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Diaz-Gutierrez I, Doyle JE, Majumder K, Wang Q, Rao MV, Bhargava A, Andrade RS. NONSUPERCHARGED RETROSTERNAL ROUX-EN-Y ESOPHAGOJEJUNOSTOMY FOR DISTAL ESOPHAGEAL RECONSTRUCTION. Ann Thorac Surg 2021; 114:1152-1158. [PMID: 34624265 DOI: 10.1016/j.athoracsur.2021.08.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/18/2021] [Accepted: 08/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Delayed distal esophageal reconstruction with nonsupercharged jejunum is an option when gastric conduit is not available. Our aim is to describe a single-center experience with distal esophageal reconstruction with retrosternal Roux-en-Y esophagojejunostomy (RYEJ) and compare perioperative outcomes with retrosternal gastric pull-up (GP). METHODS We conducted an IRB-exempt retrospective chart review of patients undergoing esophagostomy closure via retrosternal route at our institution from January 2009 to July 2019. We excluded patients with colonic conduits. We compared patients with RYEJ to a contemporary cohort of GP. The anatomic criteria for RYEJ were absence of a gastric conduit and an esophageal remnant that reached the sternomanubrial joint. We recorded patient characteristics, anastomotic leak and stricture rate, postoperative complications, hospital length of stay, 30-day readmission and 90-day mortality. We performed statistical analysis with Fisher's exact test and Wilcoxon rank-sum test with significance level at p=<0.05. RESULTS We had a total of 9 patients with RYEJ and 10 patients with GP. Previous esophageal adenocarcinoma was more common in the RYEJ group (n=5) compared to the GP group (n=0), p=0.01. Patient demographics and comorbidities were comparable between groups. We found no differences in all end points including operating time, estimated blood loss, anastomotic leak or stricture rate, Clavien-Dindo class III-IV complications, hospital length of stay or mortality. CONCLUSIONS Retrosternal Roux-en-Y esophagojejunostomy without microvascular augmentation is a safe alternative for esophagostomy closure in patients with adequate esophageal length when the stomach is not available. The nonsupercharged jejunum can safely reach the level of the sternomanubrial joint.
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Affiliation(s)
- Ilitch Diaz-Gutierrez
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
| | - Jesse E Doyle
- Department of Surgery, Ross University School of Medicine, Bridgetown, Barbados
| | - Kaustav Majumder
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Madhuri V Rao
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Amit Bhargava
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Rafael S Andrade
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Hung TM, Thao Tran TP, Kien NT, Phuong TT. Formation of the upper gastrointestinal tract for patients who underwent total esophago-gastrectomy due to caustic ingestion: Case series. Ann Med Surg (Lond) 2021; 70:102846. [PMID: 34540223 PMCID: PMC8435914 DOI: 10.1016/j.amsu.2021.102846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction and importance No case has been reported regarding esophago-gastrectomy due to caustic chemicals in the literature. Case presentation The first case was a 43-year-old woman with BMI 28.5. After one month of taking a weight loss drug called HERBAL, the patient experienced vomiting, and signs of progressive dysphagia, while being unable to eat any solid food. Endoscopy results revealed many scars causing the narrowing of the esophagus, starting from the upper third of the esophagus, 25cm from the dental arch. After 2 months, she lost 26kg (BMI 18.3). Endoscopic reexamination showed the esophagus's stricture, 25cm from the dental arch. X-ray also showed that the esophagus and stomach were completely narrow and atrophied. The second case was a 37-year-old woman who suffered from domestic violence and drunk about 50 ml of toilet detergents to commit suicide. After one month, the patient went through dysphagia and was unable to eat. Esophageal endoscopy showed that the esophagus was narrowed in the upper third part, 20cm from the dental arch, which led to the inaccessibility of the conventional insertion tube that required nasoscope instead. Clinical discussion The results demonstrated many ulcer scars, retraction inside the esophagus and stomach, abnormally small volume of stomach, narrowing cardia, and pyloric stenosis. In both cases, thoracoscopic surgery was performed for esophago-gastrectomy, and the upper gastrointestinal tract was subsequently reconstructed using the ileum-right colon. Conclusions The ileum-right colon segment is a part that can be used to reconstruct the upper gastrointestinal tract following esophago-gastrectomy. Esophagus and stomach were damaged due to caustic ingestion, causing the stricture, narrowing and tightening of both organs. In these cases, the upper gastrointestinal tract was reconstructed via esophagus-ileum anastomosis in the left-hand neck. Ileocolic parts can be used to reshape the digestive track following total esophago-gastrectomy.
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Ishii K, Tsubosa Y, Nakao J, Haneda R, Ishii Y, Booka E, Mayanagi S, Araki J, Yasunaga Y, Nakagawa M. Utility of the evaluation of blood flow of remnant esophagus with indocyanine green in esophagectomy with jejunum reconstruction: Case series. Ann Med Surg (Lond) 2021; 62:21-25. [PMID: 33489111 PMCID: PMC7808916 DOI: 10.1016/j.amsu.2020.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Pedicled jejunal flap can be utilized with various tips for esophageal reconstruction in patients with a history of gastrectomy or those who have undergone synchronous esophagogastrectomy. However, the rate of anastomosis leakage is high; therefore, we considered the evaluation of blood flow of the remnant esophagus with indocyanine green in setting the anastomosis site. METHODS Fifty patients who underwent radical esophagectomy with pedicled jejunal flap between January 2011 and June 2020 were identified. From June 2019, blood flow in the pedicled jejunum and remnant esophagus were evaluated to set the anastomosis site of the latter. Usually, the second and third jejunal vessels are transected, and if the jejunal flap cannot reach to the anastomosis point, we actively transect the marginal vessels to stretch the jejunal flap. Microvascular anastomosis between the jejunal branches and the internal thoracic vessels is usually made, and the anastomosis site is set at the well-stained part of the esophagus. RESULTS Overall, 39 patients underwent the procedure before June 2019 (Group A), and 11 patients underwent the procedure since June 2019 (Group B). No significant difference was found in the patients' background, type of preoperative therapy, presence or absence of ligation of marginal vessels and two-stage operation between the groups. Group A had 16 cases of anastomosis leakage; B had only 1 case (p < 0.05). There were no cases of pedicled jejunum graft necrosis. CONCLUSION Assessing remnant esophageal perfusion by indocyanine green imaging in pedicled jejunum reconstruction resulted in a lower anastomotic leak rate.
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Affiliation(s)
- Kenjiro Ishii
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Junichi Nakao
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Ryoma Haneda
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Hanndayama, Higashi-ku, Hamamatsushi, Shizuoka, 431-3192, Japan
| | - Yoshitaka Ishii
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Eisuke Booka
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Shuhei Mayanagi
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Jun Araki
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Yoshichika Yasunaga
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Masahiro Nakagawa
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
- Department of Plastic Reconstructive Surgery, Hamamatsu University School of Medicine, 1-20-1 Hanndayama, Higashi-ku, Hamamatsushi, Shizuoka, 431-3192, Japan
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Relationship between the Incidence of Postoperative Fistula or Dysphagia and Resection Style, Gastric Tube Formation, and Irradiation following Free Jejunal Flap Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2663. [PMID: 32309103 PMCID: PMC7159956 DOI: 10.1097/gox.0000000000002663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/06/2020] [Indexed: 11/25/2022]
Abstract
Background: The purpose of this study was to examine the relationship between the incidence of dysphagia or fistula formation in an anastomotic region and factors such as extent of resection, gastric tube formation, and irradiation among patients who underwent free jejunal flap transfer. Methods: We retrospectively examined 100 cases (88 men and 12 women; average age, 65.8 years; range, 46–88 years) in whom the evaluation of postoperative oral intake was possible after undergoing total pharyngo-laryngo-esophagectomy (TPLE) and free jejunal flap transfer. Chi-square test (with Fisher transformation, if necessary) was performed to analyze the relationship among resection styles (the resection margin extended to the oropharynx or to the cervical esophagus and gastric tube elevation), radiation therapy history, and incidence of dysphagia or fistula formation. Results: One hundred patients were analyzed, and complications such as postoperative fistula and dysphagia occurred in 8 (8.0%) and 20 patients (20.0%), respectively. However, no significant correlation was found between various resection factors and fistula formation or adverse events. At the reconstruction site, other complications such as postoperative lymphorrhea (7%), postoperative hematoma (4%), trachea necrosis (4%), cervical flap necrosis (1%), and thyroid necrosis (1%) occurred. These complications were managed by a cervical open wound and additional minor operation as needed. Conclusion: Thus, free jejunal transfer for TPLE is a good reconstruction technique with few complications and postoperative adverse events, regardless of the extent of resection and preoperative radiation therapy.
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Maier A, Lindenmann J, Hammer G, Swatek P, Fink-Neuboeck N, Fediuk M, Thurnher D, Smolle-Juettner FM. Interposition of Retrosternal Pedicled Jejunum After Hypopharyngolaryngo-Esophagogastrectomy. Ann Thorac Surg 2019; 108:e217-e219. [PMID: 31181201 DOI: 10.1016/j.athoracsur.2019.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/10/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
Abstract
Reconstruction of the upper gastrointestinal tract presents a surgical challenge after esophagogastrectomy, especially when it includes hypopharyngolaryngectomy. Reconstruction is generally undertaken with interposed colon as a substitute conduit, but it carries several risks. Alternative reconstruction of the foregut with pedicled retrosternal jejunum anastomosed at the level of the base of the tongue is described.
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Affiliation(s)
- Alfred Maier
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Joerg Lindenmann
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.
| | - Georg Hammer
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Graz, Graz, Austria
| | - Paul Swatek
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Nicole Fink-Neuboeck
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Melanie Fediuk
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Dietmar Thurnher
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Graz, Graz, Austria
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Nucci DJ, Monnet E. Tissue blood flow to a pedicled jejunal autograft in the dog: A pilot study. Vet Surg 2017. [PMID: 28627001 DOI: 10.1111/vsu.12676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the viability of a pedicled jejunal autograft after ligation of up to 3 jejunal arteries. STUDY DESIGN Prospective crossover study. ANIMALS Three adult dogs. METHODS Dogs were instrumented for measurement of hemodynamic parameters. Two segments of jejunum with 4 arcadial vessels were isolated from the abdomen in each dog. An individual ligature was secured around the 4th, 3rd, and 2nd jejunal artery. The 1st jejunal artery was maintained to serve as the sole blood supply to the pedicled segment of jejunum. Colored microspheres were used to evaluate the effect of each ligation on tissue blood flow. RESULTS Mean arterial blood pressure (P = .709) and heart rate (P = .905) did not differ between ligation groups. Tissue blood flow to a pedicled segment of jejunum was unchanged after ligation of 3 jejunal arteries. CONCLUSION Tissue blood flow of an isolated jejunal segment maintained in normal position remains unaffected, when supplied by a single jejunal artery, after ligation of up to 3 concurrent jejunal arteries.
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Affiliation(s)
- Daniel J Nucci
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
| | - Eric Monnet
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
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Shahbazzadegan B, Samadzadeh M, Feizi I, Shafaiee Y. Management of Esophageal Burns Caused by Caustic Ingestion: A Case Report. IRANIAN RED CRESCENT MEDICAL JOURNAL 2017; 18:e12805. [PMID: 28191325 PMCID: PMC5292110 DOI: 10.5812/ircmj.12805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 09/14/2014] [Accepted: 12/14/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Domestic and industrial swallowing of caustic substances can cause acute and chronic injuries. In the acute phase of care, focus is on the immediate control of tissue damage and perforation, and in the chronic phase, the focus is on the treatment of pharyngeal narrowing and impaired swallowing. CASE PRESENTATION The patients of this report were an 18-year-old man and a 20-year-old woman, who had esophageal burns after ingesting chemicals, and for solving their nutritional problems, such as difficulty in swallowing, they had underwent surgery. Patients had continued follow-up after surgery. CONCLUSIONS Treatment of esophageal burn lesions is by immediate and delayed removing of damage outcomes.
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Affiliation(s)
- Bita Shahbazzadegan
- Department of Health Education and Promotion, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- School of Medicine, Ardabil University of Medical Sciences, Ardabil, IR Iran
| | - Mehdi Samadzadeh
- School of Medicine, Ardabil University of Medical Sciences, Ardabil, IR Iran
| | - Iraj Feizi
- School of Medicine, Ardabil University of Medical Sciences, Ardabil, IR Iran
- Corresponding Author: Iraj Feizi, School of Medicine, Ardabil University of Medical Sciences, Ardabil, IR Iran. Tel: +98-9144521835, E-mail:
| | - Yousef Shafaiee
- School of Medicine, Ardabil University of Medical Sciences, Ardabil, IR Iran
- School of Medicine, Iran University of Medical Sciences, Tehran, IR Iran
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Watanabe M, Mine S, Nishida K, Kurogochi T, Okamura A, Imamura Y. Reconstruction after esophagectomy for esophageal cancer patients with a history of gastrectomy. Gen Thorac Cardiovasc Surg 2016; 64:457-63. [PMID: 27234222 DOI: 10.1007/s11748-016-0661-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 05/18/2016] [Indexed: 12/11/2022]
Abstract
Pedicled jejunal flap and colon graft interposition are choices for esophageal reconstruction in patients with a history of gastrectomy or those who have undergone synchronous esophagogastrectomy. However, the optimal conduit in this situation is still being debated. We reviewed the literature concerning esophageal reconstruction using a conduit other than the stomach. Approximately 10 % of esophagectomized patients undergo esophageal reconstruction using pedicled jejunum or colon interposition in Japan. The jejunal graft and colon graft are selected evenly, although the percentage of jejunal graft use is gradually increasing. Microvascular supercharge was performed in most of the reports of pedicled jejunal graft reconstruction, whereas vascular enhancement was not popularly used in the reports of colon graft interposition. Although the incidences of graft loss and anastomotic leakage were comparable between grafts, mortality rates seem to be higher in patients who undergo colon graft reconstruction than in those who undergo reconstruction with a jejunal graft. Prospective comparisons of short-term outcomes as well as long-term quality of life are needed to identify the best method of reconstruction.
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Affiliation(s)
- Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Shinji Mine
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Koujiro Nishida
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takanori Kurogochi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Hackl C, Popp FC, Ehehalt K, Dendl LM, Benseler V, Renner P, Loss M, Dolderer J, Prantl L, Kühnel T, Schlitt HJ, Dahlke MH. Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report. BMC Surg 2014; 14:78. [PMID: 25319372 PMCID: PMC4202252 DOI: 10.1186/1471-2482-14-78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 10/08/2014] [Indexed: 12/18/2022] Open
Abstract
Background Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system. Case presentation A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion. Conclusions This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Marc H Dahlke
- Department of Surgery, University Medical Center Regensburg, Regensburg 93042, Germany.
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Feasibility of esophageal reconstruction using a pedicled jejunum with intrathoracic esophagojejunostomy in the upper mediastinum for esophageal cancer. Gen Thorac Cardiovasc Surg 2014; 62:627-34. [PMID: 24917205 DOI: 10.1007/s11748-014-0435-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 05/29/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE An alternative conduit is needed when the gastric tube cannot be used as an esophageal substitute for reconstruction after esophagectomy. We adopted pedicle jejunal reconstruction with intrathoracic anastomosis in the upper mediastinum under such circumstances. The aim of this study was to evaluate the feasibility of this technique. METHODS Two hundred and ten patients with esophageal cancer underwent esophagectomy and reconstruction from 1998 to 2013. Among them, 6 patients underwent colon interposition (colon group) and 13 underwent jejunum reconstruction (jejunum group) including 8 thoracoscopic anastomosis. The operative results of both groups were compared with those of 191 gastric tube reconstructions (stomach group). RESULTS The operative times in the colon and jejunum groups were significantly longer than that in the stomach group (P = 0.001 and P = 0.018, respectively). The colon group showed more operative blood loss and more frequent anastomotic leakage and ischemic stenosis of the conduit than did the stomach group (1605 vs. 530 g, P = 0.007; 50 vs. 12.6 %, P = 0.035; 16.7 vs. 0 %, P = 0.03, respectively). There was no anastomotic leakage, conduit necrosis and mortality in the jejunum group. Ischemic stenosis of the conduit occurred more frequently in jejunum group than in the stomach group (23.1 vs. 0 %, P < 0.001). However, the stenosis could be managed safely with endoscopic treatment. Patient survival in the colon and jejunum groups was consistent with that in the stomach group. CONCLUSIONS Pedicle jejunal reconstruction with intrathoracic anastomosis can be performed safely under thoracotomy or thoracoscopic surgery when stomach cannot be used as an esophageal substitute after esophagectomy.
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You B, Hou SC, Li H, Hu B. Esophagogastric reconstruction using remnant stomach with a single vessel pedicel: Technique and outcomes. Thorac Cancer 2014; 5:192-6. [PMID: 26767000 DOI: 10.1111/1759-7714.12054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 05/12/2013] [Indexed: 11/28/2022] Open
Abstract
Esophageal cancer with a history of distal gastrectomy is a clinical problem. To our knowledge there have been no reports of remnant stomach fed from the left gastroepiploic artery being used in esophageal reconstruction. We, herein, report four cases of esophagogastric reconstruction using remnant stomach with a single left gastroepiploic vascular pedicel. It is more functional to use the remnant stomach than other replacements. Meanwhile, the gastric conduit fed from the left gastroepiploic artery showed sufficient vascularity and stable gastroesophageal anastomosis. The technique and outcomes in follow-up have proven feasible and save time.
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Affiliation(s)
- Bin You
- Department of Thoracic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine Beijing, China
| | - Sheng-Cai Hou
- Department of Thoracic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine Beijing, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine Beijing, China
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Srinivasa D, Wray CJ. Total gastrectomy with isoperistaltic jejunal interposition flap for symptomatic management of gastric polyposis from familial adenomatous polyposis. J Gastrointest Oncol 2014; 5:E18-21. [PMID: 24490047 DOI: 10.3978/j.issn.2078-6891.2013.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/12/2013] [Indexed: 11/14/2022] Open
Abstract
Patients with familial adenomatous polyposis (FAP) oftentimes have extracolonic polyps. The patient discussed in this case report had innumerable gastric polyps which were significantly affecting his ability to tolerate oral intake and his overall nutrition. Medical management was not sufficiently controlling his symptoms; therefore we proceeded with surgical intervention. We discuss the use of a total gastrectomy with an Isoperistaltic jejunal interposition flap for the symptomatic management of gastric polyposis. We describe the technique used and benefits to this specific procedure when it comes to long term outcome, complications, and monitoring.
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Affiliation(s)
- Dhivya Srinivasa
- Department of Surgery, University of Texas-Houston, Houston, USA
| | - Curtis J Wray
- Department of Surgery, University of Texas-Houston, Houston, USA
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13
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Iwata N, Koike M, Kamei Y, Tanaka C, Ohashi N, Nakayama G, Nomoto S, Fujii T, Sugimoto H, Fujiwara M, Kodera Y. Antethoracic pedicled jejunum reconstruction with the supercharge technique for esophageal cancer. World J Surg 2013; 36:2622-9. [PMID: 22868971 DOI: 10.1007/s00268-012-1736-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastric tube is the first choice as an esophageal substitute for reconstruction after esophagectomy. Colon or jejunum is selected for patients in whom stomach cannot be used. Colon interposition is reported to have a high incidence of anastomotic leakage and mortality. For safer surgical treatment, the authors adopted supercharged pedicle jejunum reconstruction as the operation of choice in patients with esophageal cancer who had no stomach to use as an esophageal substitute. The aim of this study was to review our experience with this technique. METHODS From 2003 to 2009, esophagectomy and antethoracic pedicled jejunum reconstruction with the supercharge technique was performed in 27 patients with esophageal cancer at the Department of Gastroenterological Surgery (Surgery II), Nagoya University Hospital. Medical records of these 27 patients were retrospectively reviewed to determine demographic data, diagnosis, functional results, and perioperative course. RESULTS Median operating time, blood loss, hospital stay, and duration of enteral feeding were 636 min (range 454-856 min), 580 ml (range 208-1959 ml), 27 days (range 16-72 days), and 80 days (range 26-1740 days), respectively. There were no in-hospital deaths. Anastomotic leakage occurred in two patients and was successfully managed conservatively. In 2 of 27 patients, the pedicled jejunum was of insufficient length, and additional procedures were needed to complete the anastomosis. CONCLUSIONS Although antethoracic pedicled jejunum reconstruction with the supercharge technique is technically demanding, it is a reliable technique and contributes to successful reconstruction after esophagectomy for patients in whom stomach is not available for reconstruction.
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Affiliation(s)
- Naoki Iwata
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan.
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Yasuda T, Shiozaki H. Esophageal reconstruction using a pedicled jejunum with microvascular augmentation. Ann Thorac Cardiovasc Surg 2011; 17:103-9. [PMID: 21597405 DOI: 10.5761/atcs.ra.10.01648] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 01/17/2011] [Indexed: 11/16/2022] Open
Abstract
The pedicled colon segment is widely accepted as a substitute to the gastric tube in esophageal reconstruction of cases where the stomach is not available. The usefulness of reconstruction with a pedicled jejunum has also been reported in recent years. In order to make a long jejunal graft, at least the second and third jejunal vessels have to be severed. However, this leads to a decrease of circulation in the pedicled jejunum. This poor circulation was primarily responsible for the high rates of gangrene and mortality (22.2% and 46.5%, respectively) in the beginnings of jejunal reconstruction. Advances in microsurgery have now enabled surgeons to overcome these disadvantages, as a result, both the rates of gangrene and mortality have decreased to almost zero since the addition of microvascular anastomosis with the jejunal vessels and the internal thoracic vessels. At present, the reconstruction using a pedicled jejunum is a safe operation that provides such advantages as a low incidence of intrinsic disease, more active transport of food, and a lower rate of regurgitation by peristalsis, compared with the reconstruction using the pedicled colon. The disadvantage of the procedure is the relatively high rate of anastomotic leakage (11.1% to 19.2%). Improvements in the surgical procedures to overcome this disadvantage are, therefore, needed before it can be recommended without any reservations.
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Affiliation(s)
- Takushi Yasuda
- Department of Surgery, School of Medicine, Kinki University, Osaka-Sayama, Japan.
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15
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The best salvage operation method after total necrosis of a free jejunal graft? Transfer of a second free jejunal graft. J Plast Reconstr Aesthet Surg 2011; 64:1030-4. [DOI: 10.1016/j.bjps.2011.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 01/29/2011] [Accepted: 02/04/2011] [Indexed: 11/20/2022]
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Oki M, Asato H, Suzuki Y, Umekawa K, Takushima A, Okazaki M, Harii K. Salvage reconstruction of the oesophagus: a retrospective study of 15 cases. J Plast Reconstr Aesthet Surg 2009; 63:589-97. [PMID: 19303831 DOI: 10.1016/j.bjps.2009.01.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 12/15/2008] [Accepted: 01/11/2009] [Indexed: 01/30/2023]
Abstract
Salvage reconstruction of the oesophagus is still considered a challenging procedure for all head and neck surgeons. The risk of postoperative infection and delayed wound healing is high because of thick scar formation and persistent inflammation. Furthermore, recipient vessels for free tissue transfer or vascular supercharge are not always available. Alimentary tract reconstruction with skin or musculocutaneous flap may be necessary, but this method is susceptible to fistula formation.[Nakatsuka T, Harii K, Asato H, et al. Comparative evaluation in pharyngo-oesophageal reconstruction: radial forearm flap compared with jejunal flap. A 10-year experience. Scand J Plast Reconstr Surg Hand Surg 1998; 32: 307-10] In the past 10 years, we have experienced 15 cases of salvage reconstruction of the oesophagus after prior cancer treatment or aorto-oesophageal fistula; the cervical oesophagus was reconstructed in five cases and the cervico-thoracic oesophagus in 10. In four cases of cervical oesophagus and six of cervico-thoracic oesophagus we performed free jejunal transfer including two long segment transfers with double vascular pedicle. The cervico-thoracic oesophagus was also reconstructed with pedicled alimentary tract transfer (colon interposition or jejunal pull-up) with vascular supercharge in four cases. In one case, cervical oesophageal defect was reconstructed with a latissimus dorsi musculocutaneous flap. We also used a deltopectoral flap to cover the skin defect in three cases. In three cases, a second salvage operation was necessary because of flap necrosis that was caused by unreliable recipient vessels resulting from scar formation and persistent inflammation. Successful restoration of the oesophagus and oral alimentation was achieved in 11 cases. From this study, we concluded that free jejunal transfer is a useful procedure for salvage reconstruction of the oesophagus, particularly for cervical oesophagus or short oesophageal defects. Nonetheless, surgeons should know the indications and limitations of this procedure thoroughly and always be ready to choose other reconstructive options if necessary.
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Affiliation(s)
- Masanao Oki
- Department of plastic and reconstructive surgery, Dokkyo Medical University, 880 Kitakobayashi Mibu-machi, Shimotsuga-gun, Tochigi 321-0293, Japan.
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Gabor S, Renner H, Matzi V, Ratzenhofer B, Lindenmann J, Sankin O, Pinter H, Maier A, Smolle J, Smolle-Jüttner FM. Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction. Br J Nutr 2007; 93:509-13. [PMID: 15946413 DOI: 10.1079/bjn20041383] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
After resective and reconstructive surgery in the gastrointestinal tract, oral feeding is traditionally avoided in order to minimize strain to the anastomoses and to reduce the inherent risks of the postoperatively impaired gastrointestinal motility. However, studies have given evidence that the small bowel recovers its ability to absorb nutrients almost immediately following surgery, even in the absence of peristalsis, and that early enteral feeding would preserve both the integrity of gut mucosa and its immunological function. The aim of this study was to investigate the impact of early enteral feeding on the postoperative course following oesophagectomy or oesophagogastrectomy, and reconstruction. Between May 1999 and November 2002, forty-four consecutive patients (thirty-eight males and six females; mean age 62, range 30–82) with oesophageal carcinoma (stages I–III), who had undergone radical resection and reconstruction, entered this study (early enteral feeding group; EEF). A historical group of forty-four patients (thirty-seven males and seven females; mean age 64, range 41–79; stages I–III) resected between January 1997 and March 1999 served as control (parenteral feeding group; PF). The duration of both postoperative stay in the Intensive Care Unit (ICU) and the total hospital stay, perioperative complications and the overall mortality were compared. Early enteral feeding was administered over the jejunal line of a Dobhoff tube. It started 6 h postoperatively at a rate of 10 ml/h for 6 h with stepwise increase until total enteral nutrition was achieved on day 6. In the controls oral enteral feeding was begun on day 7. If compared to the PF group, EEF patients recovered faster considering the duration of both stay in the ICU and in the hospital. There was a significant difference in the interval until the first bowel movements. No difference in overall 30 d mortality was identified. A poor nutritional status was a significant prognostic factor for an increased mortality. Early enteral feeding significantly reduces the duration of ICU treatment and total hospital stay in patients who undergo oesophagectomy or oesophagogastrectomy for oesophageal carcinoma. The mortality rate is not affected.
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Affiliation(s)
- S Gabor
- Department of Surgery, Division of Thoracic and Hyperbaric Surgery, University of Medicine Graz, A-8036 Graz, Austria.
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Okazaki M, Asato H, Takushima A, Nakatsuka T, Ueda K, Harii K. Secondary reconstruction of failed esophageal reconstruction. Ann Plast Surg 2005; 54:530-7. [PMID: 15838216 DOI: 10.1097/01.sap.0000155280.50178.fc] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Between June 1992 and November 2002, 17 patients underwent secondary reconstruction of circumferential esophageal defects due to the failure of immediate reconstruction following ablation of thoracic esophageal cancer. Salvage reconstruction was achieved using free jejunal transfer in 13 patients (including long segment with double vascular pedicle in 2 cases), skin and/or musculocutaneous flap in 2 cases, and jejunal pull-up in 2 cases. In 5 patients, the second salvage surgery was required because of the failed first salvage. However, successful restoration of the esophagus and peroral alimentation was finally achieved in 16 of 17 patients, except 1 patient with several salvage operations using skin and musculocutaneous flap because the gut was unusable. We concluded that the preferred first choice for salvage restoration is free jejunal transfer. If the length of the esophageal defect is extensive, colonic interposition or jejunal pedicle with microvascular anastomosis for supercharging is the next option. If these procedures cannot be used, the transfer of a long jejunal segment with double vascular pedicles is recommended. Reconstruction using skin and/or musculocutaneous flap is the final option. As primary wound closure is often difficult in secondary reconstruction of the esophagus, a pectoralis major musculocutaneous flap is reliable to cover the reconstructed esophagus because skin flaps located in the neck region may be damaged by neck dissection or irradiation, and coverage of the anastomosis with muscle between the digestive tracts is effective to prevent leakage.
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Affiliation(s)
- Mutsumi Okazaki
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo 113-8655, Japan.
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