Two Cases of Laparoscopic Resection of Siewert Type II Adenocarcinoma of the Esophagogastric Junction Using a Transhiatal Approach and Complicated by Hemopericardium

Background

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is rising. According to the Siewert classification, AEG was defined as a tumor with an epicenter located within 5 cm of the esophagogastric junction. Distal esophageal adenocarcinoma with an epicenter located 1 to 5 cm above the gastroesophageal junction is classified as Siewert type I; true cardia cancer with a center within 1 cm above and 2 cm below the gastroesophageal junction is classified as Siewert type II; and gastric cardia tumors with a center located 2 to 5 cm below the gastroesophageal junction are classified as Siewert type III [1].

Curative treatment is frequently multidisciplinary, but surgery is still required for resectable AEG. There is currently no agreement on the best surgical strategy for treating Siewert type II AEG. A successful therapy for type II AEG involves surgical removal of the distal esophagus during prolonged complete gastrectomy [2,3]. Compared with the transthoracic or left thoracoabdominal surgical approach, the transhiatal method might be more suitable for Siewert type II AEG in terms of short- and long-term surgical outcomes [4,5].

Hemopericardium is a serious complication of esophagogastric junction cancer surgery and can develop into life-threatening pericardial tamponade [6]. Two patients with postoperative hemopericardium were reported by Ito et al and Kats et al [7,8]. The salvage treatment of the reported patients was pericardial resection with open drainage and sternotomy, and 1 patient died on postoperative day 4. We report 2 cases of laparoscopic resection of Siewert type II AEG using a transhiatal approach complicated by hemopericardium, which were treated successfully with ultrasound-guided pericardiocentesis.

Case Reports

CASE 1:

A 67-year-old man was admitted to the hospital on January 12, 2021, for “intermittent dull pain in the epigastrium without apparent cause for 10 months”. He had a history of gastric ulcer for 7 years. Gastroscopy revealed esophageal lesions, fundus neoplasia, and chronic atrophic gastritis. Computed tomography (CT) showed that the wall of the stomach was thickened, with soft tissue nodules at the junction of the esophagus and stomach, which was consistent with gastric cancer. The CT diagnosis was Siewert type II carcinoma of the esophagogastric junction (Figure 1). Laparoscopic radical gastrectomy (total gastrectomy) was performed on January 15, 2021. The patient reported concerns of palpitation, dizziness, shortness of breath, and profuse sweating 18 h after surgery. His blood pressure was 50/29 mmHg. Bilateral breath sounds were low, with scattered rales. The abdomen was flat. There was no tenderness around the incision and no rebound pain or muscle tension. CT (Figure 2) and pericardial color Doppler ultrasound (Figure 3) showed hemopericardium. At 21 h after surgery, the patient was transferred to the Intensive Care Unit. After ultrasound-guided pericardiocentesis and drainage, his blood pressure, heart rate, and respiratory rate returned to normal, and his symptoms were significantly relieved. The pathological staging was T3N1M0 adenocarcinoma (Figure 4). After the intervention, the patient recovered and was discharged un-eventfully. Upper gastrointestinal radiography revealed that the anastomosis was unobstructed, and no leakage of contrast medium was found (Figure 5).

CASE 2:

A 69-year-old man was admitted to the hospital on April 22, 2021. The patient’s chief concerns were persistent dull pain in the middle and upper abdomen for more than 3 months and acid reflux after eating. He had a history of gallbladder polyps for 5 years. Combined with his clinical history, gastroscopy, and CT (Figure 6), Siewert type II esophagogastric junction cancer was diagnosed. On April 25, 2021, laparoscopic radical esophagogastrostomy (total gastrectomy) was performed. Physical examination revealed tachycardia and low blood pressure 23 h after surgery. Electrocardiographic monitoring indicated sinus tachycardia with suspected pericardial effusion. Pericardial hemopericardium was identified on ultrasound (Figure 7). After ultrasound-guided pericardiocentesis and drainage, the patient’s vital signs recovered. After the intervention, the patient recovered and was discharged uneventfully. The pathological staging was T2N0M0 adenocarcinoma (Figure 8).

Discussion

The main results of this report are as follows. First, our cases emphasize the importance of quick detection and intervention in postoperative hemopericardium following laparoscopic transhiatal total gastrectomy. Second, we summarize the clinical presentation, diagnosis, and treatment of hemopericardium. Third, cardiovascular color Doppler ultrasound and CT are essential for the diagnosis of postoperative hemopericardium. Ultrasound-guided pericardiocentesis and drainage is effective for the treatment of hemopericardium.

Gastric cancer can generally be classified into 2 topographical subsites, the cardia (upper stomach) and noncardia (lower stomach) [9]. For gastric cancer invading less than 3 cm of the distal esophagus, a transhiatal abdominal approach is recommended [10]. Laparoscopic total gastrectomy is worthy of further promotion because it has the advantages of reduced bleeding and postoperative pain, rapid recovery of gastrointestinal function, and a short hospital stay [11].

Hemopericardium can be due to the rupture of coronary aneurysms, tumor invasion of the pericardium, or other causes that result in bleeding into the pericardium. In our 2 cases, the laparoscopic surgical field of the esophagogastric junction cancer was next to the pericardium, and the operation may have resulted in postoperative hemopericardium in the 2 patients. Other causes of postoperative hemopericardium are as follows. First, the most common malignancies with cardiac metastases include melanoma and primary mediastinal malignancies [12], which did not include the tumors in our cases. Additionally, metastatic tumors of the heart must involve the pericardium to give rise to hemopericardium. However, in our study, the 2 patient’s tumors were classified as T3N1M0 and T2N0M0, respectively, which did not invade the pericardium. Second, hemopericardium can be due to interventional procedures with cardiac perforation, idiopathic pericarditis, potential underlying diseases, and oral medication [13]. Neither of our patients had any of the above conditions.

To avoid hemopericardium after esophagogastric junction cancer surgery, intraoperative manipulation when performing laparoscopic transhiatal esophagogastric junction cancer surgery should be avoided. In addition, the depth of tumor infiltration should be identified by preoperative CT scan in patients with esophagogastric junction cancer. Finally, patient comorbidities, such as underlying diseases and oral medication, should be identified.

Regarding clinical manifestations, our pericardial hemopericardium patients both had increased heart rate and decreased blood pressure. One patient presented with panic, shortness of breath, and sweating. Both surgeries were performed by an experienced surgeon who had performed more than 200 laparoscopic total gastrectomy procedures. Both patients underwent laparoscopic total gastrectomy for esophagogastric junction cancer, which was uneventful. The surgical techniques were performed according to the Japanese Gastric Cancer Treatment Guidelines 2018 (5th edition) [14]. Nevertheless, it cannot be determined that the hemopericardium was a technical complication. According to the Japanese Gastric Cancer Treatment Guidelines 2018 (5th edition), patients with cT2-4 can directly undergo surgery without preoperative chemoradiotherapy [14]. In our study, the patient’s cancers were classified as T3N1M0 and T2N0M0. Therefore, neither patient received neoadjuvant chemotherapy or radiation. Hemopericardium was diagnosed in both patients by CT or cardiac color Doppler ultrasound.

Ultrasound-guided pericardiocentesis and drainage was used as a safe, effective, and rapid method for treatment. The 2 patients recovered uneventfully.

Two similar cases were reported by Ito et al and Kats et al [7,8]. Both of the patients’ cases were complicated with postoperative hemopericardium. The salvage treatment for the 2 patients was pericardial resection with open drainage and sternotomy, and 1 patient died on postoperative day 4. Ito et al reported a 76-year-old man who underwent subtotal esophagectomy via a cervico-right thoracoabdominal approach for esophageal cancer. His vital signs declined on postoperative day 4. His blood pressure was 54/42 mmHg, and his pulse was 102 beats per min. Cardiac tamponade was diagnosed by chest CT), and he was rescued by pericardial resection (3.5×3.5 cm) and open drainage. Kats et al reported a 50-year-old man who underwent transhiatal esophagectomy and emergency sternotomy for adenocarcinoma of the distal esophagus. Adenocarcinoma of the distal esophagus was diagnosed, and the patient had a history of cystectomy for bladder carcinoma, alcohol abuse, and gastroesophageal reflux disease. He developed signs of bleeding with a decrease in systolic pressure and hemoglobin level just a few hours after transhiatal esophagectomy. A relaparotomy was performed, and the hiatus was reopened. His systolic pressure declined, and his central venous pressure increased, while the posterior mediastinum was explored through the enlarged hiatus. In contrast to our patients, the cardiac tamponade was diagnosed without computed tomography (CT), and this patient was rescued by exploratory thoracotomy rather than ultrasound-guided pericardiocentesis. Furthermore, the patient died on postoperative day 4, without signs of recurrent cardiac tamponade. Relaparotomy was performed again, but no explanation of the unstable condition of the patient was found.

Conclusions

Hemopericardium is a life-threatening complication for patients with esophageal-gastric junction cancer who undergo transhiatal laparoscopic surgery. We report 2 patients whose cases were complicated by hemopericardium after transhiatal laparoscopic excision of Siewert type II AEG. Early physical examinations with cardiovascular color Doppler ultrasound and CT are essential for diagnosis. Ultrasound-guided pericardiocentesis and drainage is effective for the treatment of hemopericardium.