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Mohan AT, Mahajan NN, Mardini S, Blackmon SH. Outcomes of Standardized Protocols in Supercharged Pedicled Jejunal Esophageal Reconstruction. Ann Thorac Surg 2023; 115:210-219. [PMID: 35718204 DOI: 10.1016/j.athoracsur.2022.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study evaluated clinical and patient-reported outcomes (PROs) of long-segment supercharged pedicled jejunal (SPJ) interposition after implementation of a dedicated multidisciplinary pathway and technical refinements. METHODS This study was a 6-year review of consecutive patients who underwent complex esophageal reconstruction with SPJ interposition. Clinical data were abstracted, and PRO data were collected prospectively by using the Upper Digestive Disease mobile application (UDD App). This standardized questionnaire comprised domains for mental and physical health, pain, dysphagia, reflux, hypoglycemia dumping, and gastrointestinal dumping symptoms. Operative refinements were comprehensively established by 2018. RESULTS A total of 19 patients were included in the study, 15 of whom had a history of esophageal malignant disease and neoadjuvant chemoradiation. Most patients (18; 95%) underwent delayed reconstruction after diversion. There was no 90-day mortality or flap loss. Most patients (18; 95%) achieved an enteral diet. Seven patients (37%) experienced early complications (<90 days) requiring procedural intervention. The incidence of any medical or surgical complication was similar in the earlier (2015-2017) and late (2018-2020) cohorts, but aspiration events, surgical site infections, anastomotic leak rates, and median hospital stay (reduced from 15 days [IQR, 10-21 days] to 9 days [IQR, 9-13 days]) improved in the contemporary cohort. PRO data were collected in 14 of 15 (93%) living patients. Severe symptoms in at least 1 domain were reported by most patients (11; 79%) and improved over time. CONCLUSIONS Dedicated care pathways allow standardization of complex procedures, and targeted modifications may optimize recovery and patient outcomes. This cohort of patients may report severe symptoms that require ongoing monitoring and intervention.
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Affiliation(s)
- Anita T Mohan
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nandita N Mahajan
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Samir Mardini
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shanda H Blackmon
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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2
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Supercharged Jejunal Interposition. Thorac Surg Clin 2022; 32:529-540. [PMID: 36266038 DOI: 10.1016/j.thorsurg.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Complex esophageal reconstruction represents a high risk and challenging procedure. A dedicated pathway with multispecialty teams can facilitate a systematic checklist approach to perioperative management and evaluation of long-term outcomes. Refinements in the operative technique for supercharged pedicled jejunum (SPJ) for long segment interposition in esophageal reconstruction are reviewed in this article. Medical and surgical complications among this complex niche group of patients are significant and require care in specialist centers with a focused team. Patient-reported outcomes (PROs) in long-segment SPJ interposition are recognized to provide additional monitoring of surgical outcomes and may help guide interventions for subsequent symptom control.
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Poelsler L, Koch O, Gaggl A, Presl J, Hutter J, Brandtner C, Emmanuel K. Microvascular myocutaneous and cutaneous free flap reconstruction in patients with terminal esophagostomy after complicated oncological esophagus resection. Eur Surg 2021. [DOI: 10.1007/s10353-021-00744-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Summary
Background
Persisting anastomotic leakage after oncological esophagectomy is a severe problem associated with high mortality and morbidity. Unfortunately, treatment options with promising results are scarce, especially when conventional operative and endoscopic methods have failed. Due to limitation of oral intake and the need for artificial nutrition, quality of life (QOL) is reduced. Microvascular myocutaneous and cutaneous free flap (MFF) reconstruction could be a promising alternative.
Methods
This retrospective case series presents 7 patients treated between March 2017 and November 2020 at our surgical department, with persisting postoperative anastomotic leakage without further feasible treatment options. All patients received anastomotic MFF reconstruction; used flaps and important intraoperative factors like microvascular anastomosis were evaluated. Complications and patient contentment was assessed.
Results
The included 7 male patients had median age of 65.15 years (range: 48–75). MFF function was adequate in 6/7 patients, one flap necrosis was encountered. Whereas 5 patients initially had good results, surgical revision was performed in 1 patient to ensure graft function. Postoperative complications appeared in 6/7 patients. Mean duration of inpatient care was 63 days (range: 24–156). At the time of evaluation, 1 patient has died of his malignant disease. No more additional nutrition was needed in 3/6 patients with adequate graft function. Most patients reported improved QOL after MFF.
Conclusion
MFF free flap can be an alternative treatment option for patients with terminal esophagostomy after complicated oncological esophagus resection without further treatment options. The renewed ability of oral food intake results in a significant improvement of QOL.
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Abstract
Salvage esophagectomy is an option for patients with recurrent or persistent esophageal cancer after definitive chemoradiation therapy or those who undergo active surveillance after induction chemoradiation therapy. Salvage resection is associated with higher rates of morbidity compared with planned esophagectomy but offers patients with locally advanced disease a chance at improved long-term survival. Salvage resection should be preferentially performed in a multidisciplinary setting by high-volume and experienced surgeons. Technical considerations, such as prior radiation dosage, radiation field, and choice of conduit, should be taken into account.
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Jiang S, Guo C, Zou B, Xie J, Xiong Z, Kuang Y, Tang J. Comparison of outcomes of pedicled jejunal and colonic conduit for esophageal reconstruction. BMC Surg 2020; 20:156. [PMID: 32677925 PMCID: PMC7364600 DOI: 10.1186/s12893-020-00810-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND At present, the gastric tube is the first choice for esophageal reconstruction after esophagectomy for various benign and malignant diseases. However, when the stomach is not available, a pedicled jejunum or colon is used to reconstruct the esophagus. The present study aimed to compare the postoperative outcomes and quality of life of patients receiving jejunal and colonic conduits. METHODS In the present retrospective study, the clinical data of 71 patients with esophageal carcinoma, who received jejunal reconstruction (jejunum group, n = 34) and colonic reconstruction (colon group, n = 37) from 2005 to 2015, were compared. RESULTS Compared with the colon group, the jejunum group had a lower incidence of postoperative anastomotic leakage, lesser duration of postoperative drainage, and faster recovery. Furthermore, the scores were better in the jejunum group than in the colon group, in terms of short-term overall quality of life, physical function and social relationships. Moreover, the jejunal group had a significantly lower frequency of pH < 4 simultaneous reflux time > 5 min (N45) and the longest reflux time (LT) at 24 weeks after surgery. CONCLUSION In esophageal cancer, when gastric tube construction is not feasible, a pedicled jejunum may be preferred over a colonic conduit due to lower incidence of acid reflux, anastomotic leakage and higher postoperative short-term quality of life, and rapid postoperative recovery.
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Affiliation(s)
- Sicong Jiang
- Department of Thoracic Surgery, Jiangxi Cancer Hospital of Nanchang University, No. 519 Beijing East Road, Nanchang, 330006, Jiangxi, China
| | - Changying Guo
- Department of Thoracic Surgery, Jiangxi Cancer Hospital of Nanchang University, No. 519 Beijing East Road, Nanchang, 330006, Jiangxi, China
| | - Bin Zou
- Department of Thoracic Surgery, Jiangxi Cancer Hospital of Nanchang University, No. 519 Beijing East Road, Nanchang, 330006, Jiangxi, China
| | - Jianguo Xie
- Department of Thoracic Surgery, Jiangxi Cancer Hospital of Nanchang University, No. 519 Beijing East Road, Nanchang, 330006, Jiangxi, China
| | - Zhihui Xiong
- Department of Obstetrics, Tongde Hospital of Zhejiang Provience, Zhejiang, 310012, Hangzhou, China
| | - Yukang Kuang
- Department of Thoracic Surgery, Jiangxi Cancer Hospital of Nanchang University, No. 519 Beijing East Road, Nanchang, 330006, Jiangxi, China.
| | - Jianjun Tang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.
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6
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Kozhevnikov MA, Skvortsov MB, Beloborodov VA. [Quality of life after reconstructive procedures for esophageal strictures]. Khirurgiia (Mosk) 2020:18-23. [PMID: 32352663 DOI: 10.17116/hirurgia202004118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study the long-term results of reconstructive procedures for esophageal strictures and evaluate quality life after each type of esophageal repair using own criteria. MATERIAL AND METHODS The study was conducted among patients who underwent esophageal repair with gastric transplant (172), colonic transplant (25), intestinal transplant (14) and repair of short cervical strictures (7). The age of patients ranged from 5 to 60 years. All patients underwent X-ray and endoscopic examination. Survey also included external respiration function and cardiac function, digestive function, measurement of height and weight, analysis of social aspects (work, study), female genital function. Five-score scale for quality of life assessment was developed. RESULTS Long-term results were studied in 218 patients for the period from 3 months to 31 years (2002-2017). Excellent and good results were obtained in 180 patients. The best results were obtained after repair of short cervical strictures (4.42 scores), good results - after esophageal repair with gastric (4.14 scores) and intestinal (4.07 scores) transplants. Colonic repair was followed by satisfactory outcome (3.16 scores). CONCLUSION Gastric and small bowel grafts are preferred for total esophageal repair due to better quality of life in long-term postoperative period.
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Affiliation(s)
- M A Kozhevnikov
- Irkutsk State Medical University of the Ministry of Health of Russia, Irkutsk, Russia
| | - M B Skvortsov
- Irkutsk State Medical University of the Ministry of Health of Russia, Irkutsk, Russia
| | - V A Beloborodov
- Irkutsk State Medical University of the Ministry of Health of Russia, Irkutsk, Russia
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Comparison of Outcomes of Total Esophageal Reconstruction With Supercharged Jejunal Flap, Colonic Interposition, and Gastric Pull-up. Ann Plast Surg 2019; 80:S274-S278. [PMID: 29634501 DOI: 10.1097/sap.0000000000001471] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Esophageal reconstruction following esophagectomy is a complex operation with significant morbidity. Gastric pull-up (GPU) has historically been the first-line operation followed by the colonic interposition (CI) graft, but recently, the use of a pedicled, supercharged jejunal flap (SJF) has reemerged as an alternative. However, comprehensive reports on outcomes of SJFs remain limited, with exceedingly few direct comparisons of outcomes. METHODS A retrospective chart review was completed for patients who underwent thoracic or total esophageal reconstruction between 2004 and 2014 at a single institution. A comparison of patient characteristics and outcomes was performed for 15 patients reconstructed with an SJF, 4 with CI, and 85 with GPU. RESULTS Ten patients in the SJF group and 3 in the CI group underwent prior GPU with complications resulting in esophageal discontinuity. The CI group had significantly longer intensive care and overall hospital stays than either other group. Forty percent (SJF), 100% (CI), and 56% (GPU) experienced at least 1 complication during their postoperative hospitalization, most frequently bowel obstruction after SJF, anastomotic leak (CI), and pulmonary complications and arrhythmias (GPU). Rates of anastomotic leakage were 13% (GPU), 75% (CI), and 13% (SJF). Reoperation was required in 27% following SJF compared with 75% following CI and 19% following GPU. There was 1 CI graft failure and no SJF failures. CONCLUSIONS The SJF is a reasonable first-line option for esophageal reconstruction, with comparable recovery, complication rate, and functional outcomes compared with the traditional GPU. When the stomach is unavailable, the SJF is superior to CI.
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The Supercharged Pedicled Jejunal Flap for Total Esophageal Reconstruction. Plast Reconstr Surg 2019; 144:1171-1180. [DOI: 10.1097/prs.0000000000006171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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9
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Abstract
Esophageal bleeding is one of the most common medical emergencies. It takes the 3rd place among all digestive hemorrhages, and accounts for 14–16 % among all gastrointestinal bleeding. The most common cause of esophageal hemorrhages is Mallory – Weiss esophageal tear (10–12 %), less often – varicose veins of the esophagus in portal hypertension syndrome (up to 4 %) and, in some cases, is esophagitis of various etiologies (up to 1.6 %). The problem of esophageal bleeding is characterized by high incidence, high mortality rate due to constant increase of portal hyper tension cases, recurrences, difficulties in diagnosis, anatomical and physiological features of the esophagus, low efficiency of the main methods of hemostasis. There are various surgical and conservative methods of hemostasis, which show a variety of opinions in the solution to the problem of stopping esophageal bleeding. In Mallory – Weiss syndrome, endoscopic hemostasis is considered to be the preferred method of treatment. Management of portal hypertension is the most difficult task; a wide range of operations is used from the minimally invasive operations to the liver transplantation, as well as endoscopic hemostasis (ligation, sclerotherapy). In esophageal bleeding, due to reflux esophagitis, mainly conservative treatment is suggested, operations are performed with recurrences or complications. Each kind of esophageal hemorrhage is considered as a separate problem.
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11
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Athanasiou A, Hennessy M, Spartalis E, Tan BHL, Griffiths EA. Conduit necrosis following esophagectomy: An up-to-date literature review. World J Gastrointest Surg 2019; 11:155-168. [PMID: 31057700 PMCID: PMC6478597 DOI: 10.4240/wjgs.v11.i3.155] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/22/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
Abstract
Esophageal conduit ischaemia and necrosis is an uncommon but devastating complication of esophagectomy and remains one of the most challenging issues in surgical practice. The incidence, time interval to develop symptoms, and clinical presentation are highly variable with no predictable pattern. Evidence comes from case reports and case series rather than randomized controlled trials. We describe the issues surrounding conduit necrosis affecting the stomach, jejunum and colon as an esophageal replacement and the advantages, disadvantages and challenges of each type of reconstruction. Diagnosis is challenging for the most experienced surgeon. Upper gastrointestinal endoscopy and computed tomography thorax with both oral and intravenous contrast is the gold standard. Management, either conservative or interventional is also a difficult decision. Management options include conservative treatment and more aggressive treatments such as stent insertion, surgical debridement and repair of the esophagus using jejunum, colon or a musculocutaneous flap. In spite of recent advances in surgical techniques, there is no reliable strategy to manage esophageal conduit necrosis. Our review covers the pathophysiology and clinical significance of esophageal necrosis while highlighting current techniques of prevention, diagnosis and treatment of this life-threatening condition.
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Affiliation(s)
- Antonios Athanasiou
- Department of Upper GI, Bariatric and Minimally Invasive Surgery, St. James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, United Kingdom
| | - Mairead Hennessy
- Department of Anaesthesia, University Hospital of Waterford, Waterford X91 ER8E, Ireland
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens, Medical School, Athens 11527, Greece
| | - Benjamin H L Tan
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
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12
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Zhong H, Li X, Liang H, Liu N, Liu Y, Zhang J, Wu X. [Tubular gastric elongation surgery for high esophageal-gastric anastomosis after resection of esophageal cancer: analysis of 5 cases]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:123-124. [PMID: 33177022 DOI: 10.3969/j.issn.1673-4254.2018.01.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To summarize our experience with tubular gastric elongation surgery for management of insufficient gastric length for high esophageal-gastric anastomosis following esophageal carcinoma resection. METHODS From September, 2015 to October 2016, 5 patients with esophageal cancer were treated in our department, including two with cervical esophageal cancer and 3 with thoracic esophageal cancer. The patients with cervical esophageal cancer underwent pharyngeal resection, total laryngectomy, esophageal varus extubation and gastric oropharyngeal anastomosis, and the patients with thoracic esophageal cancer underwent esophageal cancer resection with incisions on the left neck, the right chest and the median abdomen. During the surgery, the length of the stomach was found insufficient to allow routine oropharyngeal anastomosis, and tubular gastric elongation was conducted to extend the tubular stomach to enable successful completion of the surgery. RESULTS All the patients recovered smoothly after the surgery and were discharged after 2-3 weeks. CONCLUSIONS Tubular gastric elongation surgery can be a good choice for high esophageal-gastric anastomosis after resection of esophageal cancer in cases of insufficient tubular stomach length or high tension at the anastomosis.
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Affiliation(s)
- Hai Zhong
- Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - Xiang Li
- Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hongsen Liang
- Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - Nanbo Liu
- Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yufan Liu
- Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - Junhua Zhang
- Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - Xu Wu
- Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
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13
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Irino T, Tsekrekos A, Coppola A, Scandavini CM, Shetye A, Lundell L, Rouvelas I. Long-term functional outcomes after replacement of the esophagus with gastric, colonic, or jejunal conduits: a systematic literature review. Dis Esophagus 2017; 30:1-11. [PMID: 28881882 DOI: 10.1093/dote/dox083] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 05/30/2017] [Indexed: 12/11/2022]
Abstract
It is generally recognized that in patients with an intact stomach diagnosed with esophageal cancer, gastric tubulization and pull-up shall always be the preferred technique for reconstruction after an esophageal resection. However, in cases with extensive gastroesophageal junction (GEJ) cancer with aboral spread and after previous gastric surgery, alternative methods for reconstruction have to be pursued. Moreover, in benign cases as well as in those with early neoplastic lesions of the esophagus and the GEJ that are associated with long survival, it is basically unclear which conduit should be recommended. The aim of this study is to determine the long-term functional outcomes of different conduits used for esophageal replacement, based on a comprehensive literature review. Eligible were all clinical studies reporting outcomes after esophagectomy, which contained information on at least three years of follow-up after the operation in patients who were older than 18 years of age at the time of the operation. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic web-based search using MEDLINE, the Cochrane Library, and EMBASE databases was performed, reviewing medical literature published between January 2006 and December 2015. The scientific quality of the data was generally low, which allowed us to incorporate only 16 full text articles for the final analyses. After a gastric pull-up, the proportion of patients who suffered from dysphagia varied substantially but seemed to decrease over time with a mild dysphagia remaining during long-term follow-up. When reflux-related symptoms and complications were addressed, roughly two third of patients experienced mild to moderate reflux symptoms a long time after the resection. Following an isoperistaltic colonic graft, the functional long-term outcomes regarding swallowing difficulties were sparsely reported, while three studies reported reflux/regurgitation symptoms in the range of 5% to 16%, one of which reported the symptom severity as being mild. Only one report was available after the use of a long jejunal segment, which contained only six patients, who scored the severity of dysphagia and reflux as mild. Very few if any data were available on a structured assessment of dumping and disturbed bowel functions. Few high-quality data are available on the long-term functional outcomes after esophageal replacement irrespective of the use of a gastric tube, the right or left colon or a long jejunal segment. No firm conclusions regarding the advantages of one graft over the other can presently be drawn.
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Affiliation(s)
- T Irino
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital.,Division of Gastric Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - A Tsekrekos
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - A Coppola
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital.,Hepatobiliary Unit, Department of General Surgery, A. Gemelli Hospital, Università Cattolica del Sacro Cuore
| | - C M Scandavini
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital.,Emergency Surgery, Sant Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - A Shetye
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital
| | - L Lundell
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - I Rouvelas
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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14
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Abstract
Replacement of the native esophagus after esophagectomy is a problem that has challenged surgeons for over a century. Not only must the conduit be long enough to bridge the distance between the cervical esophagus and the abdomen, it must also have a reliable vascular supply and be sufficiently functional to allow for deglutition. The stomach, jejunum, and colon (right, left or transverse) have all been proposed as potential solutions. The stomach has gained favor for its length, reliable vascular supply and need for only a single anastomosis. However, there are times when the stomach is unavailable for use as a conduit. It is in these instances that an esophageal surgeon must have an alternative conduit in their armamentarium. In this paper, we will briefly discuss the technical aspects of jejunal and colonic interposition. We will review the recent literature with a focus on early and late outcomes. The advantages and disadvantages of both options will be reviewed.
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Affiliation(s)
- Ankur Bakshi
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - David J Sugarbaker
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Bryan M Burt
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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15
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Boshier PR, Huddy JR, Zaninotto G, Hanna GB. Dumping syndrome after esophagectomy: a systematic review of the literature. Dis Esophagus 2017; 30:1-9. [PMID: 27859950 DOI: 10.1111/dote.12488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Piers R Boshier
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - Jeremy R Huddy
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - Giovanni Zaninotto
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - George B Hanna
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
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16
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Jejunal Interposition after Failed Esophageal Atresia Repair. J Am Coll Surg 2016; 222:1001-8. [DOI: 10.1016/j.jamcollsurg.2015.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 11/21/2022]
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17
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Moore JM, Hooker CM, Molena D, Mungo B, Brock MV, Battafarano RJ, Yang SC. Complex Esophageal Reconstruction Procedures Have Acceptable Outcomes Compared With Routine Esophagectomy. Ann Thorac Surg 2016; 102:215-22. [PMID: 27217296 DOI: 10.1016/j.athoracsur.2016.02.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complex esophageal reconstruction (CER) is defined as restoring esophageal continuity in a previously operated field, using a nongastric conduit, or after esophageal diversion. This study compares the outcomes of CER with non-CER (NCER), which uses an undisturbed stomach for reconstruction. METHODS This single-institution retrospective cohort study compares 75 CERs with 75 NCERs from 1995 to 2014 that were matched for cancer versus benign disease. Distributions of demographic characteristics, comorbidities, and complications were compared between CER and NCER. Odds of mortality at 30 and 90 days were calculated with logistic regression. Overall survival was illustrated with Kaplan-Meier method and Cox proportional hazards regression. RESULTS Although patients were similar in age, sex, and preoperative comorbidities, more non-white patients underwent CER (p = 0.04). Most NCER patients had adenocarcinoma (44%) or Barrett's high-grade dysplasia (39%); most CER patients had other benign disease (44%) or squamous cell carcinoma (24%, p < 0.01). CER had statistically significantly higher rates of reoperation, pneumonia, infection, and gastrointestinal complications, and longer median length of stay than NCER. Odds of mortality for CER and NCER at 30 days (odds ratio [OR] 1.0, 95% CI: 0.1 to 16.3), 90 days (OR 2.6, 95% CI: 0.5 to 13.9) and overall (adjusted hazard ratio 1.56, 95% CI: 0.9 to 2.7) were not statistically significantly different. CONCLUSIONS Compared with NCER, CER patients had higher rates of return to the operating room, more postoperative infections and gastrointestinal complications, and longer length of stay. However, 30-day, 90-day, and overall survival were similar. CER should be offered to patients with acceptable risks and anticipated long-term survival.
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Affiliation(s)
- Jessica M Moore
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Craig M Hooker
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Daniela Molena
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Benedetto Mungo
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Malcolm V Brock
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Richard J Battafarano
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Stephen C Yang
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
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18
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Gust L, Ouattara M, Coosemans W, Nafteux P, Thomas PA, D'Journo XB. European perspective in Thoracic surgery-eso-coloplasty: when and how? J Thorac Dis 2016; 8:S387-98. [PMID: 27195136 DOI: 10.21037/jtd.2016.04.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Colon interposition has been used since the beginning of the 20(th) century as a substitute for esophageal replacement. Colon interposition is mainly chosen as a second line treatment when the stomach cannot be used, when the stomach has to be resected for oncological or technical reasons, or when the stomach is deliberately kept intact for benign diseases in young patients with long-life expectancy. During the surgery the vascularization of the colon must be carefully assessed, as well as the type of the graft (right or left colon), the length of the graft, the surgical approach and the route of the reconstruction. Early complications such as graft necrosis or anastomotic leaks, and late complications such as redundancy depend on the quality of the initial surgery. Despite a complex and time-consuming procedure requiring at least three or four digestive anastomoses, reported long term functional outcomes of colon interposition are good, with an acceptable operative risk. Thus, in very selected indications, colon interposition could be seen as a valuable alternative for esophageal replacement when stomach cannot be considered. This review aims at briefly defining "when" and "how" to perform a coloplasty through demonstrative videos.
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Affiliation(s)
- Lucile Gust
- 1 Department of Thoracic Surgery, North Hospital, Aix-Marseille University, Marseille, France ; 2 Department of Thoracic Surgery, University Hospital Campus Gasthuisberg KUZ Leuven, Leuven, Belgium
| | - Moussa Ouattara
- 1 Department of Thoracic Surgery, North Hospital, Aix-Marseille University, Marseille, France ; 2 Department of Thoracic Surgery, University Hospital Campus Gasthuisberg KUZ Leuven, Leuven, Belgium
| | - Willy Coosemans
- 1 Department of Thoracic Surgery, North Hospital, Aix-Marseille University, Marseille, France ; 2 Department of Thoracic Surgery, University Hospital Campus Gasthuisberg KUZ Leuven, Leuven, Belgium
| | - Philippe Nafteux
- 1 Department of Thoracic Surgery, North Hospital, Aix-Marseille University, Marseille, France ; 2 Department of Thoracic Surgery, University Hospital Campus Gasthuisberg KUZ Leuven, Leuven, Belgium
| | - Pascal Alexandre Thomas
- 1 Department of Thoracic Surgery, North Hospital, Aix-Marseille University, Marseille, France ; 2 Department of Thoracic Surgery, University Hospital Campus Gasthuisberg KUZ Leuven, Leuven, Belgium
| | - Xavier Benoit D'Journo
- 1 Department of Thoracic Surgery, North Hospital, Aix-Marseille University, Marseille, France ; 2 Department of Thoracic Surgery, University Hospital Campus Gasthuisberg KUZ Leuven, Leuven, Belgium
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Abstract
The management of conduit necrosis during or after esophagectomy requires the assembly of a multidisciplinary team to manage nutrition, sepsis, intravenous access, reconstruction, and recovery. Reconstruction is most often performed as a staged procedure. The initial surgery is likely to involve esophageal diversion onto the chest where possible, making an effort to preserve esophageal length. Optimization of patients before reconstruction enhances outcomes following reconstruction with either jejunum or colon after gastric conduit failure. Maintaining enteral access for feeding at all times is imperative. Management of patients should be performed at high-volume esophageal centers performing regular reconstructions.
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Affiliation(s)
- Karen J Dickinson
- Department of Thoracic Surgery, Mayo Clinic, MA-12-00-1, 200 First Street, Rochester, MN 55905, USA
| | - Shanda H Blackmon
- Department of Thoracic Surgery, Mayo Clinic, MA-12-00-1, 200 First Street, Rochester, MN 55905, USA.
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