Complete gastroesophageal junction avulsion after near drown
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A 14-year-old boy was brought to the emergency department after a near-drowning incident. He was playing in a “lazy river” at a water amusement park and became trapped against a large suction intake drain with subsequent loss of consciousness. He was rescued and brief bystander CPR was performed. On arrival, he was hemodynamically stable, fully conscious, and complained of abdominal pain. On exam, he had diffuse abrasions on his torso in the configuration of a square. His abdomen was otherwise soft and without any peritoneal signs. A chest x-ray was performed which showed pneumoperitoneum. CT scan revealed pneumomediastinum, pneumoperitoneum, and intraabdominal free fluid, particularly in the region of the esophageal hiatus.

Due to concern for hollow viscus perforation, he was taken emergently to the operating room. Initial inspection during the laparotomy revealed gross contamination with food debris and a total gastroesophageal junction (GEJ) disruption. At this time, the patient started to become hemodynamically labile, so a decision was made to perform a damage control procedure. The distal esophagus and the proximal stomach were stapled closed, leaving the patient in discontinuity. Four drains including a mediastinal drain and a gastrostomy (G) tube was placed. Instead, a large-bore nasogastric (NG) tube was placed in the esophagus above the staple line to manage secretions. Intraabdominal and mediastinal drains were placed. The fascia was closed and the patient was transferred to the Pediatric Intensive Care Unit (ICU).

His ICU stay was complicated by septic shock, respiratory failure leading to prolonged intubation, deep venous thrombosis with pulmonary embolism, bilateral pleural effusions, and general deconditioning. Parenteral nutrition was started in the immediate postoperative period. He was extubated on postoperative day 18 and fluoroscopic evaluation demonstrated a leak in the esophagus which was controlled by the mediastinal drain. The stomach was negative for leak and therefore enteral nutrition was initiated via the G tube. After extensive rehabilitation, he was discharged on day 50 with the nasogastric tube and the mediastinal drain.

Three months after his initial injury, he underwent Ivor-Lewis distal esophagectomy with gastric pull-up for esophagogastric anastomosis. For the surgery, he was positioned into a partial left lateral decubitus position for simultaneous access to the abdomen and the chest. A midline abdominal incision was made using his previous incision site. A gastric conduit was then made along the lesser curvature using a surgical GIA stapler. A right thoracotomy was performed and the distal esophagus was identified. The tabularized portion of the stomach was then advanced into the chest without difficulty and a 29 mm end-to-end anastomosis (EEA) stapler was used to complete the esophagogastric anastomosis. A leak test was performed via upper endoscopy which was negative. Finally, a jejunostomy tube was placed to allow for enteral access post-operatively.

He was extubated on postoperative day 3 and nutritionally supported with jejunostomy enteral feeds. On day 7, an esophagram showed no leak at the anastomosis and immediate stomach emptying. He was initiated on a liquid diet and discharged on day 10. At the most recent clinic visit 5 months from the reconstruction, he can tolerate a regular diet without difficulty and is gaining weight and recovering well.