Management and outcome of esophageal stenting for spontaneous esophageal perforations

Treatment of spontaneous esophageal perforation (SEP) consists of different conservative, surgical and endoscopic treatment modalities. In this study, we evaluated the clinical efficacy and the outcome of covered self-expanding stent (CSES) treatment of SEP. All patients with SEP treated by CSES at our institution between 2005 and 2014 were included in this prospective single-center study. The data were collected from a prospective database based on clinical, endoscopic and operative reports. Follow-up data were procured by contacting the patients or their family doctors. The patient data were analyzed concerning course of treatment, leakage sealing rate, complications, and mortality. Patients with iatrogenic or malignant perforations were excluded. In total, 16 patients underwent endoscopic CSES placement for SEP between 2005 and 2014. Sealing of the leakage was immediately successful in 50% (8 patients). A second stent was placed in 5 patients, but did not achieve sealing of the perforation in any case, requiring a switch in treatment to a surgical procedure (n=4) or drainage of the persisting leakage (n=4). In-hospital mortality was 13%. Only delayed treatment was identified as a risk factor for inferior outcome. Patients with successful CSES treatment had a shorter ICU- and hospital stay and had a reduced risk of developing esophageal stenosis (RR: 0.4) or persisting dysphagia despite treatment (RR: 0.33). Endoscopic treatment of SEP is beneficial to the patient if immediately successful, but in our experience, failure rates are higher than described in the literature. Secondary placement of CSES was not successful when initial stent treatment failed, while both surgical intervention and drainage of the perforation showed good results in sealing the leakage.

Functional outcome of gastrointestinal tract and quality of life after esophageal reconstruction of esophagus cancer

BACKGROUND/AIM

Information about functional outcome and quality of life after esophagectomy and esophageal reconstruction (ER) for the treatment of esophageal cancer, as evaluated by the patients themselves is limited. We aimed to study the post-surgical outcome of such patients to detect for the development of any complications that may arise from the surgery as well as to evaluate their quality of life following the surgery.

METHODS

From 1993 to 2003, 240 patients with stage I, II, or III esophageal carcinoma underwent esophagectomy at Razi Teaching Hospital located in the north of Iran. Of these, 192 patients filled out a questionnaire during a 2-year period (ranging from 12 to 48 months after surgical reconstruction). Among them, there were 134 men (69%) and 58 women (31%), and the mean age at the time of ER was 48 years (ranging from 22 to 75 years). Transhiatal esophagectomy, extended esophagectomy (three field operation), and Ivor-Lewis resection were done in 142 (73.95%), 30 (15.62%), and 20 patients (10.42%), respectively. Intestinal continuity after esophageal resection was established with stomach in 154 patients (80%), colon in 28 patients (14%), and small bowel in 10 patients (5.2%). Cervical anastomosis was established in 172 patients (89.6%), while intrathoracic anastomosis was performed in 20 patients (10.4%).

RESULTS

After ER, 66 patients (34.4%) suffered from dysphagia to solids and 50 patients (26%) required at least one or three postoperative dilatations for alleviation of symptoms. Gastroesophageal reflux was seen in 32 patients (16.66%) and was more common in thoracic anastomosis patients than in cervical anastomosis patients. Heartburn was present in 33 cases (17%), 30 of whom required medication (37%). The number of meals per day was three to four in 116 patients (60%), more than four in 51 patients (29%), and less than three in 19 patients (9.82%). The number of bowel movement per day increased in 52 patients (27%), decreased in 60 cases (31%), and unchanged in 80 patients (41%). Weight gain was reported by 38 patients (19.8%), and weight loss was reported by 50 patients (26%). No change in weight occurred in 100 patients (52%). Overall satisfaction was excellent in 29 patients (15%). Overall quality of life (work, pain-relief, vitality, and emotional status) was lower than in general population. Age, sex, and stage of cancer did not affect the functional outcome but affected the quality of life. Also patients who received cervical anastomosis and ER with colon had significantly fewer reflux symptoms. Most of the patients with colon reconstruction gained weight.

CONCLUSIONS

Self-assessment of postoperative ER by the patients after esophagectomy for malignant disease demonstrates that undesirable symptoms are frequently present at short- and long-term follow-ups. Short- and long-term functional outcome is affected by the type of reconstruction after esophagectomy. Results of this study suggest that colon graft in ER is significantly advantageous compared with other methods because of the ability of patients to gain weight and avoid developing postoperative reflux.

Simultaneous tracheal and esophageal reconstruction for thyroid cancer involving trachea and esophagus using a free bipaddled posterior tibial artery perforator flap

BACKGROUND

Simultaneous tracheal and esophageal reconstruction after tumor resection is a great challenge. Here we present an innovative operative technique to simultaneously reconstruct tracheal and esophageal defects, in which a free posterior tibial artery perforator flap was made into a free bipaddled flap to cover both tracheal and esophageal defects.

METHODS

A free bipaddled posterior tibial artery perforator flap was utilized to conduct simultaneous tracheal and esophageal reconstruction for a 72-year-old female patient with papillary thyroid carcinoma and massive trachea and esophagus invasion, who underwent radical resection.

RESULTS

Satisfactory breathing and swallowing functions were gained independent of nasal feeding and tracheotomy. Voice was still hoarse due to tumor invasion of left recurrent laryngeal nerve. During a period of 2-year follow-up, no sign of tumor recurrence was observed.

CONCLUSION

A free bipaddled posterior tibial artery perforator flap could be a decent choice for simultaneous reconstruction of large tracheal and esophageal defects.

Venous superdrained gastric tube pull-up procedure for hypopharyngeal and cervical esophageal reconstruction reduces postoperative anastomotic leakage and stricture

Gastric pull-up is a common procedure to reconstruct the continuity of the upper digestive tract after esophageal resection. However, this technique sometimes causes postoperative anastomotic leakage or stricture, resulting from insufficient blood flow at the distal end. To overcome this problem, additional microvascular venous anastomoses were performed. The purpose of this study was to compare the outcomes of post-surgical anastomotic leakage and stricture in patients with and without additional microvascular venous superdrainage after cervical esophageal and hypopharyngeal resection and gastric tube reconstruction. A total of 29 consecutive patients with esophageal or hypopharyngeal cancer who underwent total esophagectomy and hypopharyngectomy with gastric tube reconstruction in the National Organization Nagasaki Medical Center between April 2014 and May 2016 were analyzed in this study. Of these patients, 20 underwent additional venous anastomoses (superdrainage group), and 9 did not undergo additional procedures (standard group). We compared the frequency of post-surgical stricture and leakage in the two groups retrospectively. Three of nine patients (33.3%) developed postoperative leakage in the standard group, and 1 of 20 (5.0%) did so in the superdrainage group. Six of nine patients (66.7%) showed postoperative anastomotic stricture in the standard group, but none did so in the superdrainage group. Patients who did not undergo additional venous superdrainage were significantly more likely to develop postsurgical leakage (P < 0.05, Chi-square test) and anastomotic stricture (P < 0.001, Chi-square test). Our study revealed that only additional venous anastomoses could reduce the incidence of postoperative anastomotic leakage and stricture. This procedure is of merit to perform after total esophagectomy and hypopharyngectomy with gastric tube reconstruction.

Malignancy arising in a 41-year-old colonic interposition graft

The colon can be used for esophageal reconstruction after an esophagectomy. The development of a malignancy in the colonic interposition graft is rare, with less than 15 cases reported in the literature. We present a case of a 60-year-old male with high-grade dysplasia of the colonic interposition graft used for reconstruction of the esophagus, which developed 41 years after the esophageal reconstruction. The long-term complication of the development of a malignancy must be considered when using the colon for reconstruction especially when the esophageal reconstruction is performed for a benign cause.

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.

Microsurgical reconstruction of combined tracheal and total esophageal defects

OBJECTIVE

Lesions involving both the trachea and the esophagus are often considered inoperable because of the lack of reliable reconstruction. The purpose of this study was to review our experience of combined supercharged jejunal and other flaps for tracheal and esophageal reconstruction.

METHODS

A retrospective review of 5 consecutive cases with combined tracheal and total esophageal defects was performed. The esophageal defect was reconstructed with a supercharged jejunal flap, and the trachea was reconstructed with a free anterolateral thigh flap or a pedicled muscle flap.

RESULTS

Primary diagnosis included tracheostoma recurrence after a total laryngectomy for laryngeal cancer in 2 patients and tracheoesophageal fistula due to esophageal stenting for complications from prior treatment for non-Hodgkin's lymphoma, parathyroid cancer, and esophageal cancer in 3 patients, respectively. Tracheal and esophageal reconstructions were staged in 4 patients, and 1 patient received simultaneous reconstruction. Tracheal necrosis developed in 1 patient with a mediastinal tracheostoma, and the patient eventually died of infection 2 months later. The other 4 patients recovered well and resumed an oral diet.

CONCLUSIONS

Complex and often life-threatening lesions involving both the trachea and the esophagus are not necessarily inoperable. With careful planning, these combined defects can be safely reconstructed with multiple flaps with good functional outcomes and reasonable survival.

A non-randomized retrospective observational study on the subcutaneous esophageal reconstruction after esophagectomy: is it feasible in high-risk patients?

BACKGROUND

Esophageal reconstruction after esophagectomy is a complex procedure with high morbidity and mortality. Anastomotic leakage is more severe and frequent in patients with preoperative comorbidities and may present with septic conditions. Considering the possibility of an easier management of such cases, we evaluated the safety and feasibility of subcutaneous esophageal reconstruction in patients with high operative risks.

METHODS

We performed a non-randomized retrospective observational study on the 75 (subcutaneous: 21, intrathoracic: 54) esophageal cancer patients who underwent esophageal reconstruction either through subcutaneous or intrathoracic route between January 2003 and February 2015. Preoperative data including the estimated reasons for the selection of the subcutaneous route were obtained from medical charts. Clinical outcomes were evaluated and compared between the two groups.

RESULTS

The mean postoperative hospital stay was longer in the subcutaneous group than the overall group. Anastomotic leakage occurred more frequently in the subcutaneous group [10 (47.6%) vs. 7 (13%), P=0.004]. Three major leakages resulted in chronic cutaneous fistula, but were successfully treated by lower neck reconstruction using radial forearm fasciocutaneous free flap (RFFF). There was no in-hospital mortality in the subcutaneous group.

CONCLUSIONS

Subcutaneous esophageal reconstruction in high-risk patients showed a higher rate of anastomotic leakage. However, easier correction without fatal septic conditions could be obtained by primary repair or flap reconstruction resulting in lower perioperative mortality. Therefore, esophageal reconstruction through the subcutaneous route is not recommended as a routine primary option. However, in highly selected patients with unfavorable preoperative comorbidities or intraoperative findings, especially those with poor blood supply to the graft, graft hematoma or edema, or gross tumor invasion to surrounding tissues, esophageal reconstruction through the subcutaneous route may carefully be considered as an alternative to the conventional surgical techniques.

Esophagectomy with gastric conduit reconstruction for benign disease: extreme but important

Esophagectomy is usually performed to resect esophageal cancer. However, there are numerous other indications for esophagectomy, including Barrett's esophagus with high-grade dysplasia (HGD) and some benign diseases such as obstruction, end-stage achalasia, esophagus perforation or disruption, benign neoplasm, and severe caustic injury. For these patients, esophagectomy could relieve their symptom obviously. However, esophagectomy causes huge trauma, induces quite high morbidity and mortality, and may decreases patients' quality of life obviously due to postoperative reflux, dumping, anastomotic stricture and other complications. Accordingly, the considerations of a surgery must be carefully deliberated, including the underlying disorder, lesions localization, extent of disease, and options for esophageal replacement. For patients received esophagectomy and alimentary tract reconstruction, gastric conduit is the most common used replacement organ, then colon and jejunum. This review demonstrated the importance and technical experience of esophagectomy with gastric conduit reconstruction for benign diseases.

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.

Experimental reconstruction of cervical esophageal defect with artificial esophagus made of polyurethane in a dog model

The defect of esophagus after surgical excision in patients is usually replaced by autologous stomach, jejunum, or colon. The operation brings severe trauma and complications. Using artificial esophagus to replace the defect in situ can reduce the operative trauma, simplify the operative procedures, and decrease the influence to digestive function. A variety of experiments have been designed for developing a practical artificial esophagus. Nevertheless, a safe and reliable artificial esophagus is not yet available. The objective is to evaluate the possibility of the artificial esophagus made of non-degradable polyurethane materials being used in reconstruction of the segmental defect of cervical esophagus in beagles, observe the regeneration of esophageal tissue, and gather experience for future study. The cervical esophageal defects in 13 beagles were designed to 2-cm long and were constructed by the artificial esophagus made of non-degradable polyurethane materials. Nutrition supports were given after the operation. The operative mortality, anastomotic leakage, migration of artificial esophagus, and dysphagia were followed up. The regeneration of the esophageal tissues was evaluated by histopathology and immunohistochemical labeled streptavidin-biotin method. The surgical procedures were successfully completed in all beagles, and 12-month follow-ups were done. Only one beagle died of severe infection, and all others survived until being killed. The anastomotic leakage occurred in nine beagles, most of them (8/9) were cured after supportive therapy. The migration of artificial esophagus occurred in all 12 surviving beagles, and one artificial esophagus stayed in situ after migration. All 12 surviving beagles showed dysphagia with taking only fluid or soft food. No beagle died of malnutrition. The neo-esophagus was composed of granulation tissue, and the inner surface was covered by epithelium in 2-3 months completely. But the inner surface of neo-esophagus with artificial esophagus staying in situ after migration was not covered by epithelium, and the granulation tissue was infiltrated by a great deal of inflammatory cells. Antibodies against cytokeratin were positively expressed in epithelium of neo-esophagus. Up to 12 months after operation, antibodies against smooth muscle actin and desmin were both negatively expressed in neo-esophagus. The artificial esophagus made of non-degradable polyurethane reconstructing cervical esophageal defect is practicable. Although there are some problems, including anastomotic leakage, migration, and dysphagia, they are not lethal following good supportive therapy. The esophageal epithelium can regenerate with the supporting role of artificial esophagus. In the future, deformable artificial esophagus should be improved, and a much longer follow-up will be performed to evaluate whether the esophageal gland and skeletal muscle can regenerate.

The Sternocleidomastoid Myocutaneous Flap: A Laryngeal Preservation Option for Total Hypopharyngoesophageal Stenosis

Complete hypopharyngoesophageal (HPE) stenosis is rare and a challenging condition to treat. When endoscopic therapy fails, total laryngectomy with or without pharyngeal reconstruction is usually performed. We present a retrospective case series involving 3 patients with complete HPE stenosis who failed endoscopic repair and were gastrostomy dependent. All were managed successfully with the sternocleidomastoid myocutaneous (SCM) flap. A temporary fistula occurred in 1 patient. Hospitalization ranged from 5 to 15 days, patients resumed oral intake from 21 to 82 days postoperatively, and their gastrostomy tubes were removed from 28 to 165 days postoperatively. We suggest that the SCM flap is a laryngeal preservation option for reconstruction of complete HPE stenosis when endoscopic techniques fail. This flap allows HPE repair and reconstruction within the same surgical field, imposes no significant donor site morbidity, and affords good functional and cosmetic outcomes.

The cervicosternolaparotomy approach for the treatment of graft dysfunction after retrosternal esophageal reconstruction for caustic injuries

OBJECTIVE

The study purpose was to report the indications, technical aspects, and outcomes of cervicosternolaparotomy during revision surgery after esophageal reconstruction for caustic injuries.

METHODS

Patients who underwent cervicosternolaparotomy during revision surgery for graft dysfunction between 1999 and 2015 were included. Cervicosternolaparotomy was performed to mobilize and pull up the primary conduit during surgery for strictures (rescue cervicosternolaparotomy) or to allow retrosternal access for management of other graft-related complications (exposure cervicosternolaparotomy). Statistical tests were performed to identify factors associated with primary conduit preservation during rescue cervicosternolaparotomy.

RESULTS

Fifty-five patients were included (28 men; median age, 43 years). Median delay between primary reconstruction and cervicosternolaparotomy was 15 months. Exposure cervicosternolaparotomy was performed in 12 patients (22%) for redundancy (n = 8), spontaneous perforation (n = 2), and caustic reingestion (n = 2). Rescue cervicosternolaparotomy was performed in 43 patients (78%) to treat supra-anastomotic (n = 11), anastomotic (n = 23), and diffuse (n = 9) stenosis. During rescue cervicosternolaparotomy, the primary conduit was preserved in 32 patients; median length gain obtained by transplant release was 8 cm. Failure to preserve the primary conduit was associated with previous surgical repair attempts (P = .003) and lack of initial concomitant pharyngeal reconstruction (P = .039). Two patients died (4%), and 35 patients (64%) experienced operative complications. Operative outcomes were similar after rescue and exposure cervicosternolaparotomy. With a median follow-up of 4.4 years, the functional success rate was 85%.

CONCLUSIONS

Cervicosternolaparotomy during revision surgery for graft dysfunction is reliable, is associated with low morbidity and mortality, and has good results.

Postprandial hyperinsulinemic hypoglycemia in a child as a late complication of esophageal reconstruction

BACKGROUND

Postprandial hyperinsulinemic hypoglycemia (PHH) is an increasingly recognized complication of gastric bypass surgery in obese adults, distinct from the "dumping syndrome".

CASE PRESENTATION

Upon birth, primary repair of esophageal atresia was performed, and at the age of 14 months definite esophageal reconstruction was performed. At the age of 3 years, recurrent brief episodes of symptomatic hypoglycemia started. At the age of 5.7 years the girl was admitted to our clinic and investigations indicated hyperinsulinemic hypoglycemia. Oral glucose tolerance test (OGTT) and continuous glucose monitoring results revealed frequent postprandial hypoglycemic events, which were always preceded by early postprandial hyperglycemia. It was concluded that the patient had PHH caused by a delayed and hyperinsulinemic response to carbohydrate intake as a result of esophagogastric surgery. Treatment with acarbose was titrated using flash glucose monitoring, which resulted in satisfactory glucose regulation.

CONCLUSIONS

This is the first described case of a child with PHH following esophageal reconstruction.

Effectiveness and safety of bovine pericardium patch repair for cervical anastomotic leakage after oesophagectomy for cancer

Background

The objective of this study is to evaluate the effectiveness and safety of bovine pericardium patch (BPP) repair for cervical anastomotic leakage after esophageal squamous cancer.

Methods

Intractable cervical anastomotic leakage developed in 7 patients of esophageal squamous cell carcinoma undergoing cervical anastomosis. These patients received the BPP repair. The necrotic tissue around the cervical anastomosis was removed during the operation, and the defect was repaired with BPP according to the size of the leakage.

Results

The operative duration was 60-90 min (median, 75 min). There were no signs of recurrent anastomotic leakage in each patient undergoing BPP repair. Oral intake was initiated 5-8 days (median, 6 days) after the BPP repair operation without any discomfort.

Conclusions

The BPP repair is a safe and effective processing scheme for patients with cervical anastomotic fistula after resection of esophageal squamous cell carcinoma. This method may be recommended for appropriate patients with intractable cervical anastomotic fistula.

What is the best reconstruction procedure after esophagectomy? A meta-analysis comparing posterior mediastinal and retrosternal approaches

Thoracic esophagectomy is a particularly invasive and complicated surgical procedure, with a reconstruction of the gastrointestinal tract, such as the stomach, jejunum, or colon. The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. Additionally, the best anastomotic techniques after esophagectomy in terms of location (Ivor Lewis or McKeown) and suturing (manual or mechanical) are debatable. Our meta-analysis investigating postoperative complications after esophagectomy between the posterior mediastinal and retrosternal routes revealed that the posterior mediastinal route was associated with a significantly lower anastomotic leakage rate than the retrosternal route (odds ratio = 0.78, 95% confidence interval: 0.70-0.87, p < 0.0001). Conversely, pulmonary complications (odds ratio = 0.80, 95% confidence interval: 0.58-1.11, p = 0.19) and mortality between the posterior mediastinal and retrosternal routes (odds ratio = 0.79, 95% confidence interval: 0.56-1.12, p = 0.19) were not significantly different. However, the incidence of pneumonia may be lower when using the retrosternal route rather than the posterior mediastinal route for performing minimally invasive esophagectomy. The McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes; however, the Ivor Lewis procedure offers perioperative and oncological safety for tumors located under the carina. An individualized treatment strategy for selecting the optimal reconstruction procedure can be proposed in future studies based on oncological and patient risk factors considering mid- to long-term quality of life.

Complications and Functional Outcomes After Esophageal Reconstruction with an Intact Larynx

BACKGROUND

Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx.

METHODS

Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed.

RESULTS

Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post-operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30-day readmissions. At three months after operation, all patients who were not tube feed-dependent prior to surgery returned to oral intake. Of the four patients who were tube feed-dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre- and postoperatively with no voice changes.

CONCLUSIONS

Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long-term morbidity.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1227-1233, 2024.

Superdrainage Using the Cephalic Vein Due to Unsuitable Internal Thoracic Vein for Microvascular Anastomosis in Esophageal Reconstruction Using Pedicled Jejunum

The progress and popularization of microvascular surgical techniques may improve the outcomes of esophageal reconstruction using non-gastric tube (GT) grafts. A pedicled jejunum (PJ) with microvascular anastomoses is frequently selected as a reconstructed conduit for esophageal reconstruction when the GT is unavailable, and the internal thoracic (IT) vein is frequently selected as a recipient blood vessel for microvascular anastomosis. However, the IT vein may be inadequate for microvascular anastomosis because of its absence or underdevelopment. Since it is difficult to preoperatively predict such rare cases, it becomes necessary to urgently and rapidly prepare an alternative blood vessel. Herein, we present surgical procedures for superdrainage using the cephalic vein (CeV). Due the superficial nature of the CeV, it is both easy to identify and collect sufficient length. Thus, the CeV is very useful as an urgent substitute blood vessel when the IT vein is unavailable for microvascular anastomosis in esophageal reconstruction.

Flap-based Closure of Acquired Tracheoesophageal Fistulas

Iatrogenic tracheoesophageal fistulae management and repair are difficult to manage with few resourced describing management and repair. Two cases are presented describing the approach to and repair of a tracheoesophagea fistula; one with a free flap and one with local flap reconstruction. Both cases utilized allograft material to maintain separation between the alimentary and repiratory tracts. Laryngoscope, 134:3761-3764, 2024.

Alternative non-oral nutrition in a rat model: a novel modified gastrostomy technique

The gastrostomy technique is essential for esophageal reconstruction using a scaffold. To date, there are no established methods to supply nutrients through a gastrostomy tube in rats. The purpose of this study was to analyze the feasibility of a newly modified gastrostomy technique for non-oral nutrition in an adult rat model. We modified the gastrostomy technique for adult rats in a few different ways. (1) The external opening for food injection was made at the midpoint between the ears to prevent damage due to self-harm behaviour. (2) An imbedded subcutaneous tunnel was created between the internal and external openings of the gastrostomy. We compared the efficacy and safety between groups with a T-tube for biliary drainage (TT group, n=14) and a conventional silicone Foley catheter (FC group, n=7) as optimal gastrostomy tubes for in a rat model. We also evaluated the feasibility of the heparin cap connector at the end of gastrostomy tube to control food supply in the TT group (with a cap, n=7; without a cap, n=7). No mortality was observed in the TT group with a cap, whereas most rats in the FC group died within 2 weeks after the procedure. Weight loss decreased significantly in the TT group with a cap compared with all the other groups. The appearance and attitude scores were significantly better in the TT group with a cap. In addition, histologic analysis showed that the TT group a cap showed a marked decrease over time in tissue fibrosis and macrophages compared with the other experimental groups. Therefore, gastrostomy using a silicone T-tube plugged with a cap proved to be a stable and effective option for non-oral feeding in an adult rat model.

Reconstruction of Adult Tubular Esophageal Duplication with Supraclavicular Artery Island Flap: A Rare Case Presentation

Adult esophageal duplication (ED) is a rare congenital anomaly that is rarely encountered in clinical practice. There have been only a few reported cases of adult tubular esophageal duplication. A patient presented with symptoms of odynophagia and dysphagia. Upon examination, gastroscopy and X-ray contrast imaging revealed the formation of a fistula in the upper esophagus that connected to a sinus tract running along the esophagus. After managing the initial infection, an open surgery was performed. The esophageal tubular duplication was removed and the defect was reconstructed using a supraclavicular artery island (SAI) flap. The post-operative recovery was uneventful and the patient's odynophagia and dysphagia were relieved. In conclusion, ED can be effectively diagnosed through esophagogram and gastroscopy. Surgical excision is currently the preferred treatment option, and the use of the SAI flap technique shows great promise in reconstructing the esophageal defect after surgery.

Dietary habits and nutrition status in esophageal cancer patients after esophageal reconstruction

Background

Surgery is the cornerstone of the treatment of esophageal cancer (EC). This study is to evaluate the dietary habits and nutrition status in EC patients who underwent esophagectomy followed by esophageal reconstruction.

Methods

This retrospective study included patients with EC who underwent esophagectomy followed by esophageal reconstruction in the Department of Thoracic Surgery I of Peking University Cancer Hospital between February 2014 and December 2018. The primary outcomes were dietary habits and nutrition status. The secondary outcomes were gastrointestinal symptoms and quality of life (QoL).

Results

A total of 346 patients were included. At 30 months after the operation, 90.2% of the patients had recovered to regular dietary habits, 72.8% of patients had a restored frequency of preoperative regular food intake, 2.3% of the patients ate more than six times a day, and 0.6% had semi-liquid food because of bad teeth. The nutrition status remained stable after 6 months postoperatively and recovered slightly 1 year after the surgery. At 30 months after the operation, the most common gastrointestinal symptoms were reflux (38.4%), dysphagia (15.3%), hoarseness (11.8%), abdominal distension (6.6%), diarrhea (2.9%), and nausea and vomiting (2.3%). According to the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire-OG 25 (EORTC QLQ-OG 25), the factors that affected the life quality of patients during follow-up were anxiety, reflux, and dietary limitations.

Conclusions

Most patients with EC who underwent esophageal reconstruction recovered to regular dietary habits and stable nutrition status, while some may still suffer from gastrointestinal symptoms, anxiety, and dietary limitations.

Nasopharyngeal gangrenous abscess with skull base extension caused by Escherichia coli after esophageal dilatation for esophageal reconstruction

Background:

Esophageal dilatation is the most widely used treatment option for the management of esophageal strictures. Complications include bleeding, brain abscess, esophageal perforation and bacteremia. Nasopharyngeal gangrenous abscess after the esophageal dilatation is very rare. Endonasal endoscopic surgery was performed to treat the lesion and a successful result was obtained.

Case Description:

A 59-year-old woman with a previous history of dilatation for esophageal stricture was admitted with a low-grade fever, headache, neck pain and cranial nerve abnormalities including sixth nerve palsy. Imaging studies aroused suspicion of necrotic retropharyngeal tumor with clivus, condylar process and cavernous sinus invasion. Biopsy with a pharyngosope was performed by an ENT doctor. The pathology showed acute necrotic inflammation, tissue granulation and bacteria colonies. Navigation with endonasal endoscopic surgery was chosen to treat the skull base and nasopharyngeal abscess. Bacterial culture showed Escherichia coli. Symptoms improved after the operation and treatment with antibiotics.

Conclusion:

A nasopharyngeal gangrenous abscess with extension to the skull base in the case of esophageal reconstruction after esophageal dilatation is extremely rare. Physicians dealing with esophageal stricture should keep in mind that a nasopharyngeal abscess is a potential complication of esophageal dilatation.

Reconstruction with hypopharyngo-gastrostomy after esophagus extirpation due to spontaneous esophageal perforation

Despite the significant improvement in surgical and intensive care therapy, esophageal perforation is still a severe, life-threatening condition. As the underlying causes, the accompanying disorders, the localization and the extent of the inflammation vary, the surgeon may sometimes encounter unexpected situations. A 58-year-old female developed necrotizing mediastinitis due to esophageal perforation as the result of incarcerated thoracic hernia of the stomach, therefore, we had to perform esophagus extirpation and cervical esophagostomy. During the reconstruction of the intestinal tract, we found shrinkage of the complete esophageal stump with unknown cause. The gastric sleeve was joined to the hypopharynx. Insufficiency was solved with conservative therapy. The patient regained partial swallowing ability after complex dysphagia treatment. Hyophapharyngo-gastrostomy done due to non-malignant disease is extremely rare in the literature, however, it can be a surgical technique of choice if required as in our case. It should be followed by rehabilitation done by a team, with emphasis on dysphagia treatment. Orv Hetil. 2020; 161(18): 756-760.