Total laparoscopic esophageal bypass using a colonic conduit for corrosive-induced esophageal stricture

Comparison of Short-term Outcomes Between Esophageal Bypass Surgery and Self-expanding Stent Insertion in Esophageal Cancer: A Propensity Score-matched Analysis Using a Large-scale Inpatient Database

BACKGROUND

Advanced esophageal cancer is occasionally accompanied by difficulty swallowing owing to esophageal stenosis or tracheoesophageal fistula formation. Esophageal bypass surgery and stent insertion are considered feasible palliative management options. The aim of this study was to evaluate the short-term outcomes of these palliative treatments.

MATERIALS AND METHODS

Patient data were obtained from a large-scale inpatient database of 42 National University Hospitals in Japan. Patients with advanced esophageal cancer who underwent esophageal bypass surgery or stent insertion between April 2016 and March 2021 were included in this study. One-to-one propensity score matching of patients who underwent bypass surgery or stent insertion was performed. The primary outcomes were time to diet resumption and length of hospital stay after surgery. The secondary outcome was the incidence of postoperative complications.

RESULTS

In 43 propensity score-matched pairs, the incidence of postoperative respiratory complications was significantly higher in the bypass group than in the stent group (32.6% vs. 9.3%, P = 0.008). Postoperative length of hospital stay was longer in the bypass group than in the stent group (24 vs. 10 d, P < 0.001). Logistic regression analysis revealed that stent insertion was associated with a decreased risk of respiratory complications (odds ratio 0.077, P < 0.007). Among patients who underwent the interventions (bypass surgery or stent insertion) and subsequently underwent anticancer therapy (chemotherapy/radiotherapy) during hospitalization, the interval between the intervention and anticancer therapy was longer in the bypass group than in the stent group (25 vs. 7 d, P = 0.003).

CONCLUSIONS

Esophageal stent insertion provides better short-term outcomes than bypass surgery in patients with advanced unresectable esophageal cancer.

Changing trends in the minimally invasive surgery for corrosive esophagogastric stricture

Esophagogastric stricture is the troublesome long-term complication of corrosive ingestion with a significant adverse impact on the quality of life. Surgery remains the mainstay of therapy in patients where endoscopic treatment is not feasible or fails to dilate the stricture. Conventional surgical management of esophageal stricture is open esophageal bypass using gastric or colon conduit. Colon is the commonly used esophageal substitute, particularly in those with high pharyngoesophageal strictures and in patients with accompanying gastric strictures. Traditionally colon bypass is performed using an open technique that requires a long midline incision from the xiphisternum to the suprapubic area, with adverse cosmetic outcomes and long-term complications like an incisional hernia. As most of the affected patients are in the second or third decade of life minimally invasive approach is an attractive proposition. However, minimally invasive surgery for corrosive esophagogastric stricture is slow to evolve due to the complex nature of the surgical procedure. With advancements in laparoscopic skills and instrumentation, the feasibility and safety of minimally invasive surgery in corrosive esophagogastric stricture have been documented. Initial series have mainly used a laparoscopic-assisted approach, whereas more recent studies have shown the safety of a total laparoscopic approach. The changing trend from laparoscopic assisted procedure to a totally minimally invasive technique for corrosive esophagogastric stricture should be carefully disseminated to preclude adverse long-term outcomes. Also, well-designed trials with long-term follow-ups are required to document the superiority of minimally invasive surgery for corrosive esophagogastric stricture. The present review focuses on the challenges and changing trends in the minimally invasive treatment of corrosive esophagogastric stricture.

Minimal access surgery of corrosive and thermal strictures of the foregut

BACKGROUND AND AIM

: Conventional surgery for caustic/thermal strictures (CS/TS) entails considerable trauma, which may be mitigated by minimal access surgery (MAS). Experience with its use in CS/TS is both heterogeneous and limited, hence, warrants a comprehensive review.

METHODS

: Medical literature/indexing databases were systematically searched for pertinent articles published in English, from 1990 to 2021, and analysed.

RESULTS

: Fifty relevant articles, pertaining to over 200 patients, were found. They showed that MAS is feasible in CS/TS management. It reduces the access damage in chest and abdomen whilst facilitating resection or bypass of the affected gut segment through different combination of operations, sequence of steps, conduits and routes. The procedures range from completely minimal access to hybrid ones, with reduced complications and faster recovery. Hybrid procedures prove as expeditious as open ones.

CONCLUSIONS

: MAS proves efficacious in restoring alimentary continuity in corrosive/thermal strictures of the foregut.

Minimally Invasive Retrosternal Esophageal Bypass Using a Mid-Colon Esophagocoloplasty for Corrosive-Induced Esophageal Stricture

INTRODUCTION

Colonic bypass for corrosive-induced esophageal stricture is traditionally performed using an open approach. The laparoscopic mid-colon retrosternal esophageal bypass has not been previously reported. The present study is aimed to report the feasibility of laparoscopic mid-colon esophagocoloplasty and to compare the short- and medium-term outcomes with the open approach.

MATERIALS AND METHODS

Patients who underwent surgery for corrosive esophageal stricture between August 2016 and August 2019 were retrospectively analyzed. Laparoscopic procedure was preferred in patients with stricture starting at or below the level of cricopharynx and without prior laparotomy. The perioperative and medium-term outcomes of patients who underwent open and laparoscopic mid-colon bypass were compared.

RESULTS

Of the 15 patients, seven patients underwent laparoscopic mid-colon bypass, and eight patients underwent the open procedure. The duration of surgery was less in the laparoscopic group, but the difference was not significant (440 vs. 510 min, P = 0.93). Intraoperative blood loss (median) and postoperative analgesic requirement (median days) were significantly lower in laparoscopic group (200 mL vs. 350 mL, P = 0.03 & 3 vs. 5, P = 0.02). There was no significant difference in the postoperative complications, ICU and hospital stay between the two groups. At a median (range) follow-up of 14 (7-42) months, all patients in the minimally invasive colon bypass group were euphagic to regular Indian diet. Two patients in the open group developed anastomotic stricture requiring endoscopic dilatation.

CONCLUSION

Minimally invasive mid-colon esophageal bypass is a feasible procedure for selected patients with corrosive esophageal stricture with favorable short-term and comparable medium-term outcomes.

Laparoscopic-assisted Esophageal Bypass for T4b Esophageal Tumor as a Bridge to Definitive Therapy

BACKGROUND/AIM

Esophagobronchial fistula is a common complication of advanced esophageal cancer, related to respiratory distress and mortality. Esophageal bypass has been successfully utilized for palliation, as bridging to definitive chemoradiotherapy. The aim of this study is to present an extremely difficult case of a mid-esophageal squamous cell carcinoma complicated with aerodigestive fistula that was treated using 3D laparoscopic-assisted esophageal bypass with curative intent.

CASE REPORT

A 49-year-old female patient presented with T4b esophageal-squamous cell carcinoma and esophagobronchial fistula. Laparoscopic-assisted V-shaped retrosternal esophageal bypass using a gastric conduit was started, which was converted to open surgery due to respiratory distress. The patient was able to undergo chemoradiotherapy treatment.

CONCLUSION

3D laparoscopic-assisted esophageal bypass can be a safe and feasible approach in patients with advanced mid-esophageal squamous cell carcinoma and esophagobroncial fistula. Additionally to the advantages of laparoscopic surgery, this operation permits oral feeding, and can be used with possible curative intent in patients with adequate response to chemoradiotherapy.

Outcomes of Endoscopic Dilation in Patients with Esophageal Anastomotic Strictures: Comparison Between Different Etiologies

BACKGROUND AND AIMS

This retrospective study was aimed at assessing the efficacy of endoscopic dilation for esophageal anastomotic strictures, and to compare response between caustic anastomotic strictures (CAS) and non-caustic anastomotic strictures (NCAS).

MATERIALS AND METHODS

Patients with anastomotic strictures (enrolled during January 1996-December 2015) were analyzed. Short- and long-term outcomes of dilation, in terms of clinical success, refractory, and recurrent strictures were compared between NCAS and CAS. Patients with refractory and recurrent strictures were managed with adjunctive therapy including intralesional steroids. Factors predicting refractoriness at start of dilation and reasons for more than ten lifetime dilations were also evaluated.

RESULTS

Of the 142 patients, 124 (mean age-44.02; males-74) underwent dilation. Clinical success was achieved in 113 (91.3%) patients requiring a median [Interquartile range (IQR)] of 4 (2-10) sessions. The number of dilations to achieve clinical success, refractory strictures, and recurrent strictures, and the use of adjunctive therapy were significantly higher for CAS than for NCAS. Intralesional steroid use decreased periodic dilation index (PDI) significantly in CAS. Caustic etiology and starting dilation diameter of < 10 mm were found to be predictors of refractoriness, with the former alone being an independent predictor of more than ten lifetime dilations. No patient had free perforation; however, five required revision surgery.

CONCLUSION

Patients with CAS fared worse than those with NCAS in terms of number of dilations, refractoriness, recurrence of strictures, and need of adjunctive therapy. Endoscopic dilation can successfully ameliorate dysphagia due to anastomotic strictures in a majority of patients.

Transhiatal esophagectomy with gastric pull-up, pyloric exclusion and Roux-en-Y gastroenterostomy for the management of esophageal caustic injury

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The authors present a surgical option for the management of esophageal caustic injury.

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The surgery consists of a transhiatal esophagectomy with gastric pull-up, pyloric exclusion and Roux-en-Y gastroenterostomy.

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The technique can be indicated when esophagectomy is necessary and there is pyloric stenosis associated.

Introduction

Ingestion of caustic materials can lead to digestive tube perforation involving the mouth, pharynx, esophagus and stomach (Vezakis et al., 2016 [1]). In this case report, the authors opted for gastric pull-up in a case of esophageal and pyloric stenosis secondary to caustic ingestion, and a Roux-en-Y gastroenterostomy in the lower portion of the gastric pull-up.

Presentation of case

A 37 years-old male presented complaints of dysphagia, which had started 28 days before admission after the ingestion of a caustic liquid. An esophagogastroduodenoscopy was performed, and showed a complete occlusion of the esophagus, without the possibility of performing an esophagus dilatation or placing a nasoenteric tube. The option was made for a transhiatal esophagectomy with gastric pull-up, pyloric exclusion and Roux-en-Y gastroenterostomy. The patient was later admitted with a stenosis of the esophageal anastomosis, which was resolved after performing endoscopic dilatation.

Discussion

The medical team opted to use the stomach for the reconstruction of the gastrointestinal transit due to less morbidity during manipulation of that organ, as well as safer anastomosis, when compared to the colon. In this case report, the esophagus and pylorus were generally compromised, however, with no apparent damage whatsoever in the stomach. Therefore, we opted to resect the esophagus and used the stomach to perform a gastric pull-up with the exclusion of the pylorus and reconstruction with a Roux-en-Y gastroenterostomy.

Conclusion

The proposed surgery is an option when dealing with similar cases, where endoscopic dilatation is not an option, and there is an associated pyloric stenosis.

Case Report: POST ESOPHAGECTOMY ESOPHAGEAL RECONSTRUCTION IN ESOPHAGEAL INJURY DUE TO CAUSTIC MATERIALS

The esophageal caustic injury is rare, but it requires precise and complex management. A variety of reconstruction techniques have been done, but despite the increasing volume, the incidence of complications is still relatively high. We reported the experience in our center in handling esophageal reconstruction in patients with caustic esophageal injury that caused oesophageal stricture between 2014-2017. This study used case series method with literature review. The results showed that between 2014-2017, there were 3 patients with caustic esophageal injury. All patients undergoing esophageal reconstruction surgery were included under conditions of malnutrition. Two were caused by HCl and the rest by NaOH. All patients underwent a resection of stricture segment of the esophagus, either using partial or total esophagectomy. Anastomosis leakage occurred in all cases, but improved with conservative treatment. The average length of hospitalization was 27 days. The intraoperative blood loss in patients ranged from 450-700 cc. In conclusion, proper preliminary management can provide approppiate preparation of the patients for definitive or reconstructive surgery, especially to avoid malnutrition. The ideal reconstruction still could not be established, and the rate of postoperative complications was still high. The length of patient hospitalization was also relatively long.

Minimally invasive substernal colonic transposition for corrosive strictures of the upper aerodigestive tract

Corrosive upper aerodigestive tract strictures are conventionally treated by open surgery. Surgical advancements permit these strictures to be addressed with minimal invasion. Corrosive strictures treated minimally invasively over a 2-year period (2014-2015) were audited. Colonic mobilization and retrosternal tunneling were performed laparoscopically. The left colic vessel-based isoperistaltic colonic/ileocolonic segment was transposed substernally into the neck, aided by miniceliotomy. Proximal anastomosis was side-to-side esophagocolic in all patients except those who underwent pharyngolaryngectomy or partial laryngectomy, where pharyngocolic/pyriform fossa-ileal anastomosis was employed. Distal anastomoses were colo-jejunal and colocolic/ileocolic in all the patients. Enteral nutrition and ambulation were commenced on the first postoperative day. Oral nutrition was commenced following a normal contrast swallow on the seventh postoperative day. Patients were followed up on an outpatient basis. Ten adults, aged between 19 and 40 years, were treated for acid-induced strictures. Esophagus and stomach were multiply strictured in all patients. Additionally, duodenum was involved in two patients while pharynx and larynx were strictured in three patients. Two patients underwent pharyngolaryngectomy. One patient underwent partial laryngectomy. The average operative time was 240 minutes (range: 210-300 minutes). The mean blood loss was 150 mL (range: 100-200 mL). One patient (10%) had cervical anastomotic leak on the ninth postoperative day, which was resolved spontaneously. One patient (10%) had proximal anastomotic stricture, requiring dilatation thrice. One patient (10%) had the transient left recurrent laryngeal nerve paresis, which was resolved spontaneously. All the patients are on oral solid diet. The followup ranged from 5 months to 2 years. Minimal access substernal colonic transposition is feasible and efficacious in restoring alimentary continuity in corrosive strictures.

Laparoscopic retrosternal gastric pull-up for fistulized mediastinal mass

We describe the case of a patient successfully reconstructed with laparoscopic retrosternal gastric pull-up after esophagectomy for unresectable posterior mediastinal inflammatory myofibroblastic tumor, eroding into the esophagus and compressing the airways. A partial esophagectomy with esophagostomy was performed for treatment of esophageal pleural fistula and empyema, while the airways were managed with the placement of an endobronchial stent. Gastrointestinal reconstruction was performed using a laparoscopic approach to create a retrosternal tunnel for gastric conduit pull-up and cervical anastomosis. The patient was discharged uneventfully after 6 d, and has done very well at home with normal diet.

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

INTRODUCTION

Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.

PURPOSE OF THE STUDY

The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.

METHODS

An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).

RESULTS

One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.

CONCLUSIONS

The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

A new technique for intra-abdominal arteries revascularization via extra-anatomic bypass from the brachiocephalic artery with a videoscopic retrosternal tunnel

Extra-anatomic revascularizations of intra-abdominal or lower limbs arteries, or both, are indicated (1) when the aorta is unsuitable for anatomic bypasses, (2) in patients unfit for aortic surgery, (3) for graft infections, and (4) for visceral debranching during hybrid treatment of a thoracoabdominal aneurysm. We describe a new extra-anatomic bypass from the brachiocephalic artery with video-guided retrosternal tunneling. We discuss the advantages and drawbacks of this technique.