Free jejunal transfer for patients with a history of esophagectomy and gastric pull-up

Preservation of remnant esophagus during total pharyngolaryngectomy in a patient with previous subtotal esophagectomy: a case report

Background

With the improved survival rate of patients with esophageal cancer, secondary cancers, including pharyngolaryngeal cancer, have become a problem. Phanryngolaryngeal cancer surgery often requires esophagogastric anastomosis resection in patients with a previous history of subtotal esophagectomy. Owing to adhesions, especially surrounding the esophagogastric anastomosis, caused by the initial surgery, the second surgery might cause postoperative complications.

Case presentation

A 65-year-old man was diagnosed with early stage esophageal squamous cell carcinoma and underwent endoscopic mucosal dissection. However, the histopathological depth of the tumor was pT1b, and additional treatment was required. After administration of the neoadjuvant chemotherapy, he underwent thoracoscopic esophagectomy and retrosternum reconstruction via a gastric tube (pT1N3M0 stage III). Eight months after the first surgery, tumor recurrences were observed at the anastomosis and left cervical lymph node. Definitive chemoradiotherapy was performed for the recurrences, and complete response was achieved. Seven months after chemoradiotherapy, he was diagnosed with hypopharyngeal squamous cell carcinoma in the right piriform fossa (cT2N2bM0 stage IVA), and salvage surgery was chosen as treatment. The surgical findings revealed strong adhesion around the remnant esophagus, which was difficult to dissect from surrounding tissue and was associated with a risk of breaking of the anastomosis. However, indocyanine green fluorescence imaging findings indicated sufficient blood flow to preserve the remnant esophagus, including the anastomosis, even after the interruption of blood flow from the proximal side of the esophagus by total pharyngolaryngectomy. Finally, approximately 4 cm of the remnant esophagus was preserved, and the free jejunum reconstruction with cervical vascular anastomosis was performed. Moreover, the patient was discharged without complications on postoperative day 38. After 10 months of the second surgery, a metastatic lymph node was observed in the right neck. Immune checkpoint inhibitors and chemotherapy were administered, and the patient is alive and under treatment 1.5 years after the second surgery.

Conclusions

Blood supply to the remnant cervical esophagus was thought to be from the gastric conduit over the anastomosis and surrounding capillaries. Thus, the preservation of the remnant esophagus can be considered in total pharyngolaryngectomy even after < 2 years of esophagectomy by blood flow evaluation using indocyanine green fluorescence.

Preservation of remnant esophagus during total pharyngolaryngectomy in a patient with previous subtotal esophagectomy: a case report

BACKGROUND

With the improved survival rate of patients with esophageal cancer, secondary cancers, including pharyngolaryngeal cancer, have become a problem. Phanryngolaryngeal cancer surgery often requires esophagogastric anastomosis resection in patients with a previous history of subtotal esophagectomy. Owing to adhesions, especially surrounding the esophagogastric anastomosis, caused by the initial surgery, the second surgery might cause postoperative complications.

CASE PRESENTATION

A 65-year-old man was diagnosed with early stage esophageal squamous cell carcinoma and underwent endoscopic mucosal dissection. However, the histopathological depth of the tumor was pT1b, and additional treatment was required. After administration of the neoadjuvant chemotherapy, he underwent thoracoscopic esophagectomy and retrosternum reconstruction via a gastric tube (pT1N3M0 stage III). Eight months after the first surgery, tumor recurrences were observed at the anastomosis and left cervical lymph node. Definitive chemoradiotherapy was performed for the recurrences, and complete response was achieved. Seven months after chemoradiotherapy, he was diagnosed with hypopharyngeal squamous cell carcinoma in the right piriform fossa (cT2N2bM0 stage IVA), and salvage surgery was chosen as treatment. The surgical findings revealed strong adhesion around the remnant esophagus, which was difficult to dissect from surrounding tissue and was associated with a risk of breaking of the anastomosis. However, indocyanine green fluorescence imaging findings indicated sufficient blood flow to preserve the remnant esophagus, including the anastomosis, even after the interruption of blood flow from the proximal side of the esophagus by total pharyngolaryngectomy. Finally, approximately 4 cm of the remnant esophagus was preserved, and the free jejunum reconstruction with cervical vascular anastomosis was performed. Moreover, the patient was discharged without complications on postoperative day 38. After 10 months of the second surgery, a metastatic lymph node was observed in the right neck. Immune checkpoint inhibitors and chemotherapy were administered, and the patient is alive and under treatment 1.5 years after the second surgery.

CONCLUSIONS

Blood supply to the remnant cervical esophagus was thought to be from the gastric conduit over the anastomosis and surrounding capillaries. Thus, the preservation of the remnant esophagus can be considered in total pharyngolaryngectomy even after < 2 years of esophagectomy by blood flow evaluation using indocyanine green fluorescence.

Managing esophagocutaneous fistula after secondary gastric pull-up: A case report

BACKGROUND

Gastric pull-up (GPU) procedures may be complicated by leaks, fistulas, or stenoses. These complications are usually managed by endoscopy, but in extreme cases multidisciplinary management including reoperation may be necessary. Here, we report a combined endoscopic and surgical approach to manage a failed secondary GPU procedure.

CASE SUMMARY

A 70-year-old male with treatment-refractory cervical esophagocutaneous fistula with stenotic remnant esophagus after secondary GPU was transferred to our tertiary hospital. Local and systemic infection originating from the infected fistula was resolved by endoscopy. Hence, elective esophageal reconstruction with free-jejunal interposition was performed with no subsequent adverse events.

CONCLUSION

A multidisciplinary approach involving interventional endoscopists and surgeons successfully managed severe complications arising from a cervical esophago-cutaneous fistula after GPU. Endoscopic treatment may have lowered the perioperative risk to promote primary wound healing after free-jejunal graft interposition.

The ideal flap for reconstruction of circumferential pharyngeal defects: A systematic review and meta-analysis of surgical outcomes

BACKGROUND

There is a lack of consensus regarding the superiority of the common free flaps for the reconstruction of circumferential pharyngeal defects.

METHODS

A systematic literature search was conducted to identify studies reporting the complications of circumferential pharyngeal reconstruction between 2005 and 2020. Anterolateral thigh free flaps (ALTFF), jejunal free flaps (JFF), and radial forearm free flaps (RFFF) were compared. Various complications were compared by meta-analysis. Primary endpoints were fistula and stricture rates.

RESULTS

Forty studies were included (2230 patients). Stricture rate was similarly low with tubed ALTFF (13.3%, n = 36/270) and JFF (13.2%, n = 176/1334). Fistula rate was the lowest with JFF (9.2%, n = 58/634). ALTFF was associated with the lowest rates of partial and complete flap failure (3.8%, n = 6/157, and 2.8%, n = 5/178), infection (2.8%, n = 3/106), donor site morbidity (3.9%, n = 5/130), and mortality (0%, n = 0/101) within 30 days. A meta-analysis demonstrated that there was no statistically significant difference in stricture and fistula rates between ALTFF and JFF. Moreover, JFF was associated with a significantly lower fistula rate than that of RFFF (p < 0.001). ALTFF was associated with a significantly lower infection rate than that of JFF (p = 0.013).

CONCLUSIONS

The data suggest the use of ALTFF for circumferential pharyngeal defects. In the absence of randomized, prospective data, the authors hope the results presented can be used as an evidence-based reference.

Treatment protocol for secondary esophageal reconstruction using 'supercharged' colon interposition flaps

Locoregional esophageal cancer is currently treated with induction chemoradiotherapy, followed by esophagectomy with reconstruction, using a gastric conduit. In cases of conduit failure, patients are temporized with a cervical esophagostomy and enteral nutrition until gastrointestinal continuity can be established. At our institution, we favor reconstruction, using a colon interposition with a 'supercharged' accessory vascular pedicle. Consequently, we sought to examine our technique and outcomes for esophageal reconstruction, using this approach. We performed a retrospective review of all patients who underwent esophagectomy at our center between 2008 and 2018. We identified those patients who had a failed gastric conduit and underwent secondary reconstruction. Patient demographics, perioperative details, and clinical outcomes were analyzed after our clinical care pathway was used to manage and prepare patients for a second major reconstructive surgery. Three hundred and eighty eight patients underwent esophagectomy and reconstruction with a gastric conduit. Seven patients (1.8%) suffered gastric conduit loss and underwent a secondary reconstruction using a colon interposition with a 'supercharged' vascular pedicle. Mean age was 70.1 (±7.3) years, and six patients were male. The transverse colon was used in four cases (57.1%), left colon in two cases (28.6%), and right colon in one case (14.3%). There were no deaths or loss of the colon interposition at follow-up. Three patients (42.9%) developed an anastomotic leak, which resolved with conservative management. All patients had resumption of oral intake within 30 days. Utilizing a 'supercharging' technique for colon interposition may improve the perfusion to the organ and may decrease morbidity. Secondary reconstruction should occur when the patient's oncologic, physiologic, and psychosocial condition is optimized. Our outcomes and preoperative strategies may provide guidance for those centers treating this complicated patient population.

Ivor-Lewis esophagectomy for patients with squamous cell carcinoma of the thoracic esophagus with a history of total pharyngolaryngectomy

BACKGROUND

Synchronous or metachronous esophageal, and head and neck cancers are often observed, and we occasionally encounter esophageal cancer cases with a past history of total pharyngolaryngectomy (TPL) for head and neck cancers. Total esophagectomy after TPL may impair blood supply to the trachea and may cause tracheal necrosis. Meanwhile, Ivor-Lewis esophagectomy can prevent the above-mentioned risks, but there is a concern about an anastomosis with the remnant upper esophagus that lost blood supply after two surgical procedures. The surgical outcomes of Ivor-Lewis esophagectomy after TPL remain unclear. Therefore, we investigated the surgical outcomes.

METHODS

This study included patients who underwent Ivor-Lewis esophagectomy for esophageal cancer with a history of TPL at our institution between 2005 and 2017. We retrospectively investigated the patients' background characteristics and short-term surgical outcomes.

RESULTS

Twelve consecutive patients (8 men and 4 women) were included in this study. The median period between TPL and esophagectomy was 32 months (range 2-185 months). All patients underwent esophagectomy via right open thoracotomy and reconstruction using a gastric tube with intrathoracic anastomosis. Although the esophagogastric anastomosis was made on the remnant upper esophagus, which had already lost blood supply from the inferior thyroid artery, there was no case of anastomotic leakage or esophageal necrosis, and hospital mortality was not observed.

CONCLUSION

Ivor-Lewis esophagectomy for patients with a history of TPL is a safe procedure, which can prevent severe complications including anastomotic leakage or tracheal necrosis.

Back-up procedures following complicated gastric pull-up procedure for esophageal reconstruction: Salvage with intestinal flaps

BACKGROUND

Gastric pull-up (GPU) is the most common procedure for restoring the continuity of the alimentary tract. Yet, complications because of anastomotic problems are reported to be as high as 25% after this procedure. Managing the neck with anastomotic leakage or stricture following failed GPU and/or radiotherapy is formidable. We report our method, basic algorithm and results with the complicated GPU procedure management with intestinal transfers .

PATIENTS AND METHODS

Nineteen cases referred to our department with complicated esophageal reconstruction following GPU procedure were included in this report. Of the19 patients, 18 had undergone GPU procedure for reconstruction after cancer resection (mean age 55 years) and one for idiopathic esophagitis (mean age 45years). Fifteen patients presented with severe stricture formation and 4 patients with leakage from the anastomotic site. Average time between the GPU and salvage procedures was 7.3 months for patients with stricture formation and 15.5 days for patients with leakage. Pedicled colon interposition (n = 8) was used when the upper end of the gastric tube was located below the sternoclavicular junction. A free jejunal flap (n = 11) was utilized when defects were located at the neck (above the sternoclavicular junction).

RESULTS

In all patients salvage procedures with intestinal flap transfer were successful with complete flap survival. Post-operative period was uneventful except of two patients with pedicled colon interposition who presented minor leakage post-operatively (10.5%). This was treated with conservative means, leading to spontaneous healing. The average follow-up for the patients with tumor resection was 11.8 months (range: 6 to 30) after the salvage procedure. All patients resumed smooth oral intake eventually. There were 16 patients who could feed with solid diet, whereas three patients were able to tolerate only soft diet.

CONCLUSION

Intestinal tissues can be safely and successfully transferred as salvage procedures, with meticulous technique, careful patient selection and individual flap design. While gastric pull-up remains a good procedure for esophageal reconstruction, the methods described in this report are useful as back-up armaments in complicated cases. © 2015 Wiley Periodicals, Inc. Microsurgery 36:567-572, 2016.

Surgical strategies for esophageal cancer associated with head and neck cancer

Esophageal cancer is frequently associated with squamous cell carcinoma in the head and neck. Both cigarette smoking and alcohol consumption are risk factors for multiple cancers of the head and neck, as well as the esophagus. Routine screening and close follow-up for second cancers are important in patients with esophageal cancer or head and neck cancer. For this purpose, endoscopy with Lugol's staining, as well as narrow-band imaging combined with magnifying endoscopy, is a powerful tool for the early detection of esophageal cancer. Multimodal therapy is essential for patients with double cancers. When considering surgical treatment, the curability of both cancers must be carefully evaluated. If both tumors are potentially curable, each lesion should be treated individually. In patients with metachronous double cancers, the prior treatment of the first primary carcinoma often affects the treatment of the second cancer. Close cooperation among medical staff members is essential for complicated surgeries for double cancers. Techniques that are appropriate for each case must be adopted, such as careful dissection, staged operations, muscular flaps and microvascular anastomosis.

Gastropericardial fistula as a complication in a refractory gastric ulcer after esophagogastrostomy with gastric pull-up

A gastropericardial fistula, defined as penetration of a gastric lesion into the pericardium, is a rare occurrence. Such a fistula is usually associated with a huge ulcer in the gastric fundus, an ulcer within a hiatus hernia, a history of esophagogastric surgery, the concurrent use of non-steroidal anti-inflammatory drugs (NSAIDs), or Zollinger-Ellison syndrome. The patient in this case presented with shoulder pain and melena, caused by a gastropericardial fistula that had occurred as a late complication of postoperative esophagogastrostomy and a refractory gastric ulcer. Despite the severity of the condition, the patient showed great improvement after medical treatment and the fistula was cured at the end.

Esophagectomy and gastric pull-up in patients with previous free jejunal transfer

Several options exist for reconstruction after total esophagectomy in patients with esophageal carcinoma. However, the options for a major resection after previous head and neck surgery in these patients are extremely limited. The procedure performed in 2 patients requiring esophagectomy after resection for previous head and neck malignancies is described. Both patients underwent previous chemoradiation therapy and free jejunal transfer for hypopharyngeal squamous cell carcinoma. Esophagectomy and reconstruction with a cervical gastrojejunal anastomosis combined with deltopectoral flaps were performed after the diagnosis of esophageal disease. Soft tissue defects were closed with a modified deltopectoral flap using de-epithelization. The deltopectoral flap is effective not only for cutaneous resurfacing, but also to promote delayed wound healing after radiation therapy. This report demonstrates a useful multidisciplinary approach for resection and reconstruction in patients after a previous free jejunal transfer.