4 hours after compression revealed necrotic pancreatic acinar cells extending from the surface to deep within the pancreas and infiltration of inflammatory cells. CONCLUSIONS: Pancreatic compression by the assistant's forceps can contribute to pancreatic juice leakage. These findings will help to improve the procedure for lymph node dissection around the pancreas during laparoscopic gastrectomy.
Acinar Cells ; Administration, Topical ; Amylases ; Ascites ; Female ; Formaldehyde ; Gastrectomy* ; Hand Strength ; Humans ; Laparoscopy ; Lymph Node Excision* ; Lymph Nodes* ; Optical Imaging ; Pancreas ; Pancreatic Fistula ; Pancreatic Juice ; Stomach Neoplasms ; Surgical Instruments ; Swine ; Wounds, Nonpenetrating

Simultaneous creation of an enterostomy for enteral nutrition during esophagectomy has been useful in our experience, but bowel obstruction associated with intestinal fistula remains a problem. Therefore, in this study, we retrospectively reviewed 18 patients with esophageal cancer who underwent transdiaphragmatic transgastric tube enteral feeding catheter placement during gastric tube reconstruction via the mediastinal route after esophagectomy from November 2012 to March 2014. The catheter was guided from the gastric tube into the gastrointestinal tract, with the tip placed in the jejunum distal to the ligament of Treitz. From the gastric tube, the catheter was guided along the diaphragm to the anterior abdominal wall through the extraperitoneal route. No bowel obstruction associated with catheter placement has been observed in any of the patients from the time of surgery to this writing. Also, the procedure enabled jejunostomy use for more than 5 years, similar to conventional jejunostomy. We experienced 1 case of catheter deviation into the mediastinum. Overall, transgastric tube enteral feeding catheter placement for reconstruction of the posterior mediastinal gastric tube was useful for avoiding intestinal obstruction associated with jejunostomy. However, there may be a risk of catheter displacement into the mediastinum.