Esophageal reconstruction with colon tissue

Proximal Margin Involvement Following Total Gastrectomy for Seiwert III Adenocarcinoma: A Management Dilemma

Oesophagogastric junction carcinoma is now being increasingly regarded as a distinct site of neoplasia, separate from its adjacent sites. Recent advances in multimodal treatment approaches, including endoscopic procedures, oesophagectomy with three-field lymph node dissection, and definitive chemoradiotherapy, have significantly improved overall patient survival rates. Despite these advancements, the recurrence rate remains around 50% within one to three years following initial surgery. A major challenge in management arises when the resected surgical margins are involved with cancer. We present a 55-year-old man who experienced progressive dysphagia and, upon further assessment, was noted to have a Siewert III oesophagogastric junction adenocarcinoma. He underwent neoadjuvant chemotherapy before undergoing total gastrectomy with D2 lymphadenectomy with a Roux-en-Y reconstruction. Histopathological examination of the resected specimen revealed a positive proximal margin involvement. After optimization, he then underwent a salvage three-field McKeown oesophagectomy with colonic conduit reconstruction and adjuvant chemotherapy. Salvage surgery can be considered for patients with locoregional recurrence after definitive chemoradiotherapy or surgery. Other options include salvage chemoradiotherapy. Our case outlines the importance of proper patient selection for salvage surgery and highlights the choices of conduit in patients undergoing total esophagectomy post gastrectomy.  In conclusion, managing proximal margin involvement of cardioesophageal junction adenocarcinoma remains a complex and multifaceted challenge, necessitating a tailored, multidisciplinary approach. The decision-making process must consider the patient's functional status, previous treatments, and specific anatomical considerations.

GI and GU fluoroscopy in common post-op oncologic surgeries: what you need to know about this leaky business!

Over the past several years, there has been a trend of decreasing screening or diagnostic fluoroscopic examinations ordered by clinical teams, particularly double contrast gastrointestinal studies. The underlying reason is due to increasing number of endoscopic procedures performed by Gastroenterology and Urology and usage of other imaging modalities, which are either more sensitive and/or offer the ability to obtain tissue for confirmation. Many fluoroscopic studies are now tailored toward patients who have undergone gastrointestinal or genitourinary oncologic surgeries, providing both functional and anatomic information, which are important tools for patient management. Some of these surgeries are very complex and an understanding of the postoperative anatomy and potential pitfalls is important to accurately evaluate for complications. The purpose of this article is to describe techniques and indications for common post-operative fluoroscopic procedures in gastrointestinal and genitourinary oncology while reviewing normal appearances. Complications, with emphasis on postoperative leaks, will be highlighted. Familiarity with the various types of gastrointestinal surgeries and urinary diversion techniques and knowledge of the expected postsurgical appearance is essential for achieving an accurate and prompt diagnosis of complications to allow for adequate treatment and management.

Multi-stage surgery to treat oesophageal fistula that developed after chemoradiotherapy in two patients with oesophageal cancer: A case report

INTRODUCTION AND IMPORTANCE

Oesophageal fistula is a severe complication that may occasionally develop after chemoradiotherapy (CRT) for oesophageal cancer and is difficult to treat.

CASE PRESENTATION

A 51-year-old man who had undergone CRT for oesophageal cancer presented with haematemesis and was diagnosed with a descending aortic aneurysm and an oesophageal fistula. Thoracic endovascular aneurysm repair was performed to achieve haemostasis. After 3 days, the patient underwent subtotal oesophagectomy and cervical oesophagostomy with delivery of a pedicled omental flap to the exposed aortic stent. Six months later, ileocecal reconstruction was performed. The second patient was a 49-year-old woman who had undergone CRT 1 year previously. She complained of leg weakness and gait disorder. After a workup, she was diagnosed with perforation of the posterior wall of the cervical oesophagus with abscess formation and purulent spondylitis. After two spinal fusion surgeries, we performed tracheotomy and drained the cervical region to reduce local infection. After 7 days, she underwent pharyngolaryngoesophagectomy and reconstruction using a gastric conduit, to which a large section of the omental flap was attached. After the multi-stage surgery, oral intake became possible, and both patients were discharged.

CLINICAL DISCUSSION

The optimal treatment strategy for post-CRT oesophageal fistula remains controversial. Radical surgery, including oesophagectomy, is the treatment of choice, although it is associated with high mortality rates. Multi-stage surgery may be useful for reducing surgical stress in moribund patients.

CONCLUSION

We reported two cases involving radiation-induced oesophageal fistula successfully treated by multi-stage surgery without major complications.

Surgical outcomes and quality of life assessment of esophagectomy for cancer with colon conduit via retrosternal route

PURPOSE

Colon conduit is an alternative to a gastric conduit for esophagectomy in patients that stomach is not available. Surgical technique is complex and has a high risk of morbidities and mortality. Outcomes of patients are still lacking in the literature, thus aims of this study are to evaluate the safety, feasibility and long-term functional outcomes of patients who underwent esophagectomy for cancer with colon conduit via retrosternal route.

METHODS

Twenty-six patients underwent operation between August 2016 and June 2021 for malignancies. Minimally invasive esophagectomy and laparotomy were performed in accordance with the 2017 Japan Esophageal Society's guidelines. Colonic interposition was used for esophageal replacement. Outcomes were technical success, complications assessed using Clavien-Dindo classification, and patient's quality of life (QOL) based on EORTC-QOL-OES18 questionnaire.

RESULTS

Mean age was 56.0 ± 9.9 years and 21 patients (80.8%) were men. Mean operating time was 432 ± 66 min. Technical success was 100%. The average number of resected lymph nodes was 26 ± 14. Twelve patients (46.2%) experienced postoperative complications: 7/12 were classified as grade I-II, 3/12 as grade III, 1/12 as grade IV, and 1/12 as grade V (death). Patient's QOL improved during the follow-up period with median (25-75th percentiles) global EORTC-QOL-OES18 score was 29 (17-34); 13 (9-21), and 9 (6-16) at 3, 6, and 12 months, respectively. During the follow-up period, there were 4 late complications, 3 lymphatic recurrences, 5 distant metastases, and 6 deaths.

CONCLUSIONS

Colon conduit via retrosternal route after esophagectomy is feasible, safe, and could provide acceptable long-term functional outcomes.

Combined two-stage total pancreatoduodenectomy and esophagectomy for synchronous malignancy of the pancreatic corpus and the esophagus: A surgical case report

INTRODUCTION

Synchronous visceral malignancy is rare especially for esophagogastric junction adenocarcinoma combined with malignancy in the pancreas. So far only 7 cases of combined partial pancreatoduodenectomy and esophagectomy for synchronous malignancy have been described in the literature and none for combined total pancreatectomy and esophagectomy.

PRESENTATION OF CASE

We report the case of a 67-year-old male patient, who underwent multi-modality treatment including two-stage total pancreatoduodenectomy and subsequent Ivor-Lewis esophagectomy for synchronous adenocarcinoma of the distal esophagus and pancreatic multilocal metastases of a renal cell carcinoma after nephrectomy 17 years ago. Pathology revealed R0 resections for both malignancies and there were no postoperative complications. A 12 months follow-up showed no signs of recurrence and a good quality of life.

CONCLUSION

Curative-intent, combined oncological two-stage open total pancreatoduodenectomy and esophagectomy with several days interval is safe and feasible in selected cases when performed by an experienced interdisciplinary team in a high-volume surgical center.

Salvage Esophagectomy

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.

Tubed Anterolateral Thigh Free Flap for Pharyngoesophageal Reconstruction

Caustic ingestions can severely injure the upper and lower aerodigestive tract, resulting in detrimental mucosal changes both acutely and chronically. Injuries are most severe following alkaline ingestion. Esophagectomy is often recommended in patients with high-grade esophageal injuries to mitigate the risk of perforation. Esophageal reconstruction after these injuries is often delayed, and staged, allowing adequate tissue stabilization before further manipulation. Here, we report on a 25 year-old woman who presented with a high-grade caustic esophageal injury following the ingestion of an alkaline drain cleaner. She underwent an emergent thoracic esophagectomy, gastrectomy and a cervical salivary esophagostomy. Post-operatively, she developed supraglottic and hypopharyngeal strictures, but maintained a functional larynx. She subsequently underwent a staged, extrathoracic total esophageal reconstruction using an anterolateral thigh (ALT) myocutaneous free flap with laryngeal preservation. Although serial esophageal dilatations and trans-oral laser procedures for pharyngeal strictures were required, she was able to maintain the ability to swallow.

Microvascular grafting to enhance perfusion in colonic long-segment oesophageal reconstruction

PURPOSE

Oesophagectomy with long-segment colon reconstruction is the first-line treatment when the stomach is not available. Supercharging of the newly formed conduit can improve vascular function utilizing intraoperative perfusion imaging system, following thoracoscopic oesophagectomy for distal-oesophageal and gastroesophageal junction cancer. The purpose of this study is to examine the safety and efficacy of microvascular augmentation of left colonic interposition following oesophagectomy for oesophageal cancer.

METHODS

A retrospective analysis of 156 consecutive oesophagectomies between January 2016 and July 2018 was performed. All oesophagectomies involving left colon interposition with microvascular augmentation were included in the study. In all cases, oesophageal mobilization was performed thoracoscopically in prone position and the left colon was used as neo-oesophagus in an isoperistaltic fashion. Conduit perfusion was assessed with the Spy system and neck supercharging was performed using microsurgical technique.

RESULTS

A total of n = 5 (3.2%) patients were identified. Two cases had delayed and 3 had immediate reconstruction. The conduit was microsurgically augmented in 3 cases with both venous and arterial anastomoses (supercharging) and in 2 cases with venous anastomosis only (superdrainage). No anastomotic leak was identified. One case developed left recurrent laryngeal nerve palsy with associated aspiration pneumonia.

CONCLUSIONS

Supercharged colonic interposition is a safe way of oesophageal reconstruction when long-segment interposition graft is needed. In oesophageal cancer and in the absence of a viable stomach with intact gastroepiploic arcade, it should be considered a feasible option with favourable outcomes, when the expertise and facilities are available. Use of intraoperative perfusion imaging reveals improved conduit blood supply post-supercharging.

Transhiatal isoperistaltic colon interposition without cervical oesophagostomy in long-gap oesophageal atresia

BACKGROUND

Oesophageal colonic interposition in oesophageal atresia (OA) patients is almost exclusively done as a staged operation with an initial oesophagostomy and gastrostomy followed by the definitive surgery months later. This study presents a series of patients in whom a cervical oesophagostomy was not performed before the substitution surgery.

PATIENTS AND METHODS

Records of EA patients were evaluated for those who underwent colon interposition without cervical oesophagostomy.

RESULTS

There were five patients: three with pure EA and two with proximal tracheo-oesophageal fistula. A delayed primary repair could not be performed because of intra-abdominally located distal pouch. The mean age at the time of definitive operation was 5.54 (±2.7) months and the mean weight was 6.24 (±1.3) kg. A right or a left colonic segment was used for interposition keeping the proximal anastomosis within the thorax. The post-operative results were quite satisfactory within a median follow-up period of 33.2 months.

CONCLUSION

Avoiding cervical oesophagostomy and its inherent complications and drawbacks is possible in a subset of patients with long-gap EA who underwent colonic substitution surgery. This approach may be seen as an extension of the consensus that the native oesophagus should be preserved whenever possible, because it uses the native oesophagus in its entirety.

Colonic replacement of the esophagus: towards standardization of the technique

Since we have started colonic replacement of the esophagus in children, several successive modifications have led to evolution of the surgical technique aiming to decrease complications and achieve the best functional outcome. Currently, our surgical group has reached a single standardized technique that has been applied to all cases included in this report. A colonic flap (including the transverse colon) is prepared based on the left colic vessels. The proximal end of the colonic flap is transferred upwards passing at first behind the stomach and then anteriorly through the lesser omentum to traverse the thoracic cavity via a previously prepared retrosternal tunnel. The proximal end of the colonic flap is anastomosed to the proximal esophagus in the neck (end to end anastomosis). Most specifically, the distal end of the colonic flap is anastomosed to the posterior wall of the body of the stomach in order to prevent regurgitation of gastric contents into the colonic flap. The retro-sternal colon bypass is among the successful options to replace the esophagus in children. Adding a posterior cologastric anastomosis to the procedure greatly prevents gastric regurgitation that can be responsible for short- and long-term complications. LEVEL OF EVIDENCE: This is a case series with no comparison group (level IV evidence).

Esophageal reconstruction using a pedicled jejunum following esophagectomy for metastatic esophageal stricture from breast cancer in a patient with previous pancreatoduodenectomy

A 71-year-old woman with dysphagia was diagnosed with thoracic esophageal squamous cell carcinoma by endoscopic biopsy at another hospital. She had previously undergone partial breast excision with axillary lymph node dissection for right breast cancer eleven years earlier and subtotal stomach-preserving pancreatoduodenectomy with Child’s reconstruction for ampullary cancer ten years earlier. Gastrointestinal endoscopy showed a stricture due to a bulging submucosal tumor in the mid-thoracic esophagus. The tumor was diagnosed as an esophageal metastasis from breast cancer by endoscopic ultrasound-guided fine-needle aspiration biopsy. After six courses of fulvestrant, the tumor progressed, completely impeding her ability to swallow. An esophagectomy was planned in a one-stage operation because of the expectation of a prolonged survival and her strong hope of regaining oral intake. Unfortunately, she underwent emergent omental patch repair for perforation of the gastrojejunostomy site due to an anastomotic ulcer one day before the scheduled operation. Due to postoperative impairment of her performance status, she subsequently underwent a two-stage esophageal operation. In the first surgical stage, prone position thoracoscopic esophagectomy and cervical esophagostomy were performed and she was discharged with enteral nutrition on postoperative day 15. Sixty-one days after the first surgical stage, esophageal reconstruction was performed using a pedicled jejunum with microvascular anastomosis via the subcutaneous route. She was discharged without any complications 20 days after the second operation.

Esophageal caustic injuries in pediatrics: a sobering global health issue

Caustic material ingestion by children is considered a global healthcare issue, especially in low-to-middle income countries. The aim of this article was to review the epidemiology, prevention, and management of caustic material ingestion in pediatric patients, comparing low-to-middle income countries with high-income countries. We conducted an English literature review using PubMed with the following keywords: (caustic OR corrosive) AND ingestion AND (pediatric OR pediatric). Our search retrieved 253 citations; all abstracts were screened by the authors, and 52 articles were finally included in our review. Prevention is key in tackling this issue, but legislation is scarce in low-to-middle income countries. Diagnosis of caustic ingestion is mostly achieved using flexible endoscopy, computed tomography, and endoscopic ultrasound, but access is limited in low-to middle income countries and diagnosis is often delayed. After stabilizing patients, the mainstay of treatment is graded endoscopic dilatation, and rarely, esophageal replacement. We concluded that caustic ingestion represents a serious condition where prevention is the key. Once a child suffers an injury, rapid and careful evaluation of the injury with endoscopy, and a course of close observation and dilations if needed, will often avoid esophageal replacement. When necessary, the stomach is the best first option if it is viable, followed by the colon, and finally, the jejunum.

Total surgical repair for secondary aortoesophageal fistula: two case reports

We present two consecutive patients with secondary aortoesophageal fistula (AEF) who successfully underwent total repair including partial esophagectomy, removal of infected vascular prosthesis, graft replacement, and esophageal reconstruction using gastric tube concomitant to omental wrapping for staged operation in short phase. One 81-year-old male who had undergone thoracic endovascular aortic repair and another 69-year-old male who had undergone graft replacement of the descending thoracic aorta were referred to our hospital for treatment of AEF. In the first operation, partial esophagectomy, removal of infected vascular prosthesis, and graft replacement were performed via left rib-cross thoracotomy. About half a day after the operation when the patients became hemodynamically stable, esophageal reconstruction was started. The gastric tube was prepared via median laparotomy and introduced to the left thoracic cavity with the omentum through the enlarged hiatus. Thereafter, the gastric tube was anastomosed to the oral side of the esophageal stump via left thoracotomy with the same wound similar to the first operation. Finally, the graft positioned parallel to the gastric tube was completely wrapped by the omentum. Both patients could ingest orally 4 weeks after surgery and maintained no recurrence of infection.

Reflux after esophagectomy with gastric conduit reconstruction in the posterior mediastinum for esophageal cancer: original questionnaire and EORTC QLQ-C30 survey

Reflux following an esophagectomy with gastric conduit reconstruction in the posterior mediastinum is a clinically significant problem. In this study, we investigated the frequency and impact of reflux on the quality of life (QOL) among 158 patients who underwent an esophagectomy for esophageal cancer using an original questionnaire and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Version 3.0 (EORTC QLQ-C30). Reflux frequency was assessed using the original questionnaire. The number of patients who complained of reflux every day, two or three times a week, once a week, or less than once a week was 16 (10.1%), 21 (13.3%), 26 (16.5%), and 60 (38.0%), respectively. Out of 35 patients (22.2%) reported no reflux symptoms. Patients were divided into two groups: those with reflux ≥ once/week (63 patients) and those with low frequency of symptoms (95 patients). Time elapsed following surgery was the only factor to influence reflux frequency. Reflux frequency decreased within two years of surgery; however, the frequency plateaued after more than two years. QOL was assessed using the EORTC QLQ-C30. The ≥ once/week reflux group had a significantly lower global health status score than the low-frequency reflux group (59.6 ± 24.2 vs. 70.8 ± 20.7; P = 0.007). In addition, the ≥ once/week reflux group had a significantly lower social functioning score than the low-frequency reflux group (81.6 ± 24.1 vs. 88.4 ± 19.8; P = 0.035). Regarding symptoms, the ≥ once/week reflux group had significantly higher scores for fatigue, nausea, and vomiting, dyspnea and insomnia compared to the low-frequency reflux group (fatigue: 42.4 ± 21.9 vs. 28.9 ± 18.4, P < 0.001; nausea and vomiting: 17.3 ± 17.1 vs. 4.9 ± 10.6, P < 0. 001; dyspnea: 29.2 ± 26.0 vs. 21.7 ± 26.8, P = 0.043; insomnia: 22.2 ± 31.1 vs. 10.5 ± 21.7, P = 0.015). Thus, reflux after an esophagectomy was associated with a lower QOL.

Novel esophageal reconstruction technique via transmediastinal route from posterior to anterior mediastinum after esophagectomy

BACKGROUND

The incidence of metachronous esophageal squamous cell cancer (ESCC) after head and neck cancer (HNC) and in elderly patients has increased. Both elderly ESCC patients and ESCC patients after HNC surgery are at potential risk for dysphagia, and for the latter, surgery in the neck is difficult. An intrathoracic anastomosis that bypasses the cervical procedure is preferable to preserve swallowing function and reduce surgical risk. In gastrectomized patients, because the stomach cannot be used as a substitute, securing graft blood supply is critical, but microvascular anastomosis cannot be easily added in procedures for intrathoracic posterior mediastinal reconstruction. Thus, we have developed a novel technique for esophageal reconstruction in gastrectomized patients who are elderly or who had undergone HNC surgery, enabling concomitant intrathoracic anastomosis and microvascular anastomosis. The purpose of this study was to evaluate the usefulness and safety of this technique.

METHODS

The jejunal or ileocolic graft is first pulled up through the anterior mediastinum and is then passed into the right thoracic cavity via a small hole made in the anterior mediastinal pleura. The graft is finally anastomosed with the remnant esophagus in the upper posterior mediastinum. Thereafter, microvascular anastomosis is performed in the retrosternal space.

RESULTS

Four patients underwent this new reconstruction procedure with no significant postoperative complications, good swallowing function postoperatively, and no retention of food in the graft.

CONCLUSIONS

This novel transmediastinal reconstruction technique is a possible option for highly selected patients to enable intrathoracic anastomosis and the addition of microvascular anastomosis.

Alternative conduits for esophageal replacement

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.

Esophageal anastomosis - how the granulation phase of wound healing improves the incidence of anastomotic leakage

A two-stage esophagectomy with an interval for reconstruction of the esophagus creates an opportunity for the esophageal stump to recover from vessel injury and allows the formation of granulation tissue rich in proangiogenic factors, including transforming growth factor β (TGF-β) and vascular endothelial growth factor A (VEGF-A), which may have an impact on anastomosis healing. The present study comprised 25 patients (27 in total, 2 succumbed to complications following surgery) who underwent two-stage esophagectomy for squamous cell carcinoma in the Department of Gastrointestinal and General Surgery, Wrocław Medical University (Wrocław, Poland) between January 2007 and December 2012. Immunohistochemical staining for VEGF-A and TGF-β was performed to evaluate esophageal wall specimens at the time of esophagostomy construction and prior to anastomosis, in which the cervical esophagus was connected with the colon or ileum. At the time of reconstructive surgery, a significant increase in microvessel density was observed in all esophageal specimens (P<0.03). Significant differences were also identified in the immunohistochemical staining intensity of TGF-β and VEGF-A in the epithelium of all esophageal specimens between biopsies obtained from normal esophageal tissues at the time of esophagectomy and during reconstructive surgery. Delayed anastomosis construction provides an advantage for the esophageal stump to accumulate proangiogenic growth factors, which overlap with the subsequent proliferative stage of the anastomosed tissue and thus supports its recovery, creating an optimal environment for the healing of any fistulas.

Total esophagogastrectomy in the neoplasms of the esophagus and esofagogastric junction: when must be indicated?

OBJECTIVE

to analyse the indications and results of the total esophagogastrectomy in cancers of the distal esophagus and esophagogastric junction.

METHODS

twenty patients with adenocarcinomas were operated with a mean age of 55 ± 9.9 years (31-70 years), and 14 cases were male (60%). Indications were 18 tumors of the distal esophagus and esophagogastric junction (90%) and two with invasion of gastric fundus (10%) in patients with previous gastrectomy. Preoperative colonoscopy to exclude colonic diseases was performed in ten cases.

RESULTS

the surgical technique consisted of median laparotomy and left cervicotomy, followed by transhiatal esophagectomy associated with D2 lymphadenectomy. The reconstructions were performed with eight esophagocoloduodenoplasty and the others were Roux-en-Y esophagocolojejunoplasty to prevent the alkaline reflux. Three cases were stage I / II, while 15 cases (85%) were stages III / IV, reflecting late diagnosis of these tumors. The operative mortality was 5 patients (25%): a mediastinitis secondary to necrosis of the transposed colon, abdominal cellulitis secondary to wound infection, severe pneumonia, an irreversible shock and sepsis associated with colojejunal fistula. Four patients died in the first year after surgery: 3 (15%) were due to tumor recurrence and 1 (5%) secondary to bronchopneumonia. The 5-year survival was 15%.

CONCLUSION

the total esophagogastrectomy associated with esophagocoloplasty has high morbidity and mortality, requiring precise indication, and properly selected patients benefit from the surgery, with the risk-benefit acceptable, contributing to increased survival and improved quality of life.

The radiological assessment of colonic replacement of the esophagus in children: A review of 43 cases

PURPOSE

To define the characteristic radiological features following colonic replacement of the esophagus in children.

MATERIALS AND METHODS

The upper gastro-intestinal contrast studies of 43 patients who underwent colonic replacement of the esophagus at our pediatric surgery unit were available for analysis. UGI contrast studies were performed routinely in the post-surgical period in 17 cases (first asymptomatic group), while the rest of contrast studies (26) belonged to a second group of out-patients complaining of dysphagia (18) or dyspepsia (8) following colonic replacement of the esophagus. Based on our observations, we proposed a grading system to describe the degree of colonic redundancy in the thorax.

RESULTS

Redundancy of the colonic conduit in the thoracic cavity was a common radiological finding (62.8%). The redundancy was mild (grade 1) in 18 patients, moderate (grade 2) in eight, and severe (grade 3) in only one patient. In 88.9%, the redundancy was in the right hemi-thorax. Patients presenting with postoperative dysphagia had a stricture at the site of the esophago-colic anastomosis in the neck, which should be differentiated from other sites of anatomical narrowing at the inlet and outlet of the thoracic cavity. Gastro-colic reflux was common among patients who underwent colonic replacement of the esophagus without an anti-reflux procedure.

CONCLUSION

Colonic replacement of the esophagus in children results in considerable anatomical alterations. Knowledge about the normal post-surgical changes and imaging features of the commonly encountered complications can increase the diagnostic confidence among radiologists and clinicians when dealing with these cases.

Posterior Cologastric Anastomosis: An Effective Antireflux Mechanism in Colonic Replacement of the Esophagus

BACKGROUND

The colon may be used to replace a portion of the esophagus in pediatric patients, but prevention of gastrocolic reflux is a concern. We report our experience with the retrosternal colon bypass, and the effect of combining the procedure with a posterior cologastric anastomosis on prevention of gastrocolic reflux.

METHODS

The study included 35 consecutive pediatric patients who underwent retrosternal colon bypass during the period of 2010 through 2014. In standard practice, the cologastric anastomosis is performed at the anterior gastric wall. Lately, we modified our technique by shifting the cologastric anastomosis to the back of the stomach away from the anterior adhesions around the gastrostomy. In follow-up, a gastrogram was performed to check for gastrocolic reflux.

RESULTS

The indication for esophageal replacement was postcorrosive esophageal stricture in 19 patients and long gap esophageal atresia in 16 patients. Their mean ages were 51 and 16 months, respectively. No gastrocolic reflux was detected with the posterior cologastric anastomosis, whereas reflux was always present with the anterior cologastric anastomosis. We had two mortalities and one major morbidity (hematemesis and failure to thrive) that were related to regurgitation of gastric contents into the colonic conduit. The last patient was successfully managed by transferring the cologastric anastomosis from the front to the back of the stomach, with marked symptomatic and radiologic improvement.

CONCLUSIONS

After colonic replacement of the esophagus, the gastrocolic reflux represents a functional problem that may lead to serious complications. Combining a posterior cologastric anastomosis with retrosternal colon bypass is an effective way to avoid this problem.

Modified gastric pull-up reconstructions following pharyngolaryngectomy with total esophagectomy

Reconstruction following pharyngolaryngectomy with total esophagectomy is a challenging surgery to perform. Between April 2008 and August 2012, three types of modified gastric pull-up reconstruction procedures, including a gastric tube creation combined with a free jejunal transfer (n = 7), elongated gastric tube creation with vascular anastomoses (n = 2) and pedunculated gastric tube creation with Roux-en-Y anastomosis (n = 5), were performed after pharyngolaryngectomy with total esophagectomy. To clarify feasibility of these reconstructive methods, we retrospectively analyzed the short-term outcomes. There were no graft failures. Salivary fistulae were observed in two cases after high pharyngoenteral anastomoses due to oropharyngeal extension of hypopharyngeal cancers. Overall morbidity rate was 21.4%, and no deaths occurred. Although the operation time was shortest for pedunculated gastric tube reconstructions, morbidity rates were similar among all methods. All three types of modified gastric pull-up reconstruction procedures can be performed safely. We can choose one of these methods according to the tumor status and the patient condition, understanding advantages and disadvantages of each procedure.

Two-stage operation for thoracic esophageal cancer: esophagectomy and subsequent reconstruction by a free jejunal flap

When the stomach is unavailable for esophageal reconstruction due to previous gastrectomy or synchronous gastric cancer, a pedicled jejunum or colon, with or without vascular supercharge, has been the alternative. However, these reconstructions are not free from severe complications, such as necrosis. We have introduced a new surgical technique for delayed esophageal reconstruction using a free jejunal flap. We used this technique in 11 patients. Four weeks after subtotal esophagectomy, reconstruction using free jejunal flaps was performed. A free jejunum was placed at the pre-sternum, and the internal thoracic artery and vein were usually used as the recipient vessels. There were no cases of flap necrosis and no hospital deaths. Anastomotic leakage occurred in two cases. Both leakages were cured by conservative treatment. Delayed esophageal reconstruction using a free jejunal flap can be considered to be a safe procedure when the stomach is unavailable as an esophageal substitute.

Isoperistaltic left colic graft interposition via a retrosternal approach for esophageal reconstruction in patients with a caustic stricture: mortality, morbidity, and functional results

PURPOSE

To report our results of treating esophageal caustic stricture with an isoperistaltic left colic graft interposed via a retrosternal route.

METHODS

We reviewed 70 patients who underwent substernal left colon interposition, performed retrosternally, for an esophageal caustic stricture, between January, 1999 and December, 2011.

RESULTS

The median operative time in this series was 3 h. A pharyngoplasty was performed in 10 patients (14.28 %), the thoracic inlet was found to be enlarged in 33 patients (47.1 %), and posterior cologastric anastomosis was performed in 58 patients (82.8 %). Two patients (2.8 %) died. Minor and major postoperative complications developed in 28 patients (40 %), including graft ischemia in 2 (2.8 %) and cervical anastomotic leakage in 14 (20 %). Five patients (7.14 %) developed a cervical anastomotic stricture. The functional results were satisfactory.

CONCLUSION

Retrosternal isoperistaltic left colic transplant interposition is an excellent long-term replacement for an esophageal caustic stricture. If performed by experienced surgeons, this procedure is effective for esophageal reconstruction.

Antethoracic pedicled jejunum reconstruction with the supercharge technique for esophageal cancer

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.

Two-stage operation for synchronous triple primary cancer of the esophagus, stomach, and ampulla of Vater: report of a case

A 69-year-old man with jaundice was diagnosed with cancer of the ampulla of Vater by endoscopic retrograde cholangiopancreatography and abdominal computed tomography. A screening gastrointestinal endoscopy showed middle thoracic esophageal cancer and early gastric cancer on the anterior wall of the lower gastric body. We chose a two-stage operation for synchronous triple primary cancer of the esophagus, stomach, and ampulla of Vater, in order to safely perform the curative resection of these three cancers. The first-stage operation consisted of a right transthoracic subtotal esophagectomy with mediastinal and cervical lymph node dissection, an external esophagostomy in the neck, and a gastrostomy. Thirty-five days after the first surgery, a total gastrectomy with regional lymph node dissection, and a pancreatoduodenectomy with Child's reconstruction were performed as the second-stage surgery. Esophageal reconstruction was achieved using the ileocolon via the percutaneous route without vascular anastomosis.

"Supercharged" isoperistaltic colon interposition for long-segment esophageal reconstruction

BACKGROUND

When the stomach is not available, long-segment esophageal reconstruction remains a surgical challenge. Since 2005, we have used a "supercharged" isoperistaltic colon interposition conduit for long-segment esophageal reconstruction that reestablishes a dual blood supply.

METHODS

An institutional database search of 449 patients who underwent esophagectomy from 2005 to 2012 identified 11 consecutive patients who underwent long-segment esophageal reconstruction using an isoperistaltic supercharged right (n=9) or left (n=2) colon conduit. All conduits were routed through the anterior mediastinum, maintaining the middle colic (right) or ascending left colic vessels (left) in situ, with reimplantation of the ileocolic vessels (right) or middle colic vessels (left) into the left internal thoracic artery and brachiocephalic vein to improve distal conduit blood flow.

RESULTS

Patients were a mean age of 64 years (range, 47 to 76 years). Seven patients had a history of malignancy and 4 had a benign process. The stomach was unavailable for reconstruction due to prior gastric operations (n=9) or neoplastic involvement (n=2). All reimplanted vessels demonstrated excellent flow by Doppler evaluation. Esophagocolonic healing was successful in all patients; however, 1 patient required a temporary stent.

CONCLUSIONS

Supercharged isoperistaltic colon interposition appears to be an excellent option for the challenging situation where long-segment esophageal reconstruction is needed and the stomach is not available. The additional effort required to reestablish a dual blood supply appears justified to minimize ischemic-related morbidity. Unlike long-segment small bowel "supercharged" techniques, adequate blood supply to the distal conduit may still be present in case thrombosis of the reimplanted vessels occurs.

The role of ultrasound and computed tomography in the evaluation of subcutaneous esophageal bypass in a dysphagic patient

Several conditions require subcutaneous colon bypass surgery in the esophageal diseases treatment. Esophageal reconstructions are high risk procedures because of their morbidity and mortality rate. Cervical anastomotic strictures, colon transplant redundancy, recurrent dysphagia, intestinal obstruction, regurgitation, and aspiration are the most frequent late complications. The patient assessment should be performed with noninvasive methods in order to prevent long-term complications. We report the use of ultrasound (US) and computed tomography (CT) for evaluating a dysphagic patient, after subcutaneous esophageal bypass. A thorax and upper abdomen contrast media CT study with volume rendering reconstruction was performed in order to evaluate late post operative complications. In addition a US examination, performed after CT scan, was used for the assessment of the colonic wall and its vascularization. The subcutaneous esophageal bypass allowed for an effective ultrasound evaluation with no additional discomfort for the patient. ultrasonography has been shown effective in the esophageal bypass follow up, when subcutaneous colon bypass surgery was performed. The ultrasonography evaluation, also thanks to a Doppler flowmetry, allowed completing the patient assessment without additional invasive procedures or contrast. Thus it may be performed as a first level evaluation or in the follow up of subcutaneous esophageal bypass patients.

Left colonic graft in esophageal reconstruction for caustic stricture: mortality and morbidity

The adequacy of the blood supply to the left colon graft and its ability to transport food effectively from pharynx to stomach made it an esophageal substitute of choice, particularly in esophageal caustic stricture. From 1999 to 2009, 60 patients underwent colon interposition for esophageal caustic stricture (n= 57) and cancer (n= 3). An isoperistaltic colonic graft based on the left colonic artery could be used in all of these patients. The substernal route was used exclusively, and upper thoracic inlet was opened when necessary. The isoperistaltic left colonic graft interposed by substernal route represents the surgical procedure of choice in all operations performed for esophageal substitution during the study period. The operative mortality rate was 3.3%. A cervical fistula occurred in 10 patients (16.6%) and cervical anastomotic stricture in five patients (8.3%). Dilation was required in all the stricture of the esophageal colonic anastomosis with good response. The isoperistaltic left colic transplant supplied by the left colic pedicle is an excellent long-term replacement organ for the esophageal caustic stenosis. When performed by experienced surgeons, the left isoperistaltic esophagocoloplasty is a satisfactory surgical method for esophageal reconstruction with acceptable early morbidity and good long-term functional results.

Esophageal reconstruction using a pedicled jejunum with microvascular augmentation

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.