Management of Conduit Necrosis Following Esophagectomy

Conduit Ischemia After Esophagectomy: A Spectrum of Clinical Manifestations, Prevention, and Management

This article outlines the anatomic and physiologic basis for gastric conduit ischemia and the range of its possible manifestations, from superficial mucosal ischemia to gross conduit necrosis. Methods by which these complications are suspected and ultimately diagnosed are discussed, focusing on clinical and laboratory signs as the harbingers and the use of imaging and endoscopy for confirmation. From there, management options are detailed based on the Esophagectomy Complications Consensus Group classification of esophageal leak and gastric necrosis. Finally, the short- and long-term implications of these complications are reviewed.

Predictors of anastomotic leak and conduit necrosis after oesophagectomy: Results from the oesophago-gastric anastomosis audit (OGAA)

BACKGROUND

Both anastomotic leak (AL) and conduit necrosis (CN) after oesophagectomy are associated with high morbidity and mortality. Therefore, the identification of preoperative, modifiable risk factors is desirable. The aim of this study was to generate a risk scoring model for AL and CN after oesophagectomy.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018-December 2018. Definitions for AL and CN were those set out by the Oesophageal Complications Consensus Group. Univariate and multivariate analyses were performed to identify risk factors for both AL and CN. A risk score was then produced for both AL and CN using the derivation set, then internally validated using the validation set.

RESULTS

This study included 2247 oesophagectomies across 137 hospitals in 41 countries. The AL rate was 14.2% and CN rate was 2.7%. Preoperative factors that were independent predictors of AL were cardiovascular comorbidity and chronic obstructive pulmonary disease. The risk scoring model showed insufficient predictive ability in internal validation (area under the receiver-operating-characteristic curve [AUROC] = 0.618). Preoperative factors that were independent predictors of CN were: body mass index, Eastern Cooperative Oncology Group performance status, previous myocardial infarction and smoking history. These were converted into a risk-scoring model and internally validated using the validation set with an AUROC of 0.775.

CONCLUSION

Despite a large dataset, AL proves difficult to predict using preoperative factors. The risk-scoring model for CN provides an internally validated tool to estimate a patient's risk preoperatively.

Microvascular reconstruction in salvaging the gastric conduit post-esophagectomy after iatrogenic right gastroepiploic vessel injury

The preservation of the right gastroepiploic vessels is essential to ensure proper perfusion of the gastric conduit following esophagectomy. The loss of these vessels can lead to conduit ischemia or necrosis, resulting in significant postoperative complications. Traditional approaches such as colonic or jejunal interposition require extensive surgery and multiple anastomoses. In this report, we present our successful experience of salvaging the gastric tube through microvascular reconstruction following iatrogenic injury to the right gastroepiploic vessels in two cases. The first case involved re-anastomosis of the right gastroepiploic vein, while the second case required reconstruction of both the artery and vein during esophagectomy in a single setting. The procedures were performed by an experienced surgical team using microvascular techniques. Both patients had uneventful postoperative courses without any anastomotic leakage or major complications. Adequate perfusion of the salvaged gastric tube was confirmed intraoperatively using indocyanine green fluorescence perfusion imaging. In conclusion, immediate microvascular reconstruction offers a viable solution by restoring perfusion of the gastric tube in cases of right gastroepiploic vessel injury during esophagectomy.

Restoring the perfusion of accidentally transected right gastroepiploic vessels during gastric conduit harvest for esophagectomy using microvascular anastomosis: a case report and literature review

BACKGROUND

Esophagectomy remains the standard treatment for esophageal cancer or esophagogastric junction cancer. The stomach, or the gastric conduit, is currently the most commonly used substitute for reconstruction instead of the jejunum or the colon. Preservation of the right gastric and the right gastroepiploic vessels is a vital step to maintain an adequate perfusion of the gastric conduit. Compromise of these vessels, especially the right gastroepiploic artery, might result in ischemia or necrosis of the conduit. Replacement of the gastric conduit with jejunal or colonic interposition is reported when a devastating accident occurs; however, the latter procedure requires a more extensive dissection and multiple anastomosis.

CASE PRESENTATION

A 61-year-old male with a lower third esophageal squamous cell carcinoma (cT3N1 M0) who received neoadjuvant chemoradiation with a partial response. He underwent esophagectomy with a gastric conduit reconstruction. However, the right gastroepiploic artery was accidentally transected during harvesting the gastric conduit, and the complication was identified during the pull-up phase. An end-to-end primary anastomosis was performed by the plastic surgeon under microscopy, and perfusion of the conduit was evaluated by the ICG scope, which revealed adequate vascularization of the whole conduit. We continued the reconstruction with the revascularized gastric conduit according to the perfusion test result. Although the patient developed minor postoperative leakage of the esophagogastrostomy, it was controlled with conservative drainage and antibiotic administration. Computed tomography also demonstrated fully enhanced gastric conduit. The patient resumed oral intake smoothly later without complications and was discharged at postoperative day 43.

CONCLUSION

Although the incidence of vascular compromise during harvesting of the gastric conduit is rare, the risk of conduit ischemia is worrisome whenever it happens. Regarding to our presented case, with the prompt identification of the injury, expertized vascular reconstruction, and a practical intraoperative evaluation of the perfusion, a restored gastric conduit could be applied for reconstruction instead of converting to more complicated procedures.

Non-occlusive mesenteric ischemia in reconstructive digestive tract surgery

OBJECTIVE

To analyze the mechanisms of non-occlusive mesenteric ischemia (NOMI) after digestive tract surgery.

MATERIAL AND METHODS

NOMI occurred in 10 (0.4%) patients after reconstructive digestive tract surgery between 2015 and 2021. There were 4 women and 6 men aged 29-92 years (67 [60; 71]). Patients differed from each other in the nature of baseline disease and surgical approach. All patients underwent standardized surgical interventions. There were no intraoperative complications.

RESULTS

Median of surgery time was 372.5 (246.25; 548.75) min, blood loss - 450 (200; 725) ml. These parameters conformed to the type of surgery. There were no specific clinical signs of NOMI. Lactic acidosis (>4 mmol/L) occurred in 7 patients after 1-3 postoperative days. In 6 patients, fulminant NOMI developed after 1-2 postoperative days with subsequent multiple organ failure syndrome and septic shock. All patients underwent emergency redo surgery. Multivisceral gastrointestinal necrosis occurred in 5 patients, gastric conduit necrosis - 3, colon necrosis - 1, gastric stump necrosis - 1 patient. Mortality rate was 80%. Two patients survived.

CONCLUSION

NOMI manifested as a septic shock in 60% of patients that was due to fulminant development of multivisceral necrosis after 1-2 postoperative days. Timely diagnosis of reversible NOMI in these cases was impossible. Extensive visceral necrosis in early postoperative period is probably associated with intraoperative critical ischemia of digestive organs.

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.

Successful surgical treatment for nonocclusive mesenteric ischemia of a wide area of the intestine accompanied by gastric conduit necrosis after esophagectomy for esophageal cancer: a case report and review of the literature

BACKGROUND

Nonocclusive mesenteric ischemia (NOMI) has been reported to be a life-threating disease. Gastric conduit necrosis is known as a critical postoperative complication after esophagectomy for esophageal cancer. We encountered a rare case of NOMI of a wide area of the intestine accompanied by gastric conduit necrosis after esophagectomy, which was successfully treated with an emergency operation.

CASE PRESENTATION

A 67-year-old man presented with dysphagia. He was diagnosed with middle thoracic advanced esophageal cancer. After neoadjuvant chemotherapy, he underwent subtotal esophagectomy with lymphadenectomy and gastric conduit reconstruction. On postoperative day (POD) 2, he had diarrhea, high fever, and low blood pressure, which were treated with catecholamines. Laboratory data revealed acidosis and severe sepsis with multi-organ failure, including the kidneys. Although enhanced computed tomography did not exhibit definite findings of bowel ischemia, upper gastrointestinal endoscopy revealed necrotic mucosal changes in the whole gastric conduit. Therefore, we made a diagnosis of septic shock caused by gastric conduit necrosis and performed an emergency operation. When we explored the abdominal cavity, we found not only gastric conduit necrosis but also intermittent necrotic changes in the intestinal wall from the jejunum to the rectum. Therefore, NOMI was diagnosed. We performed an excision of the gastric conduit and 2 m of the small intestine, as well as total colectomy. After the second operation, prostaglandin E1 was administered intravenously as the treatment for NOMI, and sepsis was improved. On POD 122, he was self-discharged. He died of recurrence of lung metastasis from the esophageal cancer 9 months after the first operation.

CONCLUSION

When a patient has a critical status, including severe sepsis or severe acidosis, after esophagectomy, we should consider the possibility of NOMI in addition to gastric conduit necrosis and aim to diagnose and treat it immediately with an urgent operation.

Residual esophageal necrosis after radical esophagectomy for esophagogastric cancer: A case report

A 66-year-old man was diagnosed with advanced esophagogastric junction cancer and referred to our institution (Department of Gastroenterological Surgery, Chiba Cancer Center) for treatment. Computed tomography imaging confirmed the presence of a tumor, extending from the lower thoracic esophageal to the esophagogastric junction, with swelling of the upper mediastinal lymph nodes. Based on the criteria of the International Union against Cancer Committee (UICC, 8th Edition), the staging was confirmed as follows: 101R, 107 and 106 pre. Based on these findings, a clinical diagnosis of EGJ cancer was made, with a UICC 8th classification of cT3N1M0 c-stage-III. Preoperative chemotherapy was performed, with tumor shrinkage obtained after three courses of chemotherapy (using S-1 plus oxaliplatin). Subsequently, esophagectomy with three-field lymph node dissection and gastric tube reconstruction, via the intrathoracic route, was performed. On postoperative day 2, the patient developed an idiopathic pneumothorax, with brown-green drainage from the chest tube. A repeat thoracotomy was performed, confirming the presence of brown-green pleural fluid and necrosis of esophageal tissue. The area of necrosis was situated 4 cm on the oral side of the anastomosis, with greater necrosis of the right than left side. There was no evidence of necrosis of the gastric tube. The necrotic residual esophagus was excised and reconstructed, as an external fistula on the left side of the neck. On day 38, after the second surgery, reconstruction of the esophageal conduit and gastric tube, via the jejunum, was performed. At 7 months after discharge, the patient was symptom free, with no evidence of cancer recurrence.

Complications After Esophagectomy

Esophagectomy is the mainstay for treating esophageal cancers and other pathology. Even with refinements in surgical techniques and the introduction of minimally invasive approaches, the overall morbidity remains formidable. Complications, if not quickly recognized, can lead to significant long-term sequelae and even death. Vigilance with a high degree of suspicion remains the surgeon's greatest ally when caring for a patient who has recently undergone an esophagectomy. In this review, we highlight different approaches in dealing with anastomotic leaks, chyle leaks, cardiopulmonary complications, and later functional issues after esophagectomy.

The Difficult Esophageal Conduit

A variety of esophageal diseases are treated with esophagectomy, from benign to esophageal cancer. Careful attention must be given to management of the difficult conduit, including patients who have had prior gastric surgery and other procedures, patients with conditions such as diabetic gastroparesis, which can affect the stomach as a future usable conduit, and patients who have an absent or unusable stomach. In these situations, consideration should be raised for the use of alternative conduits, including jejunal and colonic interposition conduits. The esophageal surgeon should also be adept at management of intraoperative difficulties with the conduit.

Robotic substernal esophageal bypass and reconstruction with gastric conduit-frequently overlooked minimally invasive option

Modern esophagectomy includes the esophageal extirpation with immediate reconstruction of the gastrointestinal (GI) continuity via posterior mediastinal route. In the majority of cases tubularized stomach is chosen as the conduit of choice. Other conduits, such as colon or small bowel can be used for these purposes as well. In rare circumstances use of the alternative route for the conduit placement is required. Authors describe the technique of robotic substernal esophageal bypass and reconstruction of the esophageal continuity.

Conduit necrosis following esophagectomy: An up-to-date literature review

Esophageal conduit ischaemia and necrosis is an uncommon but devastating complication of esophagectomy and remains one of the most challenging issues in surgical practice. The incidence, time interval to develop symptoms, and clinical presentation are highly variable with no predictable pattern. Evidence comes from case reports and case series rather than randomized controlled trials. We describe the issues surrounding conduit necrosis affecting the stomach, jejunum and colon as an esophageal replacement and the advantages, disadvantages and challenges of each type of reconstruction. Diagnosis is challenging for the most experienced surgeon. Upper gastrointestinal endoscopy and computed tomography thorax with both oral and intravenous contrast is the gold standard. Management, either conservative or interventional is also a difficult decision. Management options include conservative treatment and more aggressive treatments such as stent insertion, surgical debridement and repair of the esophagus using jejunum, colon or a musculocutaneous flap. In spite of recent advances in surgical techniques, there is no reliable strategy to manage esophageal conduit necrosis. Our review covers the pathophysiology and clinical significance of esophageal necrosis while highlighting current techniques of prevention, diagnosis and treatment of this life-threatening condition.

Diagnosis, assessment, and management of surgical complications following esophagectomy

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.

PHARYNGO-ILEO-COLO-ANASTOMOSIS WITH MICRO-VASCULAR BLOOD SUPPLY AUGMENTATION FOR ESOPHAGO-GASTRIC REPLACEMENT DUE TO ESOPHAGO-GASTRIC NECROSIS AFTER CAUSTIC INGESTION

BACKGROUND

Complete esophago-gastric necrosis after caustic ingestion is a challenging surgical scenario for reconstruction of the upper digestive transit.

AIM

To present a surgical technique for reconstruction of the upper digestive tract after total esophagectomy and gastrectomy due to esophageal and gastric necrosis.

METHOD

The transit was re-established by means of a pharyngo-ileo-colic interposition with microsurgical arterial and venous anastomosis for augmentation of blood supply. Colo-duodeno-anastomosis and ileo-transverse colic anastomosis were performed for complete digestive transit reconstruction.

RESULT

This procedure was applied in a case of 41 years male attempted suicide by ingesting alkali caustic liquid (concentrated sodium hydroxide). Total necrosis of the esophagus and stomach occurred, which required initially total esophago-gastrectomy, closure at the level of the crico-pharyngeal sphincter and jejunostomy for enteral feeding with a highly deteriorated quality of life . The procedure was performed later and there were no major early and late postoperative complications and normal nutritional conditions were re-stablished.

CONCLUSION

The procedure is feasible and must be managed by multidisciplinary team in order to re-establish a normal quality of life.

Anastomotic Leakage after Upper Gastrointestinal Surgery: Surgical Treatment

BACKGROUND

Anastomotic leakage after upper gastrointestinal surgery is associated with major morbidity and mortality. In recent years, there was a major paradigm shift in the management of leakage after upper gastrointestinal surgery from surgical towards conservative and endoscopic treatment approaches as first-line treatment options.

METHODS

We conducted a PubMed literature search using combinations of the keywords 'leakage', 'complication', 'esophagectomy', 'gastrectomy', and 'pancreatectomy' to identify relevant publications.

RESULTS

Surgical re-intervention after esophagectomy, gastrectomy, or pancreatectomy is still indicated in selected patients, depending on the severity of symptoms, the condition of the patient, and failure of initiated treatment. Furthermore, surgical revision after esophagectomy and gastrectomy is indicated for early leakage and depends on the extent of anastomotic disruption and the condition of tissue.

CONCLUSION

Surgical re-intervention still plays a crucial role in the management of leakage after upper gastrointestinal surgery, especially in critically ill patients and after failure of conservative or endoscopic treatment.

Management of gastric conduit dehiscence with self-expanding metal stents: a case report on salvaging the gastric conduit

Background

Three-hole minimally invasive esophagectomy (3HMIE) is one of the most radical procedures in gastrointestinal surgery. It involves thoracoscopic dissection of the esophagus followed by creation of a gastric conduit in the abdomen with anastomosis in the neck, and is associated with significant morbidity. Gastric conduit dehiscence is one of the most morbid complications following esophagectomy. Historically, the standard of care in this situation has been conduit diversion with delayed esophageal reconstruction.

Case presentation

Here, we report two patients with a timely diagnosis of gastric conduit dehiscence of staple line after 3HMIE who were salvaged successfully with endoscopic placement of self-expanding metal stents.

Conclusion

Endoscopic stents may be used in selected cases of gastric conduit dehiscence after 3HMIE to salvage the conduit.

Roux-en-Y augmented gastric advancement: An alternative technique for concurrent esophageal and pyloric stenosis secondary to corrosive intake

Select group of patients with concurrent esophageal and gastric stricturing secondary to corrosive intake requires colonic or free jejunal transfer. These technically demanding reconstructions are associated with significant complications and have up to 18% ischemic conduit necrosis. Following corrosive intake, up to 30% of such patients have stricturing at the pyloro-duodenal canal area only and rest of the stomach is available for rather less complex and better perfused gastrointestinal reconstruction. Here we describe an alternative technique where we utilize stomach following distal gastric resection along with Roux-en-Y reconstruction instead of colonic or jejunal interposition. This neo-conduit is potentially superior in terms of perfusion, lower risk of gastro-esophageal anastomotic leakage and technical ease as opposed to colonic and jejunal counterparts. We have utilized the said technique in three patients with acceptable postoperative outcome. In addition this technique offers a feasible reconstruction plan in patients where colon is not available for reconstruction due to concomitant pathology. Utility of this technique may also merit consideration for gastroesophageal junction tumors.