# Gastric Emphysema Related to Percutaneous Endoscopic Gastrostomy After Two-Stage Esophagectomy: A Report of Two Cases

## TL;DR

Two patients with diabetes developed gastric emphysema after minimally invasive esophagectomy and PEG placement, highlighting the need for careful postoperative monitoring.

## Contribution

Reports two cases linking gastric emphysema to PEG placement after two-stage esophagectomy in diabetic patients.

## Key findings

- Gastric emphysema occurred within 30 days of minimally invasive esophagectomy in both patients.
- Delayed gastric emptying was identified as a potential cause of increased intragastric pressure leading to gastric emphysema.
- Both patients had a history of diabetes mellitus, suggesting a possible association with postoperative complications.

## Abstract

Patients with esophageal cancer who have severe complications such as diabetes sometimes require two-stage surgery. Herein, we describe two cases of gastric emphysema that were treated at our facility after the patients had previously undergone minimally invasive esophagectomy as the first-stage surgical treatment of esophageal cancer. Case 1: A 72-year-old man with a history of diabetes mellitus (DM) was diagnosed with esophageal cancer and an esophageal obstruction and subsequently underwent percutaneous endoscopic gastrostomy (PEG) placement followed by neoadjuvant chemoradiotherapy. The treatment efficacy was good; once the tumor was deemed resectable, the patient underwent robot-assisted minimally invasive esophagectomy and cervical esophagostomy placement as the first stage of surgical treatment. The patient had a good postoperative course and was discharged on postoperative day (POD) 10. However, on POD 16, he returned to the hospital with abdominal distension. Computed tomography (CT) revealed gastric emphysema and hepatic portal vein gas. Conservative treatment was initiated as there were no signs of peritoneal irritation. An upper gastrointestinal (GI) series revealed delayed gastric emptying (DGE); therefore, replacement of the PEG with a percutaneous endoscopic gastrojejunostomy (PEG-J) was necessary. On POD 42, the patient underwent reconstructive surgery as the second-stage surgical treatment of esophageal cancer. Case 2: A 74-year-old man had a history of DM, chronic renal failure, and PEG placement for dysphagia caused by left recurrent nerve palsy after thoracic aortic aneurysm surgery. The patient underwent a thoracoscopic esophagectomy with cervical esophagostomy placement as the first-stage surgical treatment of esophageal cancer. On POD 6, the patient developed abdominal distension, his CT showed gastric emphysema. An upper GI series was performed, which showed DGE. After conservative treatment and improvement in his general condition, the patient underwent a jejunostomy placement on POD 30. Both patients developed gastric emphysema related to PEG placement after undergoing esophagectomy as the first-stage surgical treatment of esophageal cancer. Additionally, both patients had a history of DM. Gastric emphysema, which is thought to be caused by increased intragastric pressure due to postoperative DGE, developed within 30 days of undergoing minimally invasive esophagectomy in both patients. Therefore, the rate of nutrient administration and symptoms should be carefully monitored during the postoperative management of patients with these characteristics.