Adult Chest Surgery

Chapter 21. Options for Esophageal Replacement 

 

Reconstructing a functional esophageal replacement after surgical resection for esophageal malignancy is among the most difficult surgical challenges. Morbidity and mortality rates are high, and the quality of remaining life is profoundly affected by the quality of the functional result obtained. To quote the late Dr. Robert Ginsberg, "Probably no area of reconstructive surgery demands more versatility of approach and technique."1

The preceding chapters in Part 2 concerning esophageal and proximal stomach malignancy are authored by surgeons selected for their experience and expertise with the most frequently used operations. Each chapter provides detailed and comprehensive information on a specific approach, including indications, perioperative management, operative technique, and complications. This chapter provides information pertinent to the choice of available options. Selection is influenced by the highly variable circumstances associated with the individual patient. The merits and demerits of available options are highlighted and include observations relating to both theorgan used and the route employed. Hiebert and Bredenberg have provided an excellent synopsis of this information that warrants review.Specific clinical circumstances that influence or direct selection are noted.

ORGAN SELECTION

There are two primary objectives of the organ-selection process. The first is to restore the elements of normal esophageal function, that is, to maintain the ability to swallow a normal diet comfortably, to retain the ability to burp or vomit when necessary, and to minimize the potential for reflux, regurgitation, and aspiration. The second objective is to select a conduit for replacement that provides minimal morbidity and operative mortality. Needless to say, these obviously desirable objectives are rarely, if ever, totally achieved.

Stomach

Stomach is by far the most popular selection for esophageal replacement after resection of malignant disease (Fig. 21-1). Some form of gastric transposition is usually the simplest and safest option. When mobilized adequately, the stomach almost always can be elevated to the level of the cervical esophagus or pharynx. Maintenance of an adequate blood supply requires preservation of the familiar gastroepiploic vascular arcade. A single anastomosis restores the gastrointestinal continuity.

Figure 21-1.

 

Stomach is the preferred graft for malignant esophageal replacement. Several configurations have been devised. Depicted here is a conduit in which the whole stomach is used.

Whole Stomach

The term whole stomach indicates that the entire stomach is transposed for the replacement (see Fig. 21-1), in contrast to using the gastric tube, in which the main body of the stomach is retained in its abdominal location. In whole-stomach transposition, the left gastric and short gastric vessels are divided, the pylorus and duodenum are liberated using a Kocher maneuver, and variable lengths of the proximal lesser curvature and lesser omentum are resected along with the esophagus. The greater the length and width of the lesser curvature removed, the more tubular and hence longer is the gastric explant. When transposed, it is important to avoid compression of the explant at the level of the diaphragmatic hiatus and at the thoracic inlet in the neck. A pyloroplasty or pyloromyotomy commonly is added, although the indications for this relatively minor addition remain controversial. Long-term functional results are usually satisfactory.3

Failure of the gastric conduit most commonly is due to inadequacy of the blood supply at the upper end of the transposed stomach, which may result in anastomotic leak, dehiscence, and rarely, a potentially devastating necrosis of the upper end of the stomach.

Reflux from the interposed stomach into the residual esophagus or pharynx is a potentially serious problem. In general, the higher the anastomosis (upper thorax or neck), the lower is the incidence of significant reflux.

Gastric Tubes

Long tubular segments of stomach may be fashioned from the greater-curvature side of the stomach (Fig. 21-2A ). The blood supply again is derived from the gastroepiploic arcade. The detailed techniques for preparation of both "reversed" and "nonreversed" gastric tubes have been clearly described by Fell and Ximenes-Netto.A gastric tube, fashioned with the diameter of the normal esophagus, is the least bulky of the esophageal replacements and passes with minimal compression through the diaphragmatic hiatus, the substernal space or posterior mediastinum, and the thoracic inlet into the neck. The length of tube created varies with the extent of greater curvature selected (between the gastric antrum and the splenic hilum). Provided that the gastroepiploic circulation is preserved, it is always possible to create a tube sufficiently long that it can be elevated to any level in the neck.

Figure 21-2.

 

For most procedures involving esophageal replacement with a stomach graft, the tube is created along the length of the greater curvature (between the gastric antrum and the splenic hilum), and the remainder of the stomach is discarded (A). B, C. Techniques for reversed and nonreversed gastric tubes, respectively.

The reversed gastric tube (Fig. 21-2B ) requires preservation of the left gastroepiploic vessels at the splenic hilum. The marginal arcade is preserved, and the more robust right gastroepiploic vessels are divided at the antral end of the stomach. The nonreversed gastric tube is carried on the right gastroepiploic artery, with division of the gastric end of the tube at or close to the splenic hilum (Fig. 21-2C ).

The communication between right and left gastroepiploic vessels appears variable and is sometimes flimsy or missing from the marginal arcade (usually toward the splenic end). It would appear, however, that there is almost always a satisfactory circulation, maintained through collateral vessels, in the gastrocolic and gastrosplenic omenta, provided that the left gastric circulation remains intact. Technically, the simplest of these reconstructions is a reversed gastric tube without dissection or interruption of vessels in the splenic hilum. Fell and Ximenes-Netto have reported a large and favorable experience with this procedure.4

These tubes are largely selected as esophageal replacements for benign conditions, but from time to time they may provide a solution in complex problems of management for malignancy. Bypass for malignant tracheoesophageal fistula is such an example (see Chap. 23).

Jejunum

The jejunum presents a more difficult substitute than stomach (Fig. 21-3). Preparation of the vascular supply is more difficult owing to the complexity of the mesenteric arcade, especially in obese patients. Long segments of jejunum rarely can be fashioned without significant angulation and redundancy in the distal part of the transplant, which may be managed by a resection and additional anastomosis for the redundant loop. An interposed segment requires three anastomoses.

Figure 21-3.

 

Jejunal grafts are preferred for malignant esophageal replacement in the three situations depicted here. A. Jejunal segment after distal esophageal resection. B. Jejunal replacement for esophagus and proximal or entire segment (Roux-en-Y). C. A free segment requiring microvascular vessel anastomosis interposed in the cervical region.

Jejunum is preferable as a replacement for resected esophageal malignancy in relatively few instances. The first is replacement with jejunum after a distal esophageal resection (Fig. 21-3A ). A pedicled jejunal segment is interposed between the lower thoracic esophagus and the proximal stomach. The segment may function as an effective barrier to subsequent reflux. A second instance is replacement for the esophagus and the proximal or entire stomach when the malignancy involves a sufficient extent of both organs (Fig. 21-3B ). Some proximal gastric malignancies are managed by total gastrectomy combined with an esophagectomy, which may extend to the upper thorax or neck. A Roux-en-Y jejunal replacement is used commonly in Japan, where most of the population is lean, and identification and mobilization of the omental vascular arcades are much easier than in obese patients. A third instance is a free segment requiring microvascular vessel anastomosis interposed in the cervical region (Fig. 21-3C ). This operation usually requires two surgical teams. Although the interposed cervical jejunum retains peristalsis, such peristalsis may not be coordinated with the swallowing reflex, and a variable degree of dysphagia can occur.

Colon

The colon is a very versatile esophageal replacement. A robust blood supply usually can be identified, mobilized, and preserved for support of the transplanted segment. The marginal artery lies close to the mesenteric border of the colon and permits preparation of a replacement without significant redundancy. The blood supply of the transplant may be supported by preservation of the right, middle, or upper left colic vessels depending on the replacement required and the vascular anatomy encountered at operation in any given patient (Fig. 21-4).

Figure 21-4.

 

Colon interposition is used by most surgeons when stomach is not available owing to previous gastric resection or esophagogastric cancer requiring an extensive or total gastrectomy. A. Colon transplant fashioned from the left and adjacent transverse components is the most reliable reconstruction for a long esophageal replacement extending from the intraabdominal cavity to the apex of the thorax or neck B. Pedicled transplant of right colon.

A colon transplant fashioned from the left and adjacent transverse components is the most reliable reconstruction for a long esophageal replacement extending from the intraabdominal cavity to the apex of the thorax or neck (Fig. 21-4A ). Furthermore, the smaller luminal diameter of the left colon, as opposed to the right colon, is closer to that of the esophagus.

A long left colon transplant requires preservation of the vascular arcade between the upper left colic and right colic vessels. This needs exposure and ligation of the main middle colic artery with preservation of its right and left divisions. The middle colic artery may be no more than a few centimeters in length, and it may be identified only after dissection in the base of the mesentery of the transverse colon. It should be remembered that the marginal artery at the splenic flexure is inadequate or even missing in approximately 5% of patients.

A pedicled transplant of right colon is a more difficult surgical exercise. The mesentery is often more bulky, the bowel lumen much larger, and the bowel wall thinner (Fig. 21-4B ). Furthermore, a right colon transplant may not reach the cervical level unless the ileocecal valve and a segment of ileum are included in the preparation.

DISADVANTAGES OF COLON TRANSPLANT

A colon transplant requires three bowel anastomoses. The colonic contents are contaminated with pathogenic bacteria, and some form of preoperative bowel preparation usually is advised. Although the colon remains peristaltic after the pedicled segment has been prepared, the peristalsis is unlikely to be functionally effective because contractions occur only at intervals measured in minutes. The colon transplant should be placed in the isoperistaltic position. Although many transplants have been placed in an antiperistaltic fashion and apparently function very well, the occasional patient will experience pain, obstruction, and even regurgitation during meals. This complication was first described to me by Mr. Ronald Belsey of Bristol (Personal communication, 1959). I have had experience with two such cases since that time, both of which warranted reoperation to obtain satisfactory swallowing.

It is often somewhat difficult to create a long colon interposition without some degree of redundancy and angulation. With the passage of time, the redundant portions may become increasingly angulated and dilated, resulting in impaired emptying and pooling of swallowed contents in the transplant. These changes are most pronounced at thoracic levels, undoubtedly secondary to the chronic effects of negative intrathoracic pressure over long periods of time. Operative correction may be needed. The distressing incidence of this late complication is well described.5

INDICATIONS FOR COLON TRANSPLANT

As stated earlier, stomach is currently an almost universal choice for esophageal replacement after resection for malignant disease. In circumstances where stomach is not available (e.g., previous gastric resection or esophagogastric cancer requiring an extensive or total gastrectomy), most surgeons select colon rather than jejunum as the alternative. Colon is also sometimes preferred for infants and children with congenital esophageal malformations whose conduit must last a lifetime (see Chap. 38).

EDITOR'S COMMENT

This chapter gives an excellent review by a world-leading authority on esophageal surgery. The pros and cons of each esophageal substitute, as well as description of which circumstances might be optimal for one or the other, is a helpful guide to future esophageal surgeons. In general, a narrow 4–5 cm conduit made parallel to the greater curvature is the best gastric tube. Although colon is larger and can reach higher more easily, I have found that jejunum is a very versatile conduit that can reach up to the carina while connected distally, and can be used as a free graft in the proximal esophageal bed.

REFERENCES

1. Ginsberg R: Selection and Placement of Conduits: Comments and controversies. In Pearson FG, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson GA, Urschel HC Jr (eds). Esophageal Surgery, Churchill Livingstone, 2002:800–801.

2. Hiebert C, Bredenberg C: Selection and placement of conduits. In Pearson FG, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson GA, Urschel HC Jr (eds), Esophageal Surgery, New York, Churchill Livingstone, 2002:794–801.

3. Orringer MB, Marshall B, Iannettoni MD: Transhiatal esophagectomy: Clinical experience and refinements. Ann Surg 230:392–400; discussion 400–3, 1999. 

4. Fell S, Ximenes-Netto M: Gastric Tubes: Reversed and Nonreversed. New York, Churchill Livingstone, 2002:945–51.

5. Netto MX: Esophageal reconstruction for benign disease. GEN 40:173–80, 1986. [PubMed: 3135234]



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