Options for Esophageal Replacement

Esophageal Replacement Options: Key Points for MCQ Exam Preparation

1. Stomach as Esophageal Replacement

Blood Supply

• Main Blood Supply: Right gastroepiploic artery.
• Venous Drainage: Right gastroepiploic vein.
• Important Considerations:
  • Left gastric artery is ligated during surgery.
  • Submucosal plexus provides a robust blood supply but thins near the fundus.
  • Anatomic Variations:
    • Right gastroepiploic artery may end midway along the greater curvature.
    • Preservation of delicate omental vessels is crucial.

Technique Preferences

• Gastroplasty: Most preferred conduit (used in over 95% of cases).
• Creation of Gastric Tube:
  • Narrow tube (~4 cm width) created by resecting the lesser curvature.
  • Facilitates better functional outcomes and reduces delayed gastric emptying.
• Mobilization Steps:
  • Open gastrohepatic ligament to access the hiatus.
  • Mobilize greater curvature, preserving right gastroepiploic vessels.
  • Kocher maneuver may be performed to increase mobility.
• Anastomosis Location:
  • Can be cervical (neck) or intrathoracic (chest).

Preferred Methods of Anastomosis

• Cervical Anastomosis:
  • Handsewn Anastomosis:
    • Two-layer technique with inner absorbable and outer nonabsorbable sutures.
  • Semimechanical Anastomosis:
    • Uses a linear stapler for the posterior wall.
    • Provides a wider passage, reducing dysphagia.
• Intrathoracic Stapled Anastomosis:
  • Performed using a circular stapler.
  • Requires careful placement to ensure oncologic safety (≥5 cm from tumor).

Alternative Gastric Tube Techniques

Reversed Gastric Tube

• Popularity: Rarely used today for malignant diseases.
• Blood Supply:
  • Based on the left gastroepiploic artery and short gastric vessels.
• Procedure:
  • Divide right gastroepiploic artery ~4 cm proximal to pylorus.
  • Create tube by stapling parallel to the greater curvature.
• Advantages:
  • Preserves part of the stomach and its function.
  • Can reach the pharynx; useful for benign diseases.
• Disadvantages:
  • Requires careful dissection near spleen.
  • Complex compared to standard gastroplasty.

Nonreversed Gastric Tube (Split Stomach)

• Technique:
  • Create an opening in the stomach using a 28-mm circular stapler.
  • Introduce linear cutting stapler through opening to form the tube.
  • Left gastric artery remains intact.
• Usage:
  • Can be used for bypass in unresectable cancer.
• Advantages:
  • Isoperistaltic tube connected to antrum.
  • Simplifies blood supply considerations.

Important Complications

• Reflux and Aspiration:
  • Due to loss of the lower esophageal sphincter mechanism.
  • Symptoms include heartburn, regurgitation, and aspiration pneumonia.
  • Management: Proton pump inhibitors (PPIs), lifestyle modifications.
• Delayed Gastric Emptying:
  • Result of vagal denervation causing pyloric dysfunction.
  • Controversy over the need for pyloric drainage procedures (e.g., pyloroplasty).
• Dumping Syndrome and Diarrhea:
  • Caused by accelerated gastric emptying.
  • Symptoms include abdominal cramps, nausea, dizziness.
  • Management: Dietary changes, medications like octreotide.
• Anastomotic Leaks:
  • Risk minimized with meticulous technique.
  • Early detection and management are crucial.
• Quality of Life Considerations:
  • Long-term functional complications can affect QOL.
  • Recovery to baseline health may take up to 1 year.

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2. Colon as Esophageal Replacement

Blood Supply

• Left Colon Interposition:
  • Main Blood Supply: Ascending branch of the left colic artery (from inferior mesenteric artery).
  • Marginal Artery of Drummond: Provides continuous blood flow along the colon.
• Right Colon Interposition:
  • Main Blood Supply: Middle colic artery (from superior mesenteric artery).
• Important Considerations:
  • Variations in colic arteries and marginal arcades.
  • Adequate blood supply must be confirmed intraoperatively.
  • Presence of arc of Riolan may complicate graft selection.

Technique Preferences

• Left Colon Interposition:
  • Preferred technique due to robust blood supply.
  • Conduit is placed in an isoperistaltic fashion.
• Right Colon Interposition:
  • Used if left colon is unsuitable (e.g., prior surgery).
  • Conduit may be placed in antiperistaltic fashion if necessary.
• Conduit Length:
  • Allows replacement up to the pharynx.
• Preoperative Assessment:
  • Colonoscopy to rule out pathology (polyps, tumors).
  • Mechanical bowel preparation may be performed.

Preferred Methods of Anastomosis

• Cologastric Anastomosis:
  • End-to-side anastomosis between colon and stomach.
  • Antireflux mechanism created by retaining a segment intra-abdominally.
• Colocolic Anastomosis:
  • Restores continuity of the colon.
• Cervical Esophagocolonic Anastomosis:
  • Handsewn anastomosis preferred for better adaptation to size differences.
• Anastomosis Technique:
  • Two-layer closure with inner absorbable and outer nonabsorbable sutures.

Important Complications

• Graft Necrosis:
  • Occurs in approximately 5% of cases.
  • Causes include vascular injury, twisting, or mesenteric atherosclerosis.
• Anastomotic Leaks:
  • Approximately 10% incidence in long-segment interpositions with cervical anastomosis.
  • Usually managed conservatively.
• Redundancy and Kinking:
  • Can lead to dysphagia and aspiration.
  • Prevention involves accurate measurement and posterior mediastinal placement.
• Reflux-Related Colitis:
  • Due to exposure of colon mucosa to gastric contents.
  • Management: PPIs, surgical revision if necessary.
• Bulging at Cervical Level:
  • Caused by air swallowing.
  • May require surgical correction to excise protruding segment.
• Intrinsic Pathology:
  • Rare development of IBD or colon cancer in the graft.

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3. Jejunum as Esophageal Replacement

Blood Supply

• Supplied by: Superior mesenteric artery.
• Vascular Pattern:
  • Segmental arteries with possible secondary arches.
• Important Considerations:
  • Limited length due to segmental blood supply.
  • Risk of ischemia increases with longer segments.
  • Anatomic Variations can affect conduit preparation.

Technique Preferences

• Roux-en-Y Jejunoplasty:
  • Commonly used when stomach and colon are unsuitable.
  • Conduit brought up to the chest through the mesentery of the transverse colon.
• Jejunal Interposition (Merendino Operation):
  • Preserves gastric reservoir function.
  • Less commonly used in cancer surgery.
• Supercharged Pedicled Jejunoplasty:
  • Microvascular augmentation to improve blood supply.
  • Arterial anastomosis to internal mammary or inferior thyroid artery.

Preferred Methods of Anastomosis

• Esophagojejunostomy:
  • Can be handsewn or performed using a circular stapler.
  • Two-layer closure enhances strength.
• Jejunojejunal Anastomosis:
  • Restores intestinal continuity.
  • Positioned at least 70 cm from the top to prevent biliary reflux.
• Anastomosis Techniques:
  • Semimechanical methods may be used.

Important Complications

• Ischemia and Necrosis:
  • Due to segmental vascular supply and limited collateral circulation.
• Technical Complexity:
  • Requires careful intraoperative assessment and microsurgical skills.
• Biliary Reflux:
  • Potential complication in Roux-en-Y reconstruction.
  • May necessitate revisional surgery.
• Postoperative Mortality and Leak Rates:
  • Mortality around 3-5%.
  • Leak rate around 5-10%.
• Functional Outcomes:
  • Generally good with preserved peristalsis.
  • Low incidence of dysphagia, regurgitation, diarrhea, and reflux.

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Comparison of Esophageal Replacement Options

Aspect	Stomach	Colon	Jejunum
Usage	Most commonly used (>95% of cases)	Second option when stomach unsuitable	Third option; used when stomach and colon unsuitable
Blood Supply	Right gastroepiploic artery and vein	Asc Br Left colic artery (left colon); middle colic artery (right colon)	Superior mesenteric artery (segmental branches)
Technique Preferences	Gastroplasty with gastric tube; single anastomosis	Left colon interposition preferred; multiple anastomoses	Roux-en-Y jejunoplasty; may require microvascular augmentation
Anastomosis Methods	Cervical (handsewn or semimechanical); intrathoracic stapled	Cologastric, colocolic, cervical anastomoses (handsewn preferred)	Esophagojejunostomy (handsewn or stapled); jejunojejunal anastomosis
Important Complications	Reflux, delayed gastric emptying, dumping syndrome, anastomotic leaks	Graft necrosis, anastomotic leaks, redundancy, reflux colitis	Ischemia, necrosis, biliary reflux, technical complexity
Advantages	Simpler procedure, robust blood supply, flexibility	Versatility, length allows replacement up to pharynx	Preserved peristalsis, good functional results when successful
Disadvantages	Potential for reflux; pyloric drainage debated	Complex procedure; higher morbidity and mortality	Limited length due to blood supply; higher technical demands

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Key Points for MCQ Exam:

• Stomach Replacement:
  • Most preferred due to simplicity and robust blood supply.
  • Blood supply relies on right gastroepiploic vessels after mobilization.
  • Reflux is a significant complication; managed with PPIs.
  • Pyloric drainage procedures (e.g., pyloroplasty) are controversial.
• Colon Replacement:
  • Used when stomach is unsuitable.
  • Requires careful intraoperative assessment of blood supply.
  • Multiple anastomoses increase complexity and risk.
  • Graft necrosis and redundancy are significant complications.
• Jejunum Replacement:
  • Option when both stomach and colon are unavailable.
  • Segmental blood supply limits length; risk of ischemia.
  • Microvascular techniques may be employed to augment blood flow.
  • Functional outcomes are generally good when successful.
• Anastomosis Techniques:
  • Handsewn anastomoses allow better adaptation, especially in colon interposition.
  • Semimechanical and stapled techniques reduce operative time but require careful execution.
  • Location of anastomosis (cervical vs. intrathoracic) affects complication rates.
• Complications:
  • Reflux is common with stomach replacement due to loss of sphincter function.
  • Graft necrosis is a critical concern with colon replacement; prevention is key.
  • Ischemia is a significant risk with jejunal interpositions due to segmental vascular supply.
  • Delayed gastric emptying and dumping syndrome are associated with stomach replacement.

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Study Tips:

• Understand Blood Supplies:
  • Stomach: Right gastroepiploic artery.
  • Colon: Left or middle colic arteries; marginal artery importance.
  • Jejunum: Segmental branches of the superior mesenteric artery.
• Remember Technique Preferences:
  • Stomach: Gastroplasty with gastric tube.
  • Colon: Left colon interposition in isoperistaltic fashion.
  • Jejunum: Roux-en-Y loop; may require supercharging.
• Focus on Complications Specific to Each Option:
  • Stomach: Reflux, need for pyloric drainage.
  • Colon: Graft necrosis, redundancy.
  • Jejunum: Ischemia due to segmental blood supply.
• Anastomosis Methods Matter:
  • Handsewn preferred in colon due to size mismatch.
  • Stapled anastomoses commonly used with the stomach.
  • Be aware of the advantages and limitations of each method.
• Comparative Understanding:
  • Stomach: Simplicity vs. reflux risk.
  • Colon: Versatility vs. complexity.
  • Jejunum: Functional benefits vs. technical challenges.

By focusing on these key points, you will be well-prepared to tackle MCQs related to esophageal replacement options, their surgical techniques, blood supplies, anastomosis methods, and associated complications.

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Note: All information is based solely on the provided context and does not include any external content.

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Milestones in Surgery for Esophageal Carcinoma

• 1877 – V. Czerny
  • First successful resection of the cervical esophagus for carcinoma.
• 1913 – F. Torek
  • First successful transthoracic resection of the esophagus.
• 1913 – W. Denk
  • Conducted cadaver and experimental animal studies on transhiatal resection of the esophagus.
• 1933 – T. Ohsawa
  • First report on transthoracic esophageal resection and esophagogastrostomy.
• 1933 – G. Turner
  • First transhiatal resection.
• 1938 – W. Adams and D. Phemister
  • First single-stage transthoracic resection and reconstruction in the United States.
• 1946 – I. Lewis
  • Performed esophageal resection and esophagogastrostomy via a right thoracotomy and laparotomy.
• 1976 – K. McKeown
  • Described the three-hole esophagectomy.
• 1978 – M. Orringer
  • Popularized transhiatal esophagectomy in the Western hemisphere.
• 1992 – A. Cushieri
  • First report on thoracoscopic esophagectomy.
• 2003 – J. Luketich
  • Popularized total thoracoscopic and laparoscopic esophagectomy.

Milestones in Esophageal Reconstruction

• 1879 – T. Billroth
  • Attempted reconstruction with skin.
• 1886 – J. Mikulicz
  • Reconstruction of the cervical esophagus using skin flaps.
• 1905 – C. Beck and A. Carrel
  • Conducted experimental animal studies on tubulization of the greater curvature of the stomach.
• 1906 – A. Carrel
  • Successful transplantation of autologous small bowel into the necks of dogs.
• 1907 – C. Roux
  • First use of a presternal jejunal loop combined with skin tube for benign esophageal stricture.
• 1911 – H. Vuillet & G. Kelling
  • Introduced colon as a substitute:
    • First attempt of two-stage resection followed by colonic interposition.

Evolution of Surgical Techniques and Mortality Rates

• Early Challenges
  • Initial esophagectomy attempts for intrathoracic esophageal cancer were largely unsuccessful.
  • Franz Torek’s 1913 transthoracic resection was a breakthrough; patient survived 13 years without reconstruction.
• Advancements in Ventilation
  • Late 1920s: Introduction of safe oro-tracheal intubation by Rowbotham and Magill enabled safer transthoracic esophagectomy.
• Refinement of Techniques (1930s-1970s)
  • Surgeons like Denk, Ohsawa, Grey Turner, Adam, Phemister, Sweet, Ivor Lewis, McKeown, Belsey, and Orringer refined esophagectomy techniques.
• Reduction in Mortality
  • Postoperative mortality was high until the 1970s.
  • 1980s-1990s: Improved medical operability and perioperative management reduced operative mortality to below 5%.
  • Current Rates: 1-2% in experienced centers.

Advances in Oncologic Operability and Survival Rates

• Enhanced Diagnostic Tools
  • Introduction of CT scans, PET scans, and endoscopic ultrasound improved selection for oncologic operability.
  • Decrease in futile exploratory thoracotomies.
• Surgical and Therapeutic Improvements
  • Better surgical techniques and induction therapy increased R0 resection rates in locally advanced (T3) carcinoma to >90%.
• Survival Outcomes
  • 5-year survival rates have risen to 35-45%.

Functional Outcomes and Quality of Life (QOL) Considerations

• Focus Shift
  • With improved oncologic outcomes, greater emphasis on functional outcomes both short and long term.
• Quality of Life (QOL)
  • High number of studies focus on QOL post-esophageal replacement.
• Ideal Conduit Characteristics
  • Mimic normal esophageal function to preserve QOL:
    • Undisturbed transport of the alimentary bolus from mouth to stomach.
    • Adequate antireflux mechanism to protect lungs from aspiration.
    • Ability to belch or vomit when necessary.

Criteria for Conduit Selection in Esophageal Replacement

• Mortality and Morbidity Reduction
  • Choice of conduit plays a crucial role in reducing surgical risks.
• Conduit Options
  • Vascularized, supercharged, long-segment jejunal graft:
    • Requires five anastomoses by two teams.
    • Higher risk of postoperative morbidity and mortality.
  • Gastric pull-up:
    • Requires only one anastomosis.
    • Lower risk compared to jejunal grafts.

• Decision Factors

  • Balance between functional outcomes and surgical risks.
  • Patient-specific factors influencing the choice of conduit type.

  

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Key Terms:

• Esophagectomy: Surgical removal of the esophagus.
• Transthoracic Resection: Removal of the esophagus through the chest.
• Transhiatal Resection: Removal of the esophagus without opening the chest.
• Esophagogastrostomy: Surgical connection between the esophagus and stomach.
• R0 Resection: Complete tumor removal with no residual disease.
• Conduit: Replacement tissue used to restore continuity after esophagus removal.

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Stomach as an Option for Esophageal Replacement

Advantages and Disadvantages

• Advantages:
  • Preferred Conduit: Used in over 95% of cases.
  • Quick and Simple Reconstruction:
    • Single Anastomosis required.
    • Robust arterial and venous supply:
      • Blood supply from the right gastroepiploic artery.
      • Venous drainage via the right gastroepiploic vein.
  • Flexibility: Can reach the neck for a cervical or hypopharyngeal anastomosis.
  • Submucosal Plexus: Strong submucosal blood supply enhances healing.
• Disadvantages:
  • Potential for Reflux: Increased risk of gastroesophageal reflux and aspiration.

  • Anatomic Variations:

    • Variations in the gastroepiploic arcade can affect blood supply.
    • Watershed zones with decreased microcirculation near the fundus.

    

Technique of Gastroplasty with Gastric Tube Creation

Mobilization of the Stomach

1. Abdominal Inspection:
   • Begin with laparotomy or laparoscopy to check for metastasis.
   • Alternatively, start with thoracotomy/VATS if tumor resectability is uncertain.
2. Dissection Steps:
   • Open the gastrohepatic ligament to expose the hiatus and right crus.
     • Left hepatic artery variations:
       • Small artery (<2 mm): Can be ligated.
       • Large artery: Preserve to prevent hepatic necrosis.
   • Mobilize the greater curvature:
     • Divide the omentum distal to the gastroepiploic arcade.
     • Preserve the right gastroepiploic vessels.
   • Divide the gastroepiploic arcade near the spleen.
     • Stay peripheral to the omentum to preserve delicate connections.
     • Avoid damaging the spleen; use ultrasonic devices if necessary.
   • Dissect the gastrodiaphragmatic area:
     • Retract the fundus to the right to expose the left crus.
     • Open the hiatus by incising the phrenoesophageal ligament.
     • Excise a rim of the diaphragmatic hiatus if necessary for R0 resection.
3. Ligation of Vessels:
   • Left gastric artery and vein: Ligate and divide after lymph node dissection.
   • Right gastric artery: Ligate and divide to increase mobility.
4. Increase Mobility:
   • Kocher maneuver: Elevate the duodenum and pancreas to bring pylorus to the hiatus.
5. Creating the Gastric Tube:
   • Resect the lesser curvature to create a 4 cm wide gastric tube.
     • Essential for oncologic clearance due to lymph nodes.
   • Use linear cutting staplers:
     • Start at the top of the fundus, 5 cm from the gastroesophageal junction (GEJ).
     • Staple vertically to create the tube.
   • Oversew staple line (optional):
     • Reduces leakage risk.
     • May prevent early dilation but can shorten the tube.
6. Final Steps:
   • Fix the gastric tube to the divided lesser curvature with stay sutures.
   • Pull up the tube via the cervical or thoracic incision.
   • Ensure the tube is not twisted; staple line should be medial.

Anastomosis Techniques

Cervical Anastomosis

• Approach:
  • Used in McKeown (three-hole) esophagectomy.
  • Patient positioned for laparotomy/laparoscopy and cervicotomy.
  • Left-sided cervicotomy performed simultaneously with abdominal phase.
• Procedure:
  • Identify and retract the sternocleidomastoid muscle.
  • Divide the inferior thyroid artery to access the cervical esophagus.
  • Exteriorize the esophagus and bring up the gastric conduit carefully.
    • Avoid injury to the left recurrent laryngeal nerve.
    • Avoid twisting the gastric tube.

Anastomosis Types:

Handsewn Anastomosis

• Placement of Sutures:
  • Two nonresorbable monofilament 3-0 sutures on outer sides of esophagus and stomach.
  • Posterior outer layer completed with separate or running sutures.
• Incisions:
  • Incise the gastric tube 1 cm away from the posterior outer layer.
  • Incise the esophageal wall similarly.
  • Clean and disinfect lumens to prevent contamination.
• Inner Layer Suturing:
  • Use 3-0 monofilament resorbable sutures for the posterior inner layer.
  • Advance nasogastric tube through anastomosis.
• Complete Anterior Wall:
  • Finish the anterior inner layer with running sutures.
  • Mattress sutures for the anterior outer layer to prevent tension.
• Resection of Redundant Esophagus:
  • Resect proximal esophagus to prevent pseudodiverticulum.
  • Oversew staple line to prevent ischemia.
• Closure:
  • Omentum wrap around suture line for protection.
  • Insert drain and close cervicotomy.

Semimechanical Anastomosis

• Overlap Requirement: Minimum of 5 cm.

  • Semimechanical orringer or Modified Collard anastomosis is preferred

    

• Procedure:

  • Place five separate 3-0 nonresorbable stitches forming a pentagon.
  • Incise gastric tube at base of pentagon.
  • Place sutures and use a 45-mm linear stapler to create a V-shaped back wall.
  • Complete anastomosis with sutures.
  • Advance nasogastric tube and resect tip of gastric tube.
• Advantages:
  • Wider passage reduces dysphagia.
  • Improved quality of life with fewer dilatations needed.

Intrathoracic Stapled Anastomosis

• Preferred in Minimally Invasive Esophagectomy (MIE)
• Anastomosis Location:
  • Must be oncologically safe: At least 5 cm proximal to tumor.
  • Place high in the apex of the right chest to reduce reflux risk.
• Variants:
  1. Incomplete Gastric Tube Creation:
     • Bring up mobilized stomach.
     • Open lesser curvature remnant to introduce stapler.
     • Resect remnant after anastomosis.
  2. Complete Gastric Tube Creation:
     • Bring up fully created gastric tube.
     • Open proximal tube to introduce stapler.
     • Resect top end after anastomosis.
• Procedure:
  • Prepare Esophagus:
    • Apply a purse-string suture around the esophageal wall.
    • Introduce anvil of circular stapler into esophagus.
  • Prepare Stomach:
    • Gastrotomy performed away from staple line.
    • Introduce stapler head and connect to anvil.
  • Anastomosis Completion:
    • Fire stapler to create anastomosis.
    • Inspect "doughnuts" for completeness.
    • Resect gastric remnant using a linear stapler.
    • Advance nasogastric tube through anastomosis.

Alternative Gastric Tube Techniques

Reversed Gastric Tube

• Popularity: Rarely used today for malignant diseases.
• Blood Supply:
  • Based on the left gastroepiploic artery and short gastric vessels.
• Procedure:
  • Divide right gastroepiploic artery ~4 cm proximal to pylorus.
  • Create tube by stapling parallel to the greater curvature.
• Advantages:
  • Preserves part of the stomach and its function.
  • Can reach the pharynx; useful for benign diseases.
• Disadvantages:
  • Requires careful dissection near spleen.
  • Complex compared to standard gastroplasty.

Nonreversed Gastric Tube (Split Stomach)

• Technique:
  • Create an opening in the stomach using a 28-mm circular stapler.
  • Introduce linear cutting stapler through opening to form the tube.
  • Left gastric artery remains intact.
  • gastric Tube being pedicled on RGEA
• Usage:
  • Can be used for bypass in unresectable cancer.
• Advantages:
  • Isoperistaltic tube connected to antrum.
  • Simplifies blood supply considerations.

Complications

Reflux

• Incidence:
  • Up to 58% of patients experience reflux symptoms postoperatively.
  • Severe reflux esophagitis observed in up to 76% of symptomatic patients.
• Symptoms:
  • Heartburn, regurgitation, dysphagia, vomiting, aspiration pneumonia.
• Risk Factors:
  • Intrathoracic anastomosis associated with higher incidence than cervical anastomosis.
• Management:
  • Proton pump inhibitors (PPIs) reduce acid secretion.
  • Lifestyle modifications to reduce symptoms.

Gastric Emptying–Related Symptoms

Pyloric Drainage Procedures: Necessary or Not?

• Issue:
  • Vagal denervation leads to gastric dysmotility and pyloric dysfunction.
  • Causes delayed gastric emptying and related symptoms.
• Symptoms:
  • Early satiety, fullness, heartburn, dysphagia, aspiration pneumonia.
• Pyloric Drainage Options:
  • Pyloroplasty, pyloromyotomy, digitoclasia, botulinum toxin injection.
• Controversy:
  • Potential Benefits:
    • May improve early and late gastric emptying.
    • Reduces obstructive symptoms.
  • Potential Risks:
    • Complications from drainage procedures (e.g., leaks).
    • Dumping syndrome due to rapid gastric emptying.
    • Increased bile reflux leading to esophagitis or metaplasia.
• Studies:
  • Mixed results from randomized controlled trials.
  • Meta-analyses show contradictory results; routine use not universally supported.

• Alternatives:

  • Botulinum toxin injection: Mixed evidence on efficacy.

  

Gastric Tube vs. Whole Stomach

• Gastric Tube Advantages:
  • Reduced delayed gastric emptying due to smaller volume.
  • Law of Laplace: Smaller radius increases pressure, aiding emptying.
• Whole Stomach Advantages:
  • Better recovery of gastric motility over time.
  • May lead to better long-term alimentary comfort.
• Conclusion:
  • Choice depends on surgeon preference and patient-specific factors.
  • Gastric tube often preferred due to lower incidence of delayed emptying.

Treatment of Delayed Gastric Emptying

• Balloon Dilatation:
  • Effective in some patients with gastric outlet obstruction.
• Prokinetic Agents:
  • Erythromycin stimulates gastric motility as a motilin agonist.
• Rescue Procedures:
  • Rescue pyloroplasty for persistent, disabling symptoms.

Intestinal Metaplasia and Gastric Drainage

• Concern:
  • Bile and acid reflux may lead to Barrett's esophagus in long-term survivors.
• Risk Factors:
  • Pyloric drainage procedures increase bile reflux.
• Studies:
  • Higher incidence of metaplasia in patients with drainage procedures.
• Recommendation:
  • Avoid routine pyloric drainage to reduce risk of metaplasia.

Dumping Syndrome and Diarrhea

• Incidence:
  • Reported in 10% to 50% of patients post-esophagectomy.
• Symptoms:
  • Early symptoms: Abdominal cramps, nausea, dizziness, sweating.
  • Late symptoms: Reactive hypoglycemia.
• Causes:
  • Accelerated gastric emptying due to loss of pyloric function.
  • Vagal denervation contributes to symptoms.
• Management:
  • Dietary modifications:
    • Small, frequent meals.
    • Avoid simple carbohydrates.
    • Do not drink fluids with meals.
  • Medications:
    • Pectin or guar to increase viscosity.
    • Acarbose to slow glucose absorption.
    • Octreotide to inhibit vasoactive peptides.

Quality of Life After Surgery

• Improved Survival Rates:
  • 5-year survival approaching 50% due to advancements.
• Impact of Complications:
  • Morbidity affects up to 50% of patients.
  • Complications include anastomotic leaks, pulmonary issues, and functional disorders.
• Recovery Time:
  • Up to 1 year to recover baseline health-related quality of life (HRQL).
  • Patients may not reach baseline if disease recurs within 2 years.
• Focus on Minimizing Complications:
  • Meticulous surgical technique is crucial.
  • Minimally Invasive Esophagectomy (MIE) shows promising results.
    • Reduced pulmonary complications and better HRQL in early months.
• Importance of Early Discharge:
  • Patients discharged before 10 days have better HRQL outcomes.
• Surgeon and Team Experience:
  • High-volume centers with experienced teams have better outcomes.
  • Experience reduces learning curve challenges of MIE.

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Key Terms:

• Gastroplasty: Surgical reconstruction of the stomach to replace the esophagus.
• Gastric Tube: A portion of the stomach fashioned into a tube to substitute the esophagus.
• Anastomosis: Surgical connection between two structures.
• Reflux Esophagitis: Inflammation of the esophagus due to acid reflux.
• Pyloroplasty: Surgical procedure to widen the opening of the pylorus.
• Dumping Syndrome: Rapid gastric emptying causing gastrointestinal and vasomotor symptoms.
• Health-Related Quality of Life (HRQL): A patient's overall well-being encompassing physical, mental, and social aspects.

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Colon as an Option for Esophageal Replacement

Historical Background

• 1911 – H. Vuillet and G. Kelling
  • First described the use of the colon as an esophageal substitute.
• 1950s–1960s – Further Development
  • Popularized by:
    • Orsoni
    • Reboud
    • Waterston
    • Belsey
    • Lortat-Jacob
    • Others

Advantages of Using Colon

• Versatility:
  • Length availability allows replacement of the entire esophagus up to the pharynx.
• Robust Blood Supply:
  • From the left colic artery.
  • Presence of the marginal artery (artery of Drummond) permits linear interposition without redundancy or kinking.

• Reduced Gastrointestinal Complications:

  • Potentially reduced delayed gastric emptying.
  • Reduced reflux when the stomach is retained.

  

Disadvantages

• Complex Procedure:
  • Requires at least three anastomoses.
  • Longer operative time.
• Higher Rates of Complications:
  • Increased risk of necrosis, morbidity, and mortality.

Indications and Contraindications

• Indications:
  • When the stomach cannot be used as a conduit.
  • When the stomach must be resected for oncological reasons (e.g., tumors involving the distal esophagus and lesser curvature).
• Contraindications:
  • Presence of an aortic aneurysm.
  • Extensive atheromatosis involving the superior mesenteric artery.
  • Previous colon surgery.
  • Severe colonic inflammatory bowel disease (IBD) or colonic tumors.
  • Scattered diverticulosis (relative contraindication).

Anatomy and Blood Supply

• Blood Supply:
  • Superior Mesenteric Artery:
    • Middle colic artery
    • Right colic artery
    • Ileocolic artery
  • Inferior Mesenteric Artery:
    • Left colic artery
• Marginal Artery (Artery of Drummond):
  • Interconnects colic arteries.
  • Allows for a continuous blood supply along the colon.

• Anatomic Variations:

  • Variations in colic arteries and marginal arcades can compromise the use of the colon, especially for a long-segment interposition.
  • Arc of Riolan: An arterioarterial anastomosis that may preclude the use of long-segment colon interposition.

  

Preoperative Management

• Diagnostic Assessments:
  • Colonoscopy:
    • Recommended for elderly patients or those with a history of colonic polyps.
  • Angiography:
    • Typically not useful, but may be indicated in cases of previous abdominal surgery involving colonic or major abdominal vessels.
• Bowel Preparation:
  • Mechanical bowel preparation (e.g., polyethylene glycol) is commonly performed.
  • Enemas are rarely required.
  • Recent evidence suggests that omitting bowel preparation may reduce the incidence of cervical leakage.
• Antibiotic Prophylaxis:
  • Broad-spectrum antibiotics administered intravenously before surgery and continued for 48 hours postoperatively.
  • Oral antibiotics may reduce infection risk, but this is controversial.

Technique of Left Colon Interposition

Preparation and Mobilization

• Mobilize the Left Colon:
  • Incise the white line of Toldt to free the colon from peritoneal attachments.
  • Mobilize the transverse colon by detaching it from the omentum.
  • Mobilize the splenic flexure.
  • For long-segment interposition, mobilize the hepatic flexure, right colon, and cecum.

Vascular Assessment

• Identify Vessels:
  • Locate the ascending branch of the left colic artery (primary blood supply).
  • Visualize the middle and right colic arteries.
  • Use transillumination in obese patients to assist in identifying vessels.
• Measure Required Length:
  • Measure the distance from the neck to the origin of the ascending branch of the left colic artery using a tape.
  • Measure over the arterial arcades, not the colon itself.
• Test Clamping:
  • Place atraumatic vascular clamps on:
    • Base of the middle colic artery.
    • Base of the right colic artery (if more length is needed).
    • Marginal artery at the proximal transection site.
  • Assess for pulsations to ensure adequate blood flow.

Transection and Anastomosis

• Divide the Middle Colic Artery:
  • Ligate and divide the middle colic artery and vein close to their origin.
• Transect the Colon:
  • Proximal colon transected using a linear cutting stapler.
  • Pass the colon behind the stomach through the lesser gastrohepatic omentum up to the hiatus.
• Avoid Twisting:
  • Ensure the colonic conduit is not axially twisted during mobilization.
• Determine Length:
  • Gently stretch the colon to determine precise length needed for anastomosis.
• Transect the Left Colon:
  • Transect using a linear cutting stapler.
  • Marginal artery left intact; small branches divided over ~1 cm on both sides.

Cologastric Anastomosis

• First Anastomosis:
  • End-to-side anastomosis between colon and stomach.
  • Anastomosis site on the posterior side of the stomach, close to the greater curvature, one-third down from the fundus.
• Antireflux Mechanism:
  • 8–10 cm of the graft retained under the diaphragm to act as an antireflux device.
  • The fundus acts as a flap valve over the intra-abdominal colon segment.
• Suturing Technique:
  • Inner layer: 3-0 absorbable sutures.
  • Outer layer: 3-0 nonabsorbable sutures.
  • Both layers use running sutures.

Colocolic Anastomosis

• Second Anastomosis:
  • Reanastomose the colon by connecting the right and left colon.
  • Extensive mobilization allows for easy approximation.

Cervical Anastomosis

• Third Anastomosis:
  • Performed similarly to cervical anastomosis with the stomach.
  • Handsewn anastomosis preferred for better adaptation.
  • Nasogastric tube inserted through the anastomosis to decompress the stomach.
  • Temporary gastrostomy may be placed.

Technique of Right Colon Interposition

• Indications:
  • Preferred by some surgeons.
  • Used when left colon vascularization is compromised.
• Graft Based on:
  • The middle colic artery.
• Procedure:
  • Similar principles of dissection and length measurement as in left colon interposition.
  • Identify the right colic artery; incise mesentery along it.
  • Test clamping to assess vascularization.
  • For long segments, include the cecum and terminal ileum, requiring division of the ileocolic artery.
  • Proceed with anastomoses as described.

Variations and Technical Considerations

• Isoperistaltic vs. Antiperistaltic Interposition:
  • Isoperistaltic interposition is preferred to maintain natural peristalsis.
  • Antiperistaltic interposition may be used if vascular anatomy necessitates.

• Vascular Challenges:

  • Variations may require creative solutions, such as patching the mesenteric artery if the middle colic artery splits early.

  

  • Superdrainage:
    • Anastomosis of the marginal vein to neck veins to improve venous drainage.
  • Supercharged Colon Interposition:
    • Arterial anastomosis to enhance arterial supply and prevent ischemia.

Outcomes and Complications

Mortality and Morbidity

• Postoperative Mortality:
  • Ranges between 10% and 20%.
  • Higher than mortality associated with gastric pull-up.
• Graft Necrosis:
  • Occurs in approximately 5% of cases.
  • Causes include:
    • Vascular damage from clamps or ligatures.
    • Rotation or twisting of the vascular pedicle.
    • Strangulation at the hiatus.
    • Undetected mesenteric atherosclerosis.

Anastomotic Leaks

• Incidence:
  • Rare in short-segment coloplasty with intrathoracic anastomosis.
  • Approximately 10% in long-segment interposition with cervical anastomosis.
• Management:
  • Usually treated conservatively.
  • Rarely requires revisional surgery.

Bulging and Redundancy

• Bulging of Supraclavicular Colon:
  • Due to air swallowing.
  • May cause dysphagia.
  • Revisional surgery may be necessary to excise protruding segment.
• Redundancy of Interposed Colon:
  • More common after retrosternal interposition.
  • Leads to mechanical kinking, causing dysphagia and aspiration.
  • Prevention:
    • Meticulous surgical technique.
    • Accurate measurement of colon length.
    • Posterior mediastinal route preferred to reduce risk.

Strictures and Fibrosis

• Fibrosis at Graft Top End:
  • Caused by venous ischemia due to venous congestion.
  • Results in strictures difficult to dilate.
  • Stricturoplasty may be performed.

Reflux-Related Complications

• Reflux Colitis:
  • Occurs due to colonic exposure to gastric contents.
  • Prevention:
    • Effective antireflux surgical technique.
  • Management:
    • Proton pump inhibitors (PPIs).
    • Surgical revision if necessary.
• Regurgitation and Aspiration:
  • Due to reflux and stasis in the conduit.
  • May require revisional surgery if unresponsive to medical therapy.
  • Antireflux procedures may be added, especially in children or young adults with benign conditions.

Intrinsic Pathology

• Development of IBD or Colon Cancer:
  • Rare occurrences in the interposed segment.
  • Treated according to standard protocols.

Conclusion

• Colon interposition is a valuable option when the stomach is unsuitable for esophageal replacement.
• Complexity and higher risk require careful patient selection and meticulous surgical technique.
• Understanding of vascular anatomy and potential complications is crucial for successful outcomes.

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Key Terms:

• Esophageal Replacement: Surgical procedure to reconstruct the esophagus.
• Colon Interposition: Use of a segment of the colon to replace the esophagus.
• Isoperistaltic: Segment aligned with natural peristaltic direction.
• Antiperistaltic: Segment aligned opposite to natural peristalsis.
• Marginal Artery (Artery of Drummond): Artery running along the colon's inner border.
• Arc of Riolan: An arterial connection between the superior and inferior mesenteric arteries.
• Graft Necrosis: Death of the transplanted tissue due to inadequate blood supply.
• Stricturoplasty: Surgical procedure to widen a narrowed area.
• Supercharged Interposition: Enhancing blood flow to the graft via additional arterial anastomosis.

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Jejunoplasty (Jejunal Interposition)

Historical Background

• 1907 – César Roux
  • Performed the first jejunoplasty in a 12-year-old with severe caustic injury.
  • Used a presternal esophagojejunogastrostomy; the patient lived until age 53.
• 1945 – Thompson
  • Performed a presternal jejunoplasty as a first step in treating mid-esophageal squamous cell cancer.
• 1957 – Allison et al.
  • Confirmed the utility of small bowel conduit for esophageal reconstruction.
• 1970s – Longmire
  • Described a long-segment jejunal interposition with microvascular augmentation.

Advantages and Disadvantages

• Advantages:
  • Third most commonly used method for esophageal reconstruction.
  • Jejunum can be used as:
    • Interposition graft
    • Roux-en-Y loop
    • Free vascular graft
  • Preserved peristalsis may improve functional outcomes.
• Disadvantages:
  • Segmental vascular configuration:
    • Makes it difficult to prepare a long segment.
    • Higher risk of ischemia and necrosis.
  • Technical complexity limits widespread use.

Indications

• Esophageal cancer surgery when:
  • Previous gastrectomy has been performed.
  • Total gastrectomy is needed for oncological reasons (e.g., gastroesophageal junction tumors extending into the stomach).

Anatomy and Blood Supply

• Blood Supply:
  • From the superior mesenteric artery.
  • Branches have a segmental pattern.
• Anatomic Variations:
  • Secondary arches may form, causing a ladder-type distribution.
  • Variations can lead to a curved, redundant appearance of the jejunum.

Technique of Roux-en-Y Jejunoplasty

Preparation

1. Identify the Ligament of Treitz:
   • Start by locating this ligament to find the beginning of the jejunum.
2. Assess Vascularization:
   • Use transillumination in obese patients.
   • Identify and preserve the first jejunal artery to ensure blood supply to the initial 15 cm.
3. Determine Required Length:
   • Visualize proximal two to three segmental arteries.
   • Carefully dissect these arteries from the mesentery.
4. Test Clamping:
   • Use atraumatic bulldog clamps to assess vascular adequacy.
   • Individually ligate and divide arteries and veins to achieve necessary length.

Increasing Length

• Divide Additional Arteries:
  • Dividing more arteries increases length but raises ischemia risk.
• Divide Primary Arcades:
  • Dividing one or two primary arcades while preserving secondary arcades can help.

Anastomosis

1. Transect the Jejunum:
   • About 15 cm from the ligament of Treitz using a linear cutting stapler.
2. Position the Jejunal Loop:
   • Bring the loop into the chest through the mesentery of the transverse colon.
3. Esophago-Jejunal Anastomosis:
   • Performed manually with two layers or using a circular stapler (25 or 28 mm).
4. Close Jejunal Stump:
   • Use a linear cutting stapler to prevent pseudodiverticulum formation.
5. Jejuno-Jejunal Anastomosis:
   • Connect the proximal 15 cm to the vertical limb of the jejunum at least 70 cm from the top to prevent biliary reflux.

Supercharged Pedicled Jejunoplasty

• Indications:
  • When vascularization at the top end is compromised.
• Technique:
  • Perform an arterial anastomosis to the internal mammary artery or inferior thyroid artery.

Technique of Jejunal Interposition (Merendino Operation)

• Indications:
  • When the colon is unavailable.
  • Preservation of gastric reservoir function is desired.
  • Previously advocated for high-grade dysplasia or early T1aN0M0 tumors.
• Procedure:
  • Similar preparation as Roux-en-Y jejunoplasty.
  • Perform esophago-jejunal, gastro-jejunal, and jejuno-jejunal anastomoses.

Functional Results

• Postoperative Mortality: Around 3% to 5%.
• Leak Rate: Approximately 5% to 10%.
• Symptoms:
  • Dysphagia, regurgitation, diarrhea, and reflux are rare.
• Biliary Reflux:
  • Some patients may suffer from persistent biliary reflux despite adhering to a 70 cm distance in Roux-en-Y reconstruction.
  • May require revisional surgery.

Free Vascular Grafts

Background

• Alexis Carrel (1906):
  • Described successful transplantation of autologous small bowel in dogs.
• 1970s Onwards:
  • Microsurgical technology popularized the use of free vascularized intestinal grafts.

Preferred Option

• Jejunum is preferred due to:
  • Preserved peristalsis.
  • Better functional outcomes.

Indications

• Laryngopharyngectomy patients.
• Primary indication or rescue option when other conduits are unsuitable.

Technique

1. Preparation of Jejunal Loop:
   • Select a segment ~40 cm from the ligament of Treitz.
   • Ensure optimal artery and vein length for anastomosis.
   • Choose a segment with sufficient diameter to match the pharynx base.
2. Transection and Mesentery Division:
   • Transect jejunum proximally and distally.
   • Divide mesentery on both sides of the feeding artery and draining vein.
3. Vascular Anastomosis:
   • Performed by a plastic surgery team using microsurgical techniques.
   • Connect to the inferior thyroid artery and external jugular vein using 10-0 monofilament sutures.
4. Anastomoses:
   • Pharyngo-Jejunal Anastomosis: Performed first to stabilize the jejunum.
   • Jejuno-Esophageal Anastomosis: Performed after vascular connections.
5. Monitoring Viability:
   • Mesenterial fat may be exteriorized to monitor graft viability postoperatively.

Skin in Esophageal Reconstruction

Historical Use

• Late 19th to Early 20th Century:
  • Skin tubes were among the first attempts to restore esophageal continuity.
  • J. Mikulicz (1886):
    • Reconstruction of the cervical esophagus using skin flaps.

Current Use

• Myocutaneous Flaps:
  • Used to cover large defects in the neck.
  • Examples include pectoralis major or deltoideopectoral muscle flaps.
• Radial Forearm Flaps:
  • Based on the radial artery and vein.
  • Used as free vascular grafts.
  • Employed to:
    • Close defects in the esophageal wall.
    • Bridge short gaps.
    • Repair secondary leaks or salivary fistulas.
• Indications:
  • Pharyngeal–cervical esophageal reconstructions.
  • Situations where bowel segments are not available (e.g., frozen abdomen).

Limitations

• Not Suitable for long-segment esophageal replacement.
• Primarily used in head and neck surgery for short segment repairs.

No Replacement

Historical Attempts

• 1879 – Theodor von Billroth
  • Performed esophageal resection without replacement.
  • Patient died of mediastinitis after bougie dilation through the mediastinum.

Recent Techniques

• "Rendezvous" Technique
  • Developed by the Marseille endoscopy group.
  • Used for stenosis or partial necrosis of an interposition.
  • Method:
    • Two scopes are introduced:
      • One from the pharynx down to the mediastinum.
      • One from the stomach up to the mediastinum.
    • Objective: Scopes meet to create a pathway.
    • Interventions:
      • Placement of a stent.
      • Multiple dilatations.
    • Outcome: Create a controlled fibrotic tube to bridge the defect.

Conduit Placement Routes

Factors Influencing Route Selection

• Extent of Visceral Resection
• Location of Anastomosis
• Incisions and Exposure Required

Common Surgical Approaches

• Left Thoracoabdominal Approach:
  • Intrathoracic anastomosis (Sweet's technique).
  • Cervical anastomosis (Belsey's technique).
• Right Thoracotomy and Laparotomy:
  • Intrathoracic anastomosis (Ivor Lewis procedure).
• Three-Hole Esophagectomy:
  • Right thoracotomy, laparotomy, and cervicotomy (McKeown's technique).
• Transhiatal Resection:
  • Laparotomy with cervical anastomosis (Orringer's technique).
• Minimally Invasive Esophagectomy (MIE):
  • Laparoscopy and right-sided VATS (Luketich's technique).

Routes for Conduit Placement

1. Posterior Mediastinal Route

• Most Commonly Used.
• Advantages:
  • Shortest route to the neck.
  • Preferred when the posterior mediastinum is unobstructed.

2. Substernal Route

• Indications:
  • When the posterior mediastinal route is unavailable due to prior surgery.
• Characteristics:
  • Slightly longer route with two angulations.
  • May cause dysphagia or bolus passage delay.
• Considerations:
  • Risk of redundancy with colon substitute.
  • Some surgeons perform a partial resection of the manubrium and clavicle head to reduce redundancy.

3. Lateral Transpleural Route

• Rarely Used.
• Placement:
  • Anterior to or behind the lung hilum.

4. Antethoracic Route

• Rarely Used.
• Placement:
  • Conduit placed outside the thorax.

5. Subcutaneous Route

• Used When Other Routes Are Unavailable.
• Indications:
  • Extremely rare cases where other routes cannot be utilized.

Summary of Routes

• Posterior Mediastinal: Preferred route; shortest and most direct.
• Substernal: Alternative when posterior mediastinum is not viable.
• Lateral Transpleural and Antethoracic: Rarely employed due to complexity and complications.
• Subcutaneous: Last resort option.

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Key Terms:

• Jejunoplasty: Reconstruction using a segment of the jejunum.
• Roux-en-Y Loop: A surgical procedure to reconstruct the gastrointestinal tract.
• Microvascular Augmentation: Enhancing blood supply via microsurgical techniques.
• Merendino Operation: Jejunal interposition preserving gastric function.
• Free Vascular Grafts: Transplantation of tissue with its blood supply using microsurgery.
• Conduit Placement: The route taken by the esophageal substitute to reach the neck.
• Posterior Mediastinal Route: Pathway through the posterior mediastinum.
• Substernal Route: Pathway behind the sternum.