GASTRIC NECROSIS AFTER FUNDOPLICATION - A NOVEL-APPROACH FOR ESOPHAGEAL PRESERVATION

An Ii-year-old boy presented moribund, with massive abdominal distensi on. A Nissen fundoplication and gastrostomy tube had been established at age 2 years. After attempts to pass a nasogastric tube were unsucce ssful, the old gastrostomy site was used to gain percutaneous access t o the stomach resulting in release of gastric contents and stabilizati on of blood pressure and perfusion. During operation, massive gastric distention with gastric necrosis was found. Subtotal gastrectomy was p erformed with stapled closure of the distal intraabdominal esophagus a nd prepyloric region. Sump suction was placed in the proximal esophagu s and the abdomen was drained widely. A distal esophageal perforation was apparent on postoperative day 19 confirmed by imaging and endoscop y. A nasoesophageal tube was passed into the abdomen, tied to a Jackso n-Pratt drain, and the composite tube repositioned in the midesophagus allowing controlled proximal and distal drainage. Six months later, a Hunt-Laurence esophagojejunal pouch was created. At age 13, the child is clinically well, and enjoys 50% of his nutritional needs orally, w ith the remainder delivered overnight via tube feedings. This case des cribes gastric necrosis after gas bloat syndrome as a late complicatio n of Nissen fundoplication. A novel approach to the management of dist al esophageal perforation allowed preservation of a functional, intact native esophagus. Copyright (C) 1998 by W.B. Saunders Company.