Surgical treatment for upper or middle esophageal carcinoma occurring after gastrectomy: a study of 52 cases

Esophagocolonic OrVil Anastomosis After Minimally Invasive Esophagectomy

Purpose: The classical colon substitution procedure is open surgery. Still, technological developments could allow a minimally invasive procedure that might improve patient outcomes. To present the efficacy and safety of esophagocolonic OrVil anastomosis after minimally invasive esophagectomy. Methods: This retrospective study included 10 patients with esophageal cancer treated with OrVil anastomosis (OA) between August 2017 and May 2021 at Department of Thoracic Surgery, Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, Nanjing, China and the Fourth Associated Hospital of Anhui Medical University. The patient's characteristic information and related perioperative indexes were collected from the hospital's electronic medical record system and the patients were followed up. Results: The mean operative time and median intraoperative blood loss were 530 ± 88 minutes and 200 (range: 100-300) mL, respectively. A median of 26 (range: 13-30) lymph nodes was dissected per patient. The median total duration of hospitalization and postoperative hospitalization was 32 (range: 24-64) and 15 (range: 12-42) days, respectively. Seven (70%) patients had postoperative pulmonary infections. Two (20%) patients had postoperative respiratory failure. No esophagocolonic anastomotic leakage was observed in all cases. One patient was complicated with postoperative colonicoduodenal anastomotic leakage after the operation and was cured. However, 1 (10%) of the remaining 9 patients died from colonicolonic anastomotic leakage during hospitalization. The living 9 cases were followed up, and the median overall survival time was 36 months. Conclusion: Colonic interposition for esophageal cancer is effective and safe using the minimally invasive OA technique.

Reconstruction of the esophagus of patients with middle thoracic esophageal carcinoma using the remnant stomach following Billroth II gastrectomy

It seems impossible to reconstruct the esophagus of patients with middle thoracic esophageal carcinoma with a history of distal gastrectomy using the remnant stomach. Although surgeons have made multiple efforts to reconstruct the esophagus using the remnant stomach, it can only be successfully used in cases of lower thoracic esophageal cancer. Additionally, the surgery is more complex than traditional esophagogastrostomy due to challenges including mobilization of the remnant stomach with the spleen and transposition of the pancreatic tail into the left hemithorax. Our operation proved that the remnant stomach, which we named as the completely mobilized remnant stomach after dissection of the feeding vessels, remained viable. We successfully integrated the completely mobilized remnant stomach in the reconstruction of the lower thoracic esophageal tract and then integrated it in Ivor Lewis esophagogastrostomy. We describe this new alternative surgical technique for the treatment of middle thoracic esophageal carcinoma in patients with a history of distal gastrectomy in this study. Clinical data of 23 patients from 2008 to 2019 were retrospectively analyzed. All patients underwent the Ivor Lewis procedure. All remaining vessels of the remnant stomach were dissected at their origins, and Roux-en-Y reconstruction or Braun anastomosis was performed. After esophagectomy during right thoracotomy, anastomosis of the remnant stomach and esophagus was performed. Two-field lymph node dissections were performed. There was no case of necrosis of the remnant stomach or of perioperative death. Serious complications included anastomotic leak in three cases, afferent-efferent loop syndrome in one, and anastomotic stricture in two. Application of the completely mobilized remnant stomach in Ivor Lewis esophagogastrostomy is feasible, and the surgical procedure is similar to that of normal esophagogastrostomy.

Short- and long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell cancer in patients with prior gastrectomy

BACKGROUND

The surgery for esophageal cancer arising after prior gastrectomy is technically difficult with high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic treatment for superficial SCC with high curative resection rate. But few studies are concerned about ESD under these circumstances. The aim of this study was to elucidate the short- and long-term outcomes of ESD for superficial esophageal squamous cell cancer (SCC) in patients with prior gastrectomy.

METHODS

From January 2009 to January 2019, 37 patients with prior gastrectomy who underwent ESD for superficial esophageal SCC were retrospectively enrolled at the Zhongshan Hospital, Fudan University in Shanghai, China. Rates of en bloc resection, complete resection, curative resection, incidence of postoperative bleeding, perforation and postoperative stricture were evaluated as short-term outcomes. Overall survival, and local recurrence-free survival were evaluated as long-term outcomes.

RESULTS

The rate of en bloc resection, complete resection and curative resection were 94.6%, 86.5% and 78.4%, respectively. No perforation was observed. 1 (2.7%) patient experienced postoperative bleeding. During the median observation of 43 months, 3 (8.6%) patients experienced esophageal stricture, successfully managed by balloon dilation. 3(8.6%) patients had local recurrence after ESD with 5-year local recurrence-free survival rate of 91.4%. During the observation period, 4 patients died of other reasons. The 1, 3, 5-year overall survival rates were 97.1%, 97.1% and 91.4%.

CONCLUSIONS

The short-term outcomes indicate ESD is technically difficult with lower resection completeness in patients after gastrectomy, while the long-term outcomes are rather favorable.

The completely mobilized remnant stomach: A new choice to reconstruct the esophagus in lower thoracic esophageal carcinoma with a history of distal gastrectomy

OBJECTIVE

It is a significant surgical challenge to reconstruct esophagus for the patients following distal gastrectomy (DGE). Remnant stomach seems to be a better choice compared with colon or jejunal. But many complicated surgical methods were performed because of limitation of feeding vessels. We found the remnant stomach remained viable when all the feeding vessels were dissected. We used the completely mobilized stomach to reconstruct esophagus successfully in 29 lower thoracic esophageal carcinoma patients with a history of DGE.

METHODS

The clinical data of 29 patients were retrospectively analyzed from August 2005 to March 2017 who accepted esophagoplasty by the completely mobilized remnant stomach. All the vessels of the remnant stomach were dissected including short gastric, posterior gastric, left gastric and left gastroepiploic vessels. The DGE included 2 Billroth I and 27 Billroth II.

RESULT

No perioperative death, no remnant stomach necrosis occurred. One Leakage was the iatrogenic injury on the remnant stomach. The other postoperative complications were the pulmonary infection(5) and arrhythmia(4).

CONCLUSION

The completely mobilized remnant stomach was viable and functional after dissecting all the feeding vessels. Application of it was a new and feasible surgical method to perform esophagoplasty with the simpler procedure and less complication.

European perspective in Thoracic surgery-eso-coloplasty: when and how?

Colon interposition has been used since the beginning of the 20(th) century as a substitute for esophageal replacement. Colon interposition is mainly chosen as a second line treatment when the stomach cannot be used, when the stomach has to be resected for oncological or technical reasons, or when the stomach is deliberately kept intact for benign diseases in young patients with long-life expectancy. During the surgery the vascularization of the colon must be carefully assessed, as well as the type of the graft (right or left colon), the length of the graft, the surgical approach and the route of the reconstruction. Early complications such as graft necrosis or anastomotic leaks, and late complications such as redundancy depend on the quality of the initial surgery. Despite a complex and time-consuming procedure requiring at least three or four digestive anastomoses, reported long term functional outcomes of colon interposition are good, with an acceptable operative risk. Thus, in very selected indications, colon interposition could be seen as a valuable alternative for esophageal replacement when stomach cannot be considered. This review aims at briefly defining "when" and "how" to perform a coloplasty through demonstrative videos.

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.

Esophageal replacement by colon interposition with microvascular surgery for patients with thoracic esophageal cancer: the utility of superdrainage

Replacing the thoracic esophagus with the colon is one mode of reconstruction after esophagectomy for esophageal cancer. There is, however, a high incidence of postoperative necrosis of the transposed colon. This study evaluated the outcomes of colon interposition with the routine use of superdrainage by microvascular surgery. Twenty-one patients underwent colon interposition from 2004 to 2009. The strategy for colon interposition was to: (i) use the right hemicolon; (ii) reconstruct via the subcutaneous route; (iii) perform a microvascular venous anastomosis for all patients; and (iv) perform a microvascular arterial anastomosis when the arterial blood flow was insufficient. The clinicopathologic features, surgical findings, and outcomes were investigated. The colon was used because of a previous gastrectomy in 18 patients (85.7%) and synchronous gastric cancer in three patients (14.3%). Eight patients (38.1%) underwent preoperative chemoradiotherapy including three (14.3%) treated with definitive chemoradiotherapy. Seven patients (33.3%) underwent microvascular arterial anastomosis to supplement the right colon blood supply. Pneumonia occurred in four patients (19.0%). Anastomotic leakage was observed in five patients (23.8%); however, no colon necrosis was observed. The 3-year and 5-year overall survival rates were both 50.6%. Colon interposition with superdrainage results in successful treatment outcomes. This technique is one option for colon interposition employing the right hemicolon.

Esophageal reconstruction with colon tissue

The present best practice for performing esophageal reconstruction using colon tissue was investigated in this review. The left colon has advantages in that it has less variation in blood supply and a smaller diameter than the right colon; however, the rate of graft necrosis is higher for the left colon. Additional microvascular anastomosis, which is unnecessary in most cases, may be able to resolve these issues. The colon graft should be reconstructed in an isoperistaltic fashion whenever possible in order to prevent regurgitation and improve food transit. The posterior mediastinum has the advantage of being the shortest route, but it also has the major disadvantage that graft necrosis can be severe or fatal if it occurs. In palliative or advanced cases, a retrosternal or subcutaneous route is preferred, because the posterior mediastinum is a tumor bed. However, in these cases partial excision of the manubrium and the left clavicula should be considered to release compression of the graft at the thoracic inlet. Consequently, the selection of the colon graft should be flexible and be based on the inspection of blood supply and the length needed, and thereafter microvessel anastomosis should be added in cases where graft ischemia might occur.

Multi-factor investigation of early postoperative cardiac arrhythmia for elderly patients with esophageal or cardiac carcinoma

BACKGROUND

The purpose of the present study was to analyze the risk multi-factors of postoperative cardiac arrhythmia for elderly patients with esophageal or cardiac carcinoma.

METHODS

A total of 756 operations for elderly patients (>65 years of age) with esophageal or cardiac carcinoma were performed in our department from January 1997 to December 2006. These included 197 cases (26.1%) of various types of cardiac arrhythmia after operation. Logistic regression was adopted to analyze the risk multi-factors of postoperative cardiac arrhythmia.

RESULTS

It showed that complications of other diseases before operation, selection of operation method, duration of anesthesia and operation, postoperative pain, anoxia, hypovolemia, acid-alkali disequilibrium, and electrolyte imbalance might be the risk factors of postoperative cardiac arrhythmia in elderly patients with esophageal or cardiac carcinoma, whereas minimally invasive endoscopic operation might be a protective factor.

CONCLUSIONS

In order to decrease the risk factors leading to postoperative cardiac arrhythmia for elderly patients with esophageal or cardiac carcinoma, it was necessary to completely evaluate the functions of heart and lung, improve the nutrition and metabolism of heart muscle, conduct effective breathing exercises, and correct the existing cardiac arrhythmia of such patients before operation, and perform the minimally invasive operation, shorten operation duration, relieve pain efficiently during the perioperative period, and correct hypovolemia and acid-alkali disequilibrium and electrolyte imbalance.

Operative outcome of colon interposition in the treatment of esophageal cancer: a 20-year experience

BACKGROUND

In patients with esophageal cancer and a history of gastric surgery, colonic interposition is the treatment of choice. Our aim was to review our experience with this technique and to identify possible predictors of the clinical outcome.

METHODS

Between 1986 and 2006, 43 patients underwent esophageal reconstruction accomplished by colon interposition in our surgical department. Data from these patients were collected consecutively and reviewed retrospectively.

RESULTS

Colon interposition was performed isoperistaltically in 15 patients and was performed in 28 patients anisoperistaltically. In 18 patients, the right colon was used for interposition, whereas in 25 patients, the left colon was used. The mean survival time was 23+/-29 months. Artificial ventilation more than 24h, tumor differentiation grade III, the presence of major complications, and the presence of multivisceral resection had a significant negative influence on the operative outcome of colon interposition for esophageal replacement.

CONCLUSION

Colon interposition for esophageal replacement provides a satisfactory operative outcome with high complication rates. Therefore, it should be reserved as a treatment of second choice for cases in which the stomach is not available.

Surgical outcome of colon interposition by the posterior mediastinal route for thoracic esophageal cancer

BACKGROUND

For thoracic esophageal cancer patients with a history of gastrectomy, esophageal reconstruction using segments of colon was often accomplished using the anterior mediastinal route to avoid fatal complications related to colon necrosis. Our aim was to review our experience with reconstruction by the posterior mediastinal route and assess the surgical outcomes.

METHODS

Between 1989 and August 2006, 34 esophageal cancer patients at Akita University Hospital underwent esophageal reconstruction accomplished by colon interposition by the posterior mediastinal route. Data from these patients were reviewed.

RESULTS

Colon conduits consisted of left colon segments in 4 patients and right colon segments in 30. The grafts were supplied with blood by the left colonic artery in 13 patients, the middle colonic artery in 20, and the right colonic artery in 1. The esophagocolic (pharyngocolic) anastomosis was located in the neck in 33 patients (97%) and in the thorax in 1. No patient died during the initial hospital stay. There were no instances of colon necrosis. An anastomotic fistula occurred in 3 patients (9%). Proximal anastomotic strictures occurred in 2 patients (6%). No late graft redundancies resulting in significant dysphagia occurred. Reductions in body weight did not differ from those seen when the gastric tube was used for reconstruction, and alimentary function was good after surgery. The 1-, 2-, 3-, and 5-year survival rates were 66%, 52%, 48%, and 48%, respectively.

CONCLUSIONS

Colon interposition by the posterior mediastinal route provides a good outcome and is considered the route of first choice.

Biliary laryngopharyngeal reflux: a new pathological entity

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent understanding of the harmful effects of gastric and duodenal agents on mucosa of the upper aerodigestive tract in patients with duodeno-gastro-esophageal reflux.

RECENT FINDINGS

The damaging action of duodeno-gastro-esophageal reflux on the gastro-esophageal mucosa and its potential etiological role in the development of many inflammatory and neoplastic patterns have been well documented in the literature. Recently, there has been increasing evidence that duodeno-gastro-esophageal reflux may also be related to several laryngeal disorders and clinical studies confirm that reflux after gastric resection may enhance the development of laryngeal malignancies. Finally, there have been experimental attempts to confirm that duodenal contents may contribute to inflammation and carcinogenesis in the pharynx or larynx, as it is known to do in the esophagus.

SUMMARY

The association between duodeno-gastro-esophageal reflux and laryngeal lesions is of great interest to otolaryngologists because it focuses attention on a new pathological entity that could be classified as biliary laryngopharyngeal reflux. This condition, as an acid one, seems to represent an important dangerous, endogenous risk factor involved in the pathogenesis of inflammatory, precancerous and neoplastic laryngeal lesions. For these reasons, particular attention is required in the future regarding the understanding of the local environment, individual susceptibility and clinical treatment. Finally, new antireflux therapy should be considered to control not only the acid gastric component of the refluxate but also the duodenal component.