Master Techniques in Otolaryngology - Head and Neck Surgery: Reconstructive Surgery, 1ed.

31. The Gastric Pull-up

D. Gregory Farwell

INTRODUCTION

Cancer involving the cervical esophagus, pyriform sinuses, and larynx may require removal of the cervical esophagus creating a major continuity defect of the upper digestive tract. Reestablishing a conduit for swallowing is essential to rehabilitate patients and give them an optimal quality of life after extensive extirpative surgery. Other rare diagnostic entities that may leave patients in need of esophageal reconstruction include atresia and other congenital anomalies such as tracheoesophageal fistula, caustic ingestions, and trauma. Several techniques have been used to reconstruct the cervical esophageal defect including the creation of local skin flaps (Wookey flap), tubed locoregional flaps, or tubed cutaneous flaps and microvascular enteric flaps. In certain patients, either the defect may be too large or the particular needs of the patient require the technique of pedicled enteric flaps from the abdomen such as the gastric pull-up or a colonic interposition graft. These techniques provide vascularized enteric tissue, which reestablishes a communication between the oropharynx and the rest of the gastrointestinal tract.

The gastric pull-up is the most frequently performed pedicled enteric flap used to reconstruct the esophagus. Most patients with advanced cancer involving the larynx and pyriform sinus require a laryngectomy. However, for thoracic esophageal pathology, the patient may be able to retain the larynx. These patients, with their larynx intact, have additional potential postoperative problems including aspiration and vocal fold immobility that may complicate their recovery. All patients undergoing gastric pull-up are at risk for significant morbidity and potential mortality due to the extensive nature of the surgery.

The majority of patients in need of cervical esophageal replacement have been diagnosed with cancer of the larynx, hypopharynx, or cervical esophagus. As such, they may present with dysphonia, dyspnea, dysphagia, weight loss, or pain. Often, these cancers present at a late stage due to the extensive submucosal lymphatics of the hypopharynx and cervical esophagus. As such, a careful diagnostic evaluation including a staging endoscopy is critical before embarking on aggressive surgical therapy. Any suggestion of cervical lymphadenopathy should be carefully noted and further evaluated. These cancers usually interfere with optimal alimentation so that these patients are often malnourished. An assessment of the degree of weight loss should be included in the pretreatment history. One of the major decision points in these surgical procedures is whether the larynx can be preserved. A history of hoarseness or aspiration implies laryngeal involvement with the cancer and should be carefully elicited.

A systematic evaluation should include a careful assessment of pulmonary status, a history of gastrointestinal disorders, prior abdominal surgery, and overall conditioning. Special attention should be paid to the degree of pulmonary dysfunction including prior home oxygen use and limited exercise tolerance. If the patient has had prior pulmonary function testing, these records should be obtained and reviewed. Prior gastrointestinal conditions such as peptic ulcer disease, prior percutaneous gastrostomy tube placement, and prior laparotomy may make the procedure more complex or prevent the use of a gastric conduit for esophageal replacement. The patient’s intake of tobacco and alcohol should be elicited to take steps to avoid withdrawal effects that are physically dangerous and add tremendously to hospital costs.

Examination will often require the use of in-office flexible and operative rigid endoscopy to map out the extent of the tumor and to determine resectability and extent of the surgical procedure. Special attention should be paid to the function of the larynx and the proximity of the cancer to the postcricoid and pyriform sinus regions of the hypopharynx. These findings will help to determine whether the larynx can be saved or if it will have to be resected with the esophagus. Lymph nodes should be palpated looking for any evidence of metastasis. The larynx, pharynx, and esophagus should be palpated to make sure that these structures are mobile off of the prevertebral fascia indicating lack of invasion.

The indications for a gastric pull-up reconstruction include the presence of any complete defect of the cervical and upper thoracic esophagus.

Contraindications to gastric pull-up include tumor-specific and patient-specific factors. Obviously, it is contraindicated to perform this surgery for cancers that have distant metastasis or are unresectable due to local extension into the prevertebral fascia. Many surgeons also consider involvement of the carotid artery as a relative contraindication to surgical resection.

Patient-specific contraindications include medical comorbidities such as advanced pulmonary disease that would preclude them from tolerating the procedure. Additional patient-specific contraindications would include prior abdominal or gastric surgery that might eliminate the use of the stomach as a conduit.

Imaging Studies

Historically, the esophagus was evaluated with a barium swallow esophagram. While this study can still be used to look for a mass within the esophagus, it has been largely supplanted by rigid and more recently flexible esophagoscopy. As such, barium swallow evaluations are rarely used in modern practice. Detailed anatomical imaging studies with computed tomography (CT) and/or magnetic resonance imaging are helpful in determining the extent of the lesion and the presence of metastatic lymphadenopathy. These studies can be used to evaluate for extraesophageal extension of the cancer especially in the region of the prevertebral area and the carotid artery as these may negatively impact the resectability of the cancer. Transesophageal ultrasound is commonly used to evaluate distal esophageal cancers to determine the thickness and extraesophageal extension of the cancer.

Staging of the chest and abdomen is very important in the evaluation of these cancers, and historically, chest and abdominal CT was used. Currently, PET–CT is increasingly used to stage cancers of the head and neck. This modality is especially useful for lesions involving the esophagus and hypopharynx due to their aggressive nature and tendency for metastasis to the neck, mediastinum, and lungs. Due to the morbidity and mortality of surgical treatment of these cancers, adequate staging is essential before embarking upon surgery.

Staging Endoscopy

Preoperative endoscopy should be undertaken to determine the extent of the cancer and its resectability. The proximal extent of the cancer is important as the gastric pull-up will reliably reach the inferior tonsil fossa in most patients but becomes increasingly unreliable with defects further superior. Careful evaluation of the distal esophagus is essential in determining the inferior extent of the cancer and whether the entire esophagus must be resected. Some surgeons recommend mapping biopsies of the distal esophagus despite normal-appearing mucosa due to the tendency for skip lesions and submucosal spread of the tumor. At the time of the endoscopy, evaluation of the stomach is helpful to look for any pathology that might preclude the use of the gastric conduit.

Preoperative Testing

In addition to the endoscopy and staging workup, preoperative testing should include evaluation of pulmonary function. The gastric pull-up procedure is associated with pulmonary complications that are predicted by poor presurgical pulmonary function. Additional consultation with the patient’s primary care physician or preoperative anesthesia consultation is advisable to estimate the patient’s perioperative risk and to evaluate for modifiable risk factors.

The gastric pull-up technique was first described by Ong and Lee in 1960. Since that time, minor modifications have been made to optimize the reliability of the tissue transfer. The procedure is initiated with the cervical esophagectomy and often neck dissections for oncologic cases. The creation of the gastric tube and abdominal procedure is frequently performed by a colleague in surgical oncology or thoracic surgery who is skilled in working in the abdomen and mediastinum. Since cancers of the hypopharynx and cervical esophagus require resection of the larynx for complete extirpation, most patients will have had a laryngectomy as part of their procedure, and the airway is controlled through a tracheostomy for the remainder of the procedure.

A laparotomy is made, often through a bilateral subcostal chevron incision or a midline incision. The blood supply of the stomach is multifaceted and includes contributions from the right and left gastric artery, the right gastroepiploic artery, the short gastrics, and the pancreaticogastric arteries (Fig. 31.1). For mobilization into the neck, the stomach is pedicled on its right gastroepiploic and right gastric arteries, and the remainder of the blood vessels are ligated allowing the stretch necessary to reach the pharynx (Fig. 31.2). The proximal portion of the stomach is at high risk due to vascular compromise as its blood supply is dependent upon the submucosal blood supply off of the gastroepiploics.

FIGURE 31.1 The stomach is shown in its relation to the diaphragm and abdominal viscera. The stomach will be mobilized, fashioned into a tube primarily vascularized by the right gastroepiploic artery and right gastric artery.

FIGURE 31.2 For mobilization into the neck, the stomach is pedicled on its right gastroepiploic and right gastric arteries, and the remainder of the blood vessels are ligated allowing the stretch necessary to reach the pharynx.

Several techniques have been described to optimize the chance of a successful gastric transfer. These include careful preservation of the gastroepiploic arcade during the dissection and meticulous dissection in the region of the gastrocolic ligament, capturing the arcade that is often present in this ligament to supply the proximal stomach. Blunt transhiatal dissection is then carried out from below to mobilize the thoracic esophagus (Fig. 31.3). This can often be done under direct vision to approximately the carina. Similarly, blunt dissection is performed from superiorly to carefully mobilize the superior thoracic esophagus. With blunt dissection, the recurrent laryngeal nerves are preserved laterally as the esophagus is completely mobilized from the gossamer fascia within the mediastinum and chest. A pyloromyotomy or pyloroplasty is often performed to achieve adequate drainage.

FIGURE 31.3 The esophagus is mobilized with blunt dissection from above and below to allow for its removal.

The stomach is transformed into a tube by using surgical staples to transect the extra stomach opposite the gastroepiploic artery. An approximately 4-cm-diameter tube is created to allow it to be passed retrocardiac into the neck (Fig. 31.4). Sutures are utilized to augment the staple line and minimize the chance of a leak into the thorax. The gastric tube is then passed under the heart and up into the neck for anastomosis (Fig. 31.5). Care is taken in the transfer of this tube to minimize traction on the stomach to preserve the blood supply. The diaphragm is then closed to minimize the risk of a diaphragmatic hernia.

FIGURE 31.4 The lesser curvature of the stomach is then excised with a surgical stapler to create a conduit tube for transfer through the mediastinum and into the neck.

FIGURE 31.5 The gastric tube is then “pulled up” into the neck to allow for anastomosis with the pharyngeal remnant.

The gastric tube is then secured to the hypopharyngeal mucosal margin in two layers with a deep layer involving the constrictor muscles of the pharynx and the serosa of the stomach. A second layer is performed from the mucosa of the pharynx to the mucosa of the stomach. A salivary bypass tube may be used to stent and divert secretions away from the suture line. After assuring a watertight closure, the abdomen and neck are closed over appropriate drains.

Postoperatively, the patient is often managed in the intensive care unit for initial surveillance and monitoring. Aggressive pulmonary toilet is advocated as these patients are at risk for pulmonary morbidity including pulmonary edema, pleural effusion, and aspiration pneumonia (especially with laryngeal preservation). Deep venous thrombosis prophylaxis is used with pneumatic compression stockings and subcutaneous heparin. The drains are removed as appropriate. Patients are allowed to eat 7 to 14 days after the procedure as long as there is no evidence of anastomotic leak. The diet of patients undergoing a gastric pull-up is altered, and most require frequent small meals and a prolonged period of sitting upright at least 30 inches postprandial to minimize regurgitation or aspiration if the larynx is intact.

Unfortunately, a large percentage of patients undergoing this procedure have complications. In a recent review of over 200 gastric pull-ups, 42% of patients suffered a complication. The range of complications is from 22% to 89%. The most common acute complications are respiratory in nature including pneumonitis, pleural effusion, and hemothorax (Table 31.1). Pulmonary complications are often the cause of perioperative mortality. Delayed complications are listed in Table 31.2. Mortality is a well-known possibility due to the extensive surgery and coexisting conditions in many of these patients. The rate of mortality may be as much as 15%, but most recent studies range between 2% and 11%.

TABLE 31.1 Acute Complications After Gastric Pull-up Reported in the Literature

TABLE 31.2 Delayed Complications from Gastric Pull-up Reported in the Literature

Surgical reconstruction of a cervical esophagectomy defect with a gastric pull-up is a relatively reliable technique. A percentage of these patients will demonstrate postoperative stenosis at the neopharynx and require dilation. However, most patients achieve an oral diet and can be rehabilitated with a tracheoesophageal puncture for speech. Despite an overall survival ranging from 11% to 47%, the quality of life afforded by this procedure is acceptable with excellent global and functional results but expected low results in areas of smell, taste, speech, and sexuality.

• Prior to surgical management, an exhaustive staging workup should be performed to evaluate the local resectability of the cancer and the presence of regional or distant metastasis due to the advanced stage of these cancers at presentation.

• Patients need to be aware of the gravity of their situation but understand that survivors can expect an acceptable quality of life.

• Preoperative pulmonary function testing may predict which patients are at higher risk for postoperative complications.

• The gastric tube must be harvested with great care to preserve the right short gastric and gastroepiploic arteries to insure adequate perfusion of the proximal stomach. This can reliably reach the postcricoid region and as high as the inferior tonsillar fossa in most patients.

• Cancers that require resection of the base of the tongue or tonsil fossa are associated with higher complication rates as the proximal stomach is more prone to ischemia and anastomotic leak with more superior anastomoses.

• Postoperative care is necessary to prevent and manage the complications associated with this procedure, which most frequently are pulmonary and wound.

Instruments to Have Available

• Standard head and neck surgical set

SUGGESTED READING

Wookey H. The surgical treatment of the pharynx and upper esophagus. Surg Gynecol Obstet 1942;75:499–506.

Ong GB, Lee TC. Pharyngogastric anastomosis after esophageal pharyngectomy for carcinoma of the hypopharynx and cervical esophagus. Br J Surg 1960;45:193–200.

Dumont P, Wihlm JM, Hentz JG, et al. Respiratory complications after surgical treatment of esophageal cancer. A study of 309 patients according to the type of resection. Eur J Cardiothorac Surg 1995;99(10);539–543.

Wei WI, Sham JST. Extent of resection of hypopharyngeal cancer. In: Wei WI, Sham JST, eds. Cancer of the larynx and hypopharynx. Oxford, UK: Isis Media Medical Ltd, 2000:95–104.

Ferguson MK, Durkin AE. Preoperative prediction of the risk of pulmonary complications after esophagectomy for cancer. J Thorac Cardiovasc Surg 2002;123(4):661–669.