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1
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Lin YS, Chen HC. Reconstruction of cervical esophagus for hypopharyngeal or thyroid cancer with intractable leakage at the upper end of thoracic esophagus: A scoping review and the pedicled colon flap solution. J Plast Reconstr Aesthet Surg 2025; 103:181-189. [PMID: 39999683 DOI: 10.1016/j.bjps.2025.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 12/03/2024] [Accepted: 01/24/2025] [Indexed: 02/27/2025]
Abstract
INTRODUCTION Patients with advanced hypopharyngeal cancers or thyroid cancers often require pharyngoesophageal reconstruction after tumor ablation, but complications are frequent. Anastomotic leakage, particularly in patients receiving perioperative radiation therapy, poses a significant challenge. The aim of this study was to conduct a literature review on leakage management methods and present a novel approach: utilizing a pedicled colon flap to create a diverted conduit connected to the cervical neo-esophagus. PATIENTS AND METHODS A scoping review was conducted in March 2024. Additionally, between 2004 and 2022, 17 patients underwent pedicled colon transposition to the newly reconstructed cervical neo-esophagus. Four had neoadjuvant radiation therapy for thyroid or hypopharyngeal cancer, and the pedicled colon transposition method was used to prevent anastomotic leakage after hypopharyngeal reconstruction. The other 13 suffered leakage at the junction of the cervical neo-esophagus and thoracic esophagus after reconstruction. The method involved closing the cephalic end of the thoracic esophagus and using the pedicled colon transposition to restore alimentary tract continuity. RESULTS The review identified 4 leakage prevention methods. In our clinical series, colon flap harvest averaged 4.5 h with no postoperative leakage observed. All patients resumed oral intake, but 65% experienced transient diarrhea that resolved within a month. CONCLUSION For patients who receive perioperative irradiation that complicates pharyngoesophageal reconstructions, a supercharged pedicled colon flap presents a feasible solution for managing anastomotic leakage.
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Affiliation(s)
- Ying-Sheng Lin
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan; Division of Plastic and Reconstructive Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.
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2
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Renard D, Molle G, Salmin JP. Systematic review of free jejunal flap for secondary esophageal reconstruction. ANN CHIR PLAST ESTH 2025:S0294-1260(25)00001-9. [PMID: 39814644 DOI: 10.1016/j.anplas.2025.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 12/30/2024] [Accepted: 01/02/2025] [Indexed: 01/18/2025]
Abstract
INTRODUCTION Esophagus reconstruction could be complicated by leakage, stenosis or graft loss. Salvage surgery may be needed in case of failure of endoscopic treatment or large esophagus defect. Although free jejunal flap is admitted for salvage head and neck reconstruction, few reports assess the results of free jejunal interposition in salvage esophagus reconstruction. We undertook a systematic review whose primary aim is to investigate outcomes of secondary esophageal reconstruction with free jejunal flap in terms of mortality, complications and functional results. MATERIAL AND METHOD We conducted a systematic review of the literature according to the PRISMA 2020 statements searching PubMed and Scopus databases for articles assessing free jejunal flap for secondary reconstruction after failed esophagus reconstruction. References of included studies were also screened. Studies quality was assessed using the JBI Critical Appraisal tools. RESULTS 562 studies were yielded through databases search and 328 studies were yielded through citations search. 18 articles were included in the systematic review corresponding to a total of 62 patients from 3 to 76 years old. All studies were level of evidence IV case reports or case series. We found that overall mortality was 3.2%, anastomotic fistula rate was 21%, anastomotic stricture rate was 4.8% and graft loss rate was 9.7% with survival of all jejunal regrafts. Solid oral intake was achieved in 93.0% of cases. CONCLUSION Jejunal free flap is a pertinent option for secondary esophageal reconstruction but remains a challenging surgery with high risk of complications that requires multidisciplinary team in large volume/tertiary care hospitals.
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Affiliation(s)
- D Renard
- Service de chirurgie générale et abdominale, HELORA Jolimont, rue Ferrer 159, 7100 La Louvière, Belgium.
| | - G Molle
- Service de chirurgie générale et abdominale, HELORA Jolimont, rue Ferrer 159, 7100 La Louvière, Belgium
| | - J-P Salmin
- Service de chirurgie plastique et reconstructrice, HELORA Jolimont, rue Ferrer 159, 7100 La Louvière, Belgium
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Mohan AT, Mahajan NN, Mardini S, Blackmon SH. Outcomes of Standardized Protocols in Supercharged Pedicled Jejunal Esophageal Reconstruction. Ann Thorac Surg 2023; 115:210-219. [PMID: 35718204 DOI: 10.1016/j.athoracsur.2022.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study evaluated clinical and patient-reported outcomes (PROs) of long-segment supercharged pedicled jejunal (SPJ) interposition after implementation of a dedicated multidisciplinary pathway and technical refinements. METHODS This study was a 6-year review of consecutive patients who underwent complex esophageal reconstruction with SPJ interposition. Clinical data were abstracted, and PRO data were collected prospectively by using the Upper Digestive Disease mobile application (UDD App). This standardized questionnaire comprised domains for mental and physical health, pain, dysphagia, reflux, hypoglycemia dumping, and gastrointestinal dumping symptoms. Operative refinements were comprehensively established by 2018. RESULTS A total of 19 patients were included in the study, 15 of whom had a history of esophageal malignant disease and neoadjuvant chemoradiation. Most patients (18; 95%) underwent delayed reconstruction after diversion. There was no 90-day mortality or flap loss. Most patients (18; 95%) achieved an enteral diet. Seven patients (37%) experienced early complications (<90 days) requiring procedural intervention. The incidence of any medical or surgical complication was similar in the earlier (2015-2017) and late (2018-2020) cohorts, but aspiration events, surgical site infections, anastomotic leak rates, and median hospital stay (reduced from 15 days [IQR, 10-21 days] to 9 days [IQR, 9-13 days]) improved in the contemporary cohort. PRO data were collected in 14 of 15 (93%) living patients. Severe symptoms in at least 1 domain were reported by most patients (11; 79%) and improved over time. CONCLUSIONS Dedicated care pathways allow standardization of complex procedures, and targeted modifications may optimize recovery and patient outcomes. This cohort of patients may report severe symptoms that require ongoing monitoring and intervention.
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Affiliation(s)
- Anita T Mohan
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nandita N Mahajan
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Samir Mardini
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shanda H Blackmon
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Supercharged Jejunal Interposition. Thorac Surg Clin 2022; 32:529-540. [PMID: 36266038 DOI: 10.1016/j.thorsurg.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Complex esophageal reconstruction represents a high risk and challenging procedure. A dedicated pathway with multispecialty teams can facilitate a systematic checklist approach to perioperative management and evaluation of long-term outcomes. Refinements in the operative technique for supercharged pedicled jejunum (SPJ) for long segment interposition in esophageal reconstruction are reviewed in this article. Medical and surgical complications among this complex niche group of patients are significant and require care in specialist centers with a focused team. Patient-reported outcomes (PROs) in long-segment SPJ interposition are recognized to provide additional monitoring of surgical outcomes and may help guide interventions for subsequent symptom control.
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Hung PC, Chen HY, Tu YK, Kao YS. A Comparison of Different Types of Esophageal Reconstructions: A Systematic Review and Network Meta-Analysis. J Clin Med 2022; 11:jcm11175025. [PMID: 36078955 PMCID: PMC9457433 DOI: 10.3390/jcm11175025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background: A total esophagectomy with gastric tube reconstruction is the mainstream procedure for esophageal cancer. Colon interposition and free jejunal flap for esophageal reconstruction are the alternative choices when the gastric tube is not available. However, to date, a solution for the high anastomosis leakage rates among these three types of conduits has not been reported. The aim of this network meta-analysis was to investigate the rate of anastomotic leakage (AL) among the three procedures to determine the best esophageal substitute or the future direction for improving the conventional gastric pull-up (GPU). Methods: We searched PubMed, Cochrane, and Embase databases. We included esophageal cancer patients receiving esophagectomy and excluded patients with other cancer. The random effect model was used in this network meta-analysis. The Newcastle–Ottawa Scale (NOS) was used for the quality assessment of studies in the network meta-analysis, and funnel plots were used to evaluate publication bias. The primary outcome is anastomosis leakage; the secondary outcomes are stricture formation, length of hospital stays, and mortality rate. Results: Nine studies involving 1613 patients were included in this network meta-analysis. The trend results indicated the following. Regarding anastomosis leakage, free jejunal flap was the better procedure; regarding stricture formation, colon interposition was the better procedure; regarding mortality rate, free jejunal flap was the better procedure; regarding length of hospital stay, gastric pull-up was the better treatment. Discussion: Overall, if technically accessible, free jejunal flap is a better choice than colon interposition when gastric conduit cannot be used, but further study should be conducted to compare groups with equal supercharged patients. In addition, jejunal flap (JF) cannot replace traditional gastric pull-up (GPU) due to technical complexities, more anastomotic sites, and longer operation times. However, the GPU method with the supercharged procedure would be a possible solution to lower postoperative AL. The limitation of this meta-analysis is that the number of articles included was low; we aim to update the result when new data are available. Funding: None. Registration: N/A.
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Affiliation(s)
- Pang-Chieh Hung
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Hsuan-Yu Chen
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Yu-Kang Tu
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei 106, Taiwan
| | - Yung-Shuo Kao
- Department of Radiation Oncology, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence:
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Use of free jejunal flap as a salvage procedure in the management of high corrosive esophageal re-strictures: an institutional experience and review of literature. Langenbecks Arch Surg 2022; 407:2725-2732. [PMID: 35759020 DOI: 10.1007/s00423-022-02595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND High pharyngo-esophageal strictures following corrosive ingestion continue to pose a challenge to the surgeon, particularly in the developing world. With the advancements and increased experience with microsurgical techniques, free jejunal flaps offer a viable reconstruction option in patients with high corrosive strictures with previous failed reconstruction. We review our experience with free jejunal flap in three cases with high pharyngo-esophageal stricture following corrosive ingestion, with previous failed reconstruction. MATERIALS AND METHODS A total of three patients underwent salvage free jejunal flap after failed reconstruction for high pharyngo-esophageal strictures following corrosive acid ingestion. All the three patients developed anastomotic leak and subsequent stricture, two following a pharyngo-gastric anastomosis and one following a pharyngo-colic anastomosis. The strictured segment was bridged using a free jejunal graft with microvascular anastomosis to the lingual artery and common facial vein. All patients were followed-up at regular intervals. RESULTS AND CONCLUSIONS The strictured pharyngeal anastomotic segment was successfully reconstructed with free jejunal flap in all the three patients. Patients were able to take food orally and maintain nutrition without the need of jejunostomy feeding. On long-term follow-up (median: 5 years), there was no recurrence of dysphagia and all the patients had good health-related quality of life.
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7
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Flemming S, Lock JF, Hankir M, Reimer S, Petritsch B, Germer CT, Seyfried F. Successful management of therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up: A case report. World J Clin Cases 2021; 9:3971-3978. [PMID: 34141755 PMCID: PMC8180226 DOI: 10.12998/wjcc.v9.i16.3971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/26/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric pull-up after esophagectomy is still a demanding surgical procedure and associated with considerable morbidity such as anastomotic leaks, fistulas or stenoses. These complications are usually managed by endoscopy, but in extreme cases multidisciplinary management including reoperations may be necessary. Here, we report managing therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up.
CASE SUMMARY A 70-year-old male with dysphagia and regurgitation after esophagectomy with gastric pull-up reconstruction was transferred to our tertiary hospital. Since endoscopic approaches including balloon dilatation and stenting failed, retrosternal colonic pull-up with Roux-en-Y reconstruction was performed with no subsequent adverse events.
CONCLUSION Secondary colonic pull-up is a demanding but successful surgical procedure in patients suffering from therapy-refractory complaints after esophagectomy with gastric pull-up reconstruction.
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Affiliation(s)
- Sven Flemming
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Stanislaus Reimer
- Department of Internal Medicine II, Section of Gastroenterology, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Bernhard Petritsch
- Department of Diagnostic and Interventional Radiology, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
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Ishii K, Tsubosa Y, Nakao J, Haneda R, Ishii Y, Booka E, Mayanagi S, Araki J, Yasunaga Y, Nakagawa M. Utility of the evaluation of blood flow of remnant esophagus with indocyanine green in esophagectomy with jejunum reconstruction: Case series. Ann Med Surg (Lond) 2021; 62:21-25. [PMID: 33489111 PMCID: PMC7808916 DOI: 10.1016/j.amsu.2020.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Pedicled jejunal flap can be utilized with various tips for esophageal reconstruction in patients with a history of gastrectomy or those who have undergone synchronous esophagogastrectomy. However, the rate of anastomosis leakage is high; therefore, we considered the evaluation of blood flow of the remnant esophagus with indocyanine green in setting the anastomosis site. METHODS Fifty patients who underwent radical esophagectomy with pedicled jejunal flap between January 2011 and June 2020 were identified. From June 2019, blood flow in the pedicled jejunum and remnant esophagus were evaluated to set the anastomosis site of the latter. Usually, the second and third jejunal vessels are transected, and if the jejunal flap cannot reach to the anastomosis point, we actively transect the marginal vessels to stretch the jejunal flap. Microvascular anastomosis between the jejunal branches and the internal thoracic vessels is usually made, and the anastomosis site is set at the well-stained part of the esophagus. RESULTS Overall, 39 patients underwent the procedure before June 2019 (Group A), and 11 patients underwent the procedure since June 2019 (Group B). No significant difference was found in the patients' background, type of preoperative therapy, presence or absence of ligation of marginal vessels and two-stage operation between the groups. Group A had 16 cases of anastomosis leakage; B had only 1 case (p < 0.05). There were no cases of pedicled jejunum graft necrosis. CONCLUSION Assessing remnant esophageal perfusion by indocyanine green imaging in pedicled jejunum reconstruction resulted in a lower anastomotic leak rate.
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Affiliation(s)
- Kenjiro Ishii
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Junichi Nakao
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Ryoma Haneda
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Hanndayama, Higashi-ku, Hamamatsushi, Shizuoka, 431-3192, Japan
| | - Yoshitaka Ishii
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Eisuke Booka
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Shuhei Mayanagi
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Jun Araki
- Division of Esophageal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Yoshichika Yasunaga
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Masahiro Nakagawa
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Suntou-gun, Shizuoka, 411-8777, Japan
- Department of Plastic Reconstructive Surgery, Hamamatsu University School of Medicine, 1-20-1 Hanndayama, Higashi-ku, Hamamatsushi, Shizuoka, 431-3192, Japan
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Marchi F, Kang SC, Cheong DCF, Hung SY, Wang SH, Chiu TH, Chen YT, Tsao CK. The Benefits of the Supercharged Ileocolic Flap in Patients Who Underwent Total Esophagectomy and Gastrectomy. J Reconstr Microsurg 2020; 37:475-485. [PMID: 33202456 DOI: 10.1055/s-0040-1719046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients who undergo total esophagectomy and gastrectomy present a challenging scenario for reconstructive surgeons. Several techniques have been described. However, the best choice is still a matter of debate. We aim to report our experience with the supercharged ileocolic flap, then to compare the long-term functional outcomes in cancer and caustic injury patients. We investigate the safest route of transposition and demonstrate the importance of supercharging the flap. Last, we perform a literature review to compare our results with the ones reported in the literature. METHODS A total of 36 patients underwent the supercharged ileocolic flap procedure. The details reviewed included the type of defect, flap characteristic, route of transposition, complications, patient survival, and swallowing evaluation. Survival and long-term function preservation were considered as the main outcomes. A secondary end-point was the identification of the safest route of transposition. We extracted the pertinent literature on supercharged bowel flaps from 1995 to July 2020 RESULTS: All flaps survived; only two flaps were partially lost. Thirty-three percent of the cohort experienced postoperative complications; the most common was leakage of the cervical anastomosis (17%), followed by neck wound infection (8%). The 5-year dysphagia-free survival rate was 87% in corrosive injury patients and 78% in cancer patients. The mean time to be free from dysphagia after surgery was 25.12 ± 4.55 months for corrosive patients and 39.56 ± 9.45 months for cancer patients (p = 0.118). The safest route of transposition was retrosternal extra-mediastinal. From the literature review, the data from 11 studies were extracted. CONCLUSION The supercharged ileocolic flap is a robust option for total esophageal replacement when the stomach is not available and the retrosternal route is the safest for transposition. The functional outcomes are excellent, with acceptable morbidity and a good life expectancy, either in cancer and noncancer patients. Supercharging the flap is recommended.
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Affiliation(s)
- Filippo Marchi
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taipei, Taiwan.,Department of Plastic and Reconstructive Surgery, Chang Gung University, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan.,Department of Otorhinolaryngology, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Shih Ching Kang
- Department of Trauma and Emergency Surgery, Chang Gung University, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
| | - David Chon Fok Cheong
- Department of Plastic and Reconstructive Surgery, Chang Gung University, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
| | - Shao Yu Hung
- Department of Plastic and Reconstructive Surgery, Chang Gung University, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
| | - Szu Han Wang
- Department of Plastic and Reconstructive Surgery, Chang Gung University, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
| | - Ting Han Chiu
- Department of Plastic and Reconstructive Surgery, Chang Gung University, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
| | - Yu Ting Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung University, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan
| | - Chung Kan Tsao
- Department of Plastic and Reconstructive Surgery, Chang Gung University, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Miyata H, Sugimura K, Shinno N, Hara H, Yamamoto K, Omori T, Haraguchi N, Nishimura J, Yasui M, Yamada D, Wada H, Asukai K, Takahashi H, Ohue M, Yano M. Lymph Node Metastasis and Recurrences from Esophageal Squamous Cell Carcinoma in Patients with Previous Gastrectomy. Ann Surg Oncol 2020; 27:5312-5319. [PMID: 32548753 DOI: 10.1245/s10434-020-08734-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Esophageal cancer patients sometimes have a history of previous gastrectomy. To determine whether we should resect or preserve the remnant stomach, we need to understand the frequency and sites of abdominal lymph node (LN) metastasis from esophageal cancer after gastrectomy. PATIENTS AND METHODS In 46 patients with thoracic esophageal squamous cell carcinoma (ESCC) who had a history of previous gastrectomy due to gastric cancer (n = 20) or benign disease (n = 26), the frequency and sites of any LN metastasis including LN metastasis at surgery and LN recurrence were investigated. The factors associated with abdominal LN metastasis were also examined. RESULTS The incidence of metastasis to cervical, mediastinal, and abdominal LNs at surgery was 10.8%, 30.4%, and 30.4%, respectively. The incidence of abdominal LN recurrence was 6.5%. Of 46 patients, 16 patients (34.8%) had any abdominal LN metastasis, including abdominal LN metastasis at surgery or abdominal LN recurrence. There was no significant difference in the incidence of any abdominal LN metastasis between the gastric cancer group and the benign disease group (25.0% vs. 42.3%, p = 0.222). Clinically, nodal status was identified as the only independent factor associated with the occurrence of any abdominal LN metastasis, although neither tumor location nor the reason for gastrectomy was. CONCLUSIONS The present study showed that the incidence of abdominal LN metastasis from ESCC after gastrectomy was not necessarily low, regardless of the tumor location and the reason for previous gastrectomy. This result suggests that gastrectomy should not be omitted easily in ESCC patients after previous gastrectomy.
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Affiliation(s)
- Hiroshi Miyata
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan.
| | - Keijirou Sugimura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Naoki Shinno
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hisashi Hara
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuyoshi Yamamoto
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takeshi Omori
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Naotsugu Haraguchi
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Junichi Nishimura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayoshi Yasui
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Daisaku Yamada
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Wada
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Kei Asukai
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hidenori Takahashi
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayuki Ohue
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masahiko Yano
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
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11
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Two-stage Reconstruction Using a Free Jejunum/Ileum Flap After Total Esophagectomy. Ann Plast Surg 2020; 85:638-644. [PMID: 32501843 DOI: 10.1097/sap.0000000000002421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reconstruction after esophagectomy is conventionally performed with a gastric conduit. However, in cases where a gastric conduit is unavailable, reconstructive procedures vary in terms of flap type, operative timing, and conduit route. Single-stage surgery is associated with a long operation time and high surgical stress, resulting in perioperative mortality. Recent advances in reconstructive microsurgery have made free intestinal flap transfer safe and reliable. Therefore, to overcome the shortcomings with previous methods, we performed 2-stage surgery involving free jejunum/ileum transfer for reconstruction after esophagectomy. PATIENTS AND METHODS From 2010 to 2018, 42 free jejunum/ileum flaps were transferred for reconstruction after esophagectomy in 41 patients. The diagnosis was esophageal cancer in 38 patients. All operations were performed in 2 stages. In most cases, total esophagectomy was performed in the first operation. The cervical stump of the esophagus was sutured to the cervical skin, creating an esophagostomy in the left neck. About 4 to 7 weeks after the first operation, the second operation was performed. The free jejunum/ileum flap was transferred through the subcutaneous route. Microvascular anastomosis was performed with the internal mammary artery and internal mammary vein, transverse cervical artery, internal and external jugular veins (internal jugular vein and EJV, respectively), and cephalic vein. The mean follow-up duration was 20 months. RESULTS Free jejunum/ileum transfer was performed as the first operation in 4 cases and as the second operation in 38 cases. A free jejunal flap was used in 36 cases and free ileal flap was used in 6 cases. The recipient arteries were the internal mammary artery in 38 cases and transverse cervical artery in 4 cases. The recipient veins were the internal mammary vein in 15 cases, cephalic vein in 13 cases, EJV in 10 cases, and internal jugular vein in 10 cases. The flaps survived in all cases, except 1 case (41/42, 97.6%). The complications were anastomotic leakage of the flap in 9 cases, respiratory complications in 10 cases, and ileus in 2 cases. Perioperative mortality was not noted. CONCLUSIONS Two-stage surgery using free jejunum/ileum flap transfer is a safe and reliable option for esophageal reconstruction in cases where gastric pull-up is unavailable.
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The Supercharged Pedicled Jejunal Flap for Total Esophageal Reconstruction. Plast Reconstr Surg 2019; 144:1171-1180. [DOI: 10.1097/prs.0000000000006171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Mays AC, Selber J. Salvage Surgery for Jejunal Necrosis After a Free Jejunal Transfer. Ann Surg Oncol 2019; 26:1967-1969. [PMID: 30805808 DOI: 10.1245/s10434-019-07155-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Ashley C Mays
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Jesse Selber
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA.
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Double Supercharged Jejunal Interposition for Late Salvage of Long-gap Esophageal Atresia. Ann Plast Surg 2018; 81:553-559. [DOI: 10.1097/sap.0000000000001520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chang TY, Hsiao JR, Lee WT, Ou CY, Yen YT, Tseng YL, Pan SC, Shieh SJ, Lee YC. Esophageal reconstruction after oncological total laryngopharyngoesophagectomy: Algorithmic approach. Microsurgery 2018; 39:6-13. [PMID: 29400418 DOI: 10.1002/micr.30304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 12/31/2017] [Accepted: 01/24/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Reconstruction for total laryngopharyngoesophagectomy is accomplished mainly by gastrointestinal transposition but can be complicated by anastomotic tension or associated neck-skin defect. Here, we present the results of total esophageal reconstruction by gastrointestinal transposition alone or with additional free tissue transfer and propose an algorithm accordingly. METHODS We reviewed patients who had oncologic total laryngopharyngoesophagectomy between January 2012 and January 2016. Twenty-four men and one woman were included with a mean age of 54 (range, 41-72) years. Patients were grouped by reconstruction into the gastric pull-up (GP, n = 15), colon interposition (CI, n = 2), GP combined with free jejunal flap (GPFJ, n = 6), or GP combined with anterolateral thigh flap (GPALT, n = 2) group to compare clinical outcomes. RESULTS The mean operation time was 1037.3 minutes and was significantly longer in the GPALT group than in the GP group (1235.0 ± 50.0 minutes vs. 929.7 ± 137.7 minutes, p =.009). All flaps survived. After a mean follow-up of 18 months, the overall leakage, stricture, and successful swallowing rates were 44%, 4%, and 76%, respectively. There was no significant difference in the leakage (53.3%, 50.0%, 16.7%, and 50.0%, p =.581), stricture (6.7%, 0%, 0%, and 0%, p = 1.000), or successful swallowing (73.3%, 50.0%, 83.3%, and 100%, p =.783) rates between GP, CI, GPFJ, and GPALT groups, respectively. CONCLUSIONS The proposed algorithm that ranks gastric pull-up as a priority and uses additional free tissue transfer to overcome the anastomotic tension or associated neck-skin defect is feasible.
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Affiliation(s)
- Tzu-Yen Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, Dou-Liou Branch, College of Medicine, Yunlin, Taiwan
| | - Jenn-Ren Hsiao
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ting Lee
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Yen Ou
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ting Yen
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yau-Lin Tseng
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shin-Chen Pan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shyh-Jou Shieh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yao-Chou Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Abstract
Replacement of the native esophagus after esophagectomy is a problem that has challenged surgeons for over a century. Not only must the conduit be long enough to bridge the distance between the cervical esophagus and the abdomen, it must also have a reliable vascular supply and be sufficiently functional to allow for deglutition. The stomach, jejunum, and colon (right, left or transverse) have all been proposed as potential solutions. The stomach has gained favor for its length, reliable vascular supply and need for only a single anastomosis. However, there are times when the stomach is unavailable for use as a conduit. It is in these instances that an esophageal surgeon must have an alternative conduit in their armamentarium. In this paper, we will briefly discuss the technical aspects of jejunal and colonic interposition. We will review the recent literature with a focus on early and late outcomes. The advantages and disadvantages of both options will be reviewed.
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Affiliation(s)
- Ankur Bakshi
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - David J Sugarbaker
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Bryan M Burt
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Chang EI, Hanasono MM, Butler CE. Management of Unfavorable Outcomes in Head and Neck Free Flap Reconstruction. Clin Plast Surg 2016; 43:653-667. [DOI: 10.1016/j.cps.2016.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Watanabe M, Mine S, Nishida K, Kurogochi T, Okamura A, Imamura Y. Reconstruction after esophagectomy for esophageal cancer patients with a history of gastrectomy. Gen Thorac Cardiovasc Surg 2016; 64:457-63. [PMID: 27234222 DOI: 10.1007/s11748-016-0661-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 05/18/2016] [Indexed: 12/11/2022]
Abstract
Pedicled jejunal flap and colon graft interposition are choices for esophageal reconstruction in patients with a history of gastrectomy or those who have undergone synchronous esophagogastrectomy. However, the optimal conduit in this situation is still being debated. We reviewed the literature concerning esophageal reconstruction using a conduit other than the stomach. Approximately 10 % of esophagectomized patients undergo esophageal reconstruction using pedicled jejunum or colon interposition in Japan. The jejunal graft and colon graft are selected evenly, although the percentage of jejunal graft use is gradually increasing. Microvascular supercharge was performed in most of the reports of pedicled jejunal graft reconstruction, whereas vascular enhancement was not popularly used in the reports of colon graft interposition. Although the incidences of graft loss and anastomotic leakage were comparable between grafts, mortality rates seem to be higher in patients who undergo colon graft reconstruction than in those who undergo reconstruction with a jejunal graft. Prospective comparisons of short-term outcomes as well as long-term quality of life are needed to identify the best method of reconstruction.
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Affiliation(s)
- Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Shinji Mine
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Koujiro Nishida
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takanori Kurogochi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Weiss ARR, Hackl C, Soeder Y, Schlitt HJ, Dahlke MH. Ileo-right hemi-colonic cervical pull-up on a non-supercharged ileocolic arterial pedicle: A technical and case report. World J Gastroenterol 2016; 22:3869-3874. [PMID: 27076773 PMCID: PMC4814751 DOI: 10.3748/wjg.v22.i14.3869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 01/04/2016] [Accepted: 01/30/2016] [Indexed: 02/06/2023] Open
Abstract
Esophageal reconstruction can be challenging when stomach and colon are not anatomically intact and their use as esophageal substitutes is therefore limited. Innovative individual approaches are then necessary to restore the intestinal passage. We describe a technique in which a short stump of the right hemicolon and 25 cm of ileum on a long, non-supercharged, fully mobilized ileocolic arterial pedicle were used for esophageal reconstruction to the neck. In this case, a 65 year-old male patient had accidentally indigested hydrochloric acid which caused necrosis of his upper digestive tract. An emergency esophagectomy, gastrectomy, duodenectomy, pancreatectomy and splenectomy had been performed in an outside hospital. A cervical esophagostomy and a biliodigestive anastomosis had been created and a jejunal catheter for enteral feeding had been placed. After the patient had recovered, a reconstruction of his food passage via the left and transverse colon failed for technical reasons due to an intraoperative necrotic demarcation of the colon. Our team then faced the situation that only a short stump of the right hemi-colon was left in situ when the patient was referred to our center. After intensified nutritional therapy, we reconstructed this patient’s food passage with the right hemicolon-approach described herein. After treatment of a postoperative pneumonia, the patient was discharged from hospital on the 26th postoperative day in a good clinical condition on an oral-only diet. In conclusion, individual approaches for long-segment reconstruction of the esophagus can be technically feasible in experienced hands. They do not always require arterial supercharging or free intestinal transplantation.
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Ghali S, Chang EI, Rice DC, Walsh GL, Yu P. Microsurgical reconstruction of combined tracheal and total esophageal defects. J Thorac Cardiovasc Surg 2015; 150:1261-6. [PMID: 25998466 DOI: 10.1016/j.jtcvs.2011.10.100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 09/08/2011] [Accepted: 10/09/2011] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Shadi Ghali
- Department of Plastic Surgery, the University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Edward I Chang
- Department of Plastic Surgery, the University of Texas MD Anderson Cancer Center, Houston, Tex
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, the University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Garrett L Walsh
- Department of Thoracic and Cardiovascular Surgery, the University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Peirong Yu
- Department of Plastic Surgery, the University of Texas MD Anderson Cancer Center, Houston, Tex.
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Chian KS, Leong MF, Kono K. Regenerative medicine for oesophageal reconstruction after cancer treatment. Lancet Oncol 2015; 16:e84-92. [PMID: 25638684 DOI: 10.1016/s1470-2045(14)70410-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Removal of malignant tissue in patients with oesophageal cancer and replacement with autologous grafts from the stomach and colon can lead to problems. The need to reduce stenosis and anastomotic leakage after oesophagectomy is a high priority. Developments in tissue-engineering methods and cell-sheet technology have improved scaffold materials for oesophageal repair. Despite the many successful animal studies, few tissue-engineering approaches have progressed to clinical trials. In this Review, we discuss the status of oesophagus reconstruction after surgery. In particular, we highlight two clinical trials that used decellularised constructs and epithelial cell sheets to replace excised tissues after endoscopic submucosal dissection or mucosal resection procedures. Results from the trials showed that both decellularised grafts and epithelial-cell sheets prevented stenosis. By contrast, animal studies have shown that the use of tissue-engineered constructs after oesophagectomy remains a challenge.
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Affiliation(s)
- Kerm Sin Chian
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore, Singapore.
| | - Meng Fatt Leong
- Department of Cell and Tissue Engineering, Institute of Bioengineering and Nanotechnology, Singapore, Singapore
| | - Koji Kono
- Department of Surgery, National University of Singapore, Singapore, Singapore; Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore; Department of Organ Regulatory Surgery and Advanced Cancer Immunotherapy, Fukushima Medical University, Fukushima, Japan
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Gaur P, Blackmon SH. Jejunal graft conduits after esophagectomy. J Thorac Dis 2014; 6 Suppl 3:S333-40. [PMID: 24876939 DOI: 10.3978/j.issn.2072-1439.2014.05.07] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 05/13/2014] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The jejunum is uniquely suitable for esophageal reconstruction because it is relatively abundant, does not require a formal preparation, is typically free of disease, has similar luminal size compared to the esophagus, has intrinsic peristalsis, and may not undergo senescent lengthening to the extent that colon does. METHODS To obtain data to determine the outcomes of jejunal interposition for esophageal replacement, electronic databases were searched, including MEDLINE (Ovid SP), Scopus, EMBASE (Ovid SP), Science Direct's full-text database, and the Cochrane Library from January 1990 to September 2013. RESULTS Two-hundred and forty-six abstracts were reviewed and an article search was performed on selected abstracts. Additional references from article bibliographies were included as appropriate. A thorough search of the literature demonstrates the widespread use of jejunum, either as a free, pedicled, or free- and pedicled-graft with acceptable results. CONCLUSIONS Any region of the esophagus can be replaced by jejunum, whether it is distal esophagus as a Merendino procedure for a vagal-sparing esophagectomy and segmental jejunal reconstruction connected to stomach, mid-thoracic esophagus as a pedicled jejunal interposition or free flap, cervical esophagus as a free segmental interposition, or the entire length as a long-segment super-charged pedicled jejunal interposition. When used, the jejunum is either pedicled, augmented ("super-charged"), a free segment (requiring microvascular anastomosis of artery and vein), or a combination of the above.
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Affiliation(s)
- Puja Gaur
- Division of Thoracic Surgery, Weill Cornell Medical College of Cornell University & Houston Methodist Hospital, 6550 Fannin Street, Houston, TX 77030, USA
| | - Shanda H Blackmon
- Division of Thoracic Surgery, Weill Cornell Medical College of Cornell University & Houston Methodist Hospital, 6550 Fannin Street, Houston, TX 77030, USA
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Miyamoto S, Kayano S, Fujiki M, Sakuraba M. Combined use of the cephalic vein and pectoralis major muscle flap for secondary esophageal reconstruction. Microsurgery 2013; 34:319-23. [DOI: 10.1002/micr.22209] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Shimpei Miyamoto
- Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital; Tokyo Japan
| | - Shuji Kayano
- Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital; Tokyo Japan
| | - Masahide Fujiki
- Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital East; Kashiwa Japan
| | - Minoru Sakuraba
- Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital East; Kashiwa Japan
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Okumura Y, Mori K, Yamagata Y, Fukuda T, Wada I, Shimizu N, Nomura S, Iida T, Mihara M, Seto Y. Two-stage operation for thoracic esophageal cancer: esophagectomy and subsequent reconstruction by a free jejunal flap. Surg Today 2013; 44:395-8. [PMID: 24292600 DOI: 10.1007/s00595-013-0797-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 03/04/2013] [Indexed: 01/11/2023]
Abstract
When the stomach is unavailable for esophageal reconstruction due to previous gastrectomy or synchronous gastric cancer, a pedicled jejunum or colon, with or without vascular supercharge, has been the alternative. However, these reconstructions are not free from severe complications, such as necrosis. We have introduced a new surgical technique for delayed esophageal reconstruction using a free jejunal flap. We used this technique in 11 patients. Four weeks after subtotal esophagectomy, reconstruction using free jejunal flaps was performed. A free jejunum was placed at the pre-sternum, and the internal thoracic artery and vein were usually used as the recipient vessels. There were no cases of flap necrosis and no hospital deaths. Anastomotic leakage occurred in two cases. Both leakages were cured by conservative treatment. Delayed esophageal reconstruction using a free jejunal flap can be considered to be a safe procedure when the stomach is unavailable as an esophageal substitute.
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Affiliation(s)
- Yasuhiro Okumura
- Department of Gastrointestinal Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan,
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My first 100 consecutive microvascular free flaps: pearls and lessons learned in first year of practice. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2013; 1:e27. [PMID: 25289221 PMCID: PMC4173838 DOI: 10.1097/gox.0b013e31829e1007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 05/20/2013] [Indexed: 12/12/2022]
Abstract
Background: Microvascular reconstruction for oncologic defects is a challenging and rewarding endeavor, and successful outcomes are dependent on a multitude of factors. This study represents lessons learned from a personal prospective experience with 100 consecutive free flaps. Methods: All patients’ medical records were reviewed for demographics, operative notes, and complications. Results: Overall 100 flaps were performed in 84 consecutive patients for reconstruction of breast, head and neck, trunk, and extremity defects. Nineteen patients underwent free flap breast reconstruction with 10 patients undergoing bilateral reconstruction and 2 patients receiving a bipedicle flap for reconstruction of a unilateral breast defect. Sixty-five free flaps were performed in 61 patients with 3 patients receiving 2 free flaps for reconstruction of extensive head and neck defects and 1 patient who required a second flap for partial flap loss. Trunk and extremity reconstruction was less common with 2 free flaps performed in each group. Overall, 19 patients (22.6%) developed complications and 14 required a return to the operating room. There were no flap losses in this cohort. Thorough preoperative evaluation and workup, meticulous surgical technique and intraoperative planning, and diligent postoperative monitoring and prompt intervention are critical for flap success. Conclusions: As a young plastic surgeon embarking in reconstructive plastic surgery at an academic institution, the challenges and dilemmas presented in the first year of practice have been daunting but also represent opportunities for learning and improvement. Skills and knowledge acquired from time, experience, and mentors are invaluable in optimizing outcomes in microvascular free flap reconstruction.
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Iwata N, Koike M, Kamei Y, Tanaka C, Ohashi N, Nakayama G, Nomoto S, Fujii T, Sugimoto H, Fujiwara M, Kodera Y. Antethoracic pedicled jejunum reconstruction with the supercharge technique for esophageal cancer. World J Surg 2013; 36:2622-9. [PMID: 22868971 DOI: 10.1007/s00268-012-1736-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastric tube is the first choice as an esophageal substitute for reconstruction after esophagectomy. Colon or jejunum is selected for patients in whom stomach cannot be used. Colon interposition is reported to have a high incidence of anastomotic leakage and mortality. For safer surgical treatment, the authors adopted supercharged pedicle jejunum reconstruction as the operation of choice in patients with esophageal cancer who had no stomach to use as an esophageal substitute. The aim of this study was to review our experience with this technique. METHODS From 2003 to 2009, esophagectomy and antethoracic pedicled jejunum reconstruction with the supercharge technique was performed in 27 patients with esophageal cancer at the Department of Gastroenterological Surgery (Surgery II), Nagoya University Hospital. Medical records of these 27 patients were retrospectively reviewed to determine demographic data, diagnosis, functional results, and perioperative course. RESULTS Median operating time, blood loss, hospital stay, and duration of enteral feeding were 636 min (range 454-856 min), 580 ml (range 208-1959 ml), 27 days (range 16-72 days), and 80 days (range 26-1740 days), respectively. There were no in-hospital deaths. Anastomotic leakage occurred in two patients and was successfully managed conservatively. In 2 of 27 patients, the pedicled jejunum was of insufficient length, and additional procedures were needed to complete the anastomosis. CONCLUSIONS Although antethoracic pedicled jejunum reconstruction with the supercharge technique is technically demanding, it is a reliable technique and contributes to successful reconstruction after esophagectomy for patients in whom stomach is not available for reconstruction.
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Affiliation(s)
- Naoki Iwata
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan.
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Chirica M, Vuarnesson H, Zohar S, Faron M, Halimi B, Munoz Bongrand N, Cattan P, Sarfati E. Similar outcomes after primary and secondary esophagocoloplasty for caustic injuries. Ann Thorac Surg 2012; 93:905-12. [PMID: 22364982 DOI: 10.1016/j.athoracsur.2011.12.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 12/13/2011] [Accepted: 12/16/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND The main purpose of the study was to report a comparative experience with primary and secondary esophagocoloplasty for caustic injuries. Secondary esophagocoloplasty is the main rescue option after graft loss, but data in the literature are scarce. METHODS The operative characteristics, postoperative course, and functional outcomes of 21 secondary and of 246 primary esophagocoloplasty operations performed for caustic injuries between 1987 and 2006 were compared. Intraoperative events requiring significant changes in the planned operative strategy, such as graft ischemia or necrosis, were recorded. Statistical tests were performed in both cohorts to identify factors predictive of postoperative graft necrosis. Univariate analysis was performed to identify factors predictive of functional failure after secondary esophagocoloplasty. RESULTS Operative mortality (5% vs 4%, p=0.56), morbidity (62% vs 59%, p=0.96), postoperative graft necrosis (14% vs 7%, p=0.16), and functional success (68% vs 70%, p=0.79) rates of the secondary and primary esophagocoloplasty operations were similar. Intraoperative graft ischemia at the time of secondary esophagocoloplasty was significantly associated with the risk of postoperative graft necrosis (p=0.015) and functional failure (p=0.046). At the time of primary esophagocoloplasty, intraoperative necrosis of the colon was the only independent predictive factor of postoperative graft necrosis (p<0.0001). CONCLUSIONS Secondary esophagocoloplasty is a safe and reliable salvage option after primary graft loss in patients with caustic injuries. Delayed esophagocoloplasty should be considered if intraoperative colon necrosis occurs at the time of primary reconstruction.
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Affiliation(s)
- Mircea Chirica
- Department of General, Endocrine and Digestive Surgery, Saint-Louis Hospital, Assistance publique-Hôpitaux de Paris (AP-HP), Université Paris 7 Diderot, Paris, France
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