LAUSR

A 53-year-old male with progressive dysphagia and weight loss underwent a gastroscopy, which revealed a distal third oesophageal adenocarcinoma. The patient underwent a staging computed tomography chest/abdomen/pelvis, which showed a 16-mm lesion in the left lung lingula lobe but no other lesions. On full body positron emission tomography scan, the lung lesion was glucose avid and there were no other suspicious lesions seen. The patient underwent an endobronchial ultrasound-guided biopsy of the left lung lesion, which demonstrated a second primary non-small cell lung cancer. No metastatic disease was seen on staging laparoscopy. The patient was discussed at our multidisciplinary team meeting and deemed suitable for curative oesophageal resection following chemoradiotherapy. It was determined that the patient should undergo curative treatment for his primary lung cancer following recovery from his oesophageal cancer treatment. After completing neoadjuvant chemotherapy according to the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) protocol, the patient underwent an uncomplicated hybrid Ivor–Lewis oesophagectomy (laparoscopic abdominal and open chest components). Intraoperatively, he was noted to have a redundant and mobile transverse colon with a high splenic flexure. The hiatus was assessed as able to take two fingers only. Histopathological evaluation of the operative specimen revealed a stage IIIB (ypT3N1M0) cancer. Post-operatively, the patient developed a low-volume chyle leak that failed to resolve with dietary fat restriction and somatostatin. A lipiodol lymphangiogram was performed, which showed no leak from the ligated thoracic duct and could not identify the chyle leak source. The patient had a progress chest X-ray on post-operative day 13. His chest drain was noted to be angled into the mediastinum and hypothesized to be abutting mediastinal lymphatics, exacerbating his chyle leak. The chest drain was retracted 10 cm after a routine deep inspiration. Within a few minutes, the patient had a brief episode of dyspnoea, tachypnoea and hypotension. A repeat chest X-ray did not demonstrate a pneumothorax but revealed distended colonic bowel loops in the left lower chest, which was not present prior to drain retraction (Fig. 1). A computed tomography abdomen and pelvis was arranged to rule out other pathological causes (e.g. intra-abdominal sepsis) but this was delayed as the patient became haemodynamically stable and there were other more urgent scans (i.e. stroke call) being done. The scan was performed afterhours and showed herniation of the distal transverse colon through the oesophageal hiatus causing a mechanical large bowel obstruction (Fig. 2). Unfortunately, there was a delay in recognizing these findings overnight and the patient complained of worsening left upper quadrant pain the next morning. He underwent an emergency laparoscopic converted to open reduction of the distal transverse colon (Fig. 3). The colon was non-viable and therefore resected.