Esophageal Replacement

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CHAPTER 8 Esophageal Replacement

Belinda Hsi Dickie, Richard G. Azizkhan

Colonic Interposition

Step 1: Surgical Anatomy

♦ Preserve as much native proximal esophagus as possible, especially the cricopharyngeus.

♦ Preservation of the lower esophageal sphincter is ideal; the colonic interposition conduit should bridge the defect in a course that is straight and as short as possible to encourage dependent drainage.

♦ The portion of the colon to be used for esophageal replacement depends largely on the length required. Anatomic considerations could determine whether colonic interposition is possible or an alternative should be used; prior symptomatic short colon could cause exacerbation of intestinal problems if used as a conduit.

♦ An isoperistaltic conduit consisting of transverse and descending colon in the left hemithorax in the retrohilar position is best suited for long-gap esophageal atresia. Vascular supply is based on the left colic artery and collaterals from the marginal artery of Drummond to the transverse colon (Fig. 8-1, A).

♦ An alternative conduit is the ascending or transverse colon segment based on the ileocolic and middle colic artery, respectively (Fig. 8-1, B).

Figure 8-1

Step 2: Preoperative Considerations

♦ Before any replacement procedure is done, a thorough radiologic evaluation of the stomach and gastrointestinal tract is essential.

♦ Mechanical bowel preparation and oral antibiotic should be administered the night before surgery.

♦ Perioperative parenteral antibiotics are administered.

Step 3: Operative Steps

♦ Figure 8-2 demonstrates the configuration of the colon conduit before placement in the retrohilar or substernal position.

♦ The colonic segment and its pedicle are brought anterior to the pancreas behind the stomach and through an incision made in the gastrohepatic ligament and then passed through the esophageal hiatus or through a lateral incision in the diaphragm. The retrohilar tunnel is created lateral to the descending aorta behind the aortic arch.

♦ The upper end of the colonic segment is brought through Sibson fascia posterior to the subclavian vessels and lateral to the carotid sheath. Figure 8-3, A provides a lateral perspective of the colon conduit.

♦ If a retrohilar approach is not possible, the colonic conduit can also be positioned retrosternal (Fig. 8-3, B).

♦ A delayed proximal anastomosis may be indicated if the blood supply of the cervical portion of the conduit is marginal. This can be performed several weeks later.

Figure 8-2

Figure 8-3

Closing

♦ When the entire esophagus is replaced, a cervical esophagocolostomy (or pharyngocolostomy) and a cologastrostomy are constructed.

♦ A Heineke-Mikulicz pyloroplasty and a gastrostomy are routinely done before closure.

♦ A Penrose drain in the cervical wound below the plastyma and a dependently placed chest tube in the left chest are secured before closure.

Step 4: Postoperative Care

♦ Patients should be monitored in the intensive care unit postoperatively and kept on NPO (nothing by mouth) status; parenteral nutrition is administered.

♦ A water-soluble contrast is obtained on postoperative day 7.

If no leak is observed, the cervical drain and chest tube can be removed and the patient fed.

If a leak is noted, an additional 2 weeks of NPO and repeat contrast study are done.

Most leaks are at the cervical anastomosis and usually close spontaneously; Around 50% result in stricturing that requires subsequent dilatations. The overall leak rate is between 25% and 35%.

Step 5: Pearls and Pitfalls

♦ When dividing the colon, back bleeding should be noted at both the proximal and distal ends of the segment, indicating a good blood supply.

♦ Identifying and preserving the recurrent laryngeal nerve and thoracic duct are important in dissection in the neck.

♦ A thoracic incision can be avoided in a retrosternal positioned conduit by creating the tunnel with a dual approach from the abdomen and the neck.

♦ Long-term follow-up is required. As many as 15% to 20% of patients will require operative intervention because of development of significant redundancy in the colonic conduit resulting in severe stasis or obstruction

♦ Gastroesophageal reflux is unpredictable, and if it becomes problematic, a partial-wrap fundoplication should be considered.

Gastric Transposition

Step 1: Surgical Anatomy

♦ The advantages of a whole-stomach transposition compared with the reverse gastric tube interposition include the simplicity of a single anastomosis and a long vascularized conduit without suture lines.

♦ In reverse gastric tube transposition, a preexisting gastric volume minimum of 200 to 250 mL is required to ensure that there is an adequate residual gastric reservoir after tube construction. This is especially important in patients with long-gap esophageal atresia, in whom the stomach is usually small.

Step 2: Preoperative Considerations

♦ A preoperative upper gastrointestinal contrast study should be performed to document gastric volume and determine whether the stomach is large enough for a gastric tube interposition to be performed.

♦ Mechanical bowel preparation and oral antibiotics should be administered to prepare the colon in case a gastric conduit is not possible.

Step 3: Operative Steps

Anesthetic Induction

♦ Consider insertion of an epidural for postoperative pain management.

Positioning

♦ The patient should be placed supine in a 45-degree right lateral decubitus position on the operating table.

Incision

♦ The procedure begins with an abdominal exploration and mobilization of the stomach and duodenum. If present, the gastrostomy tube is dismantled and the site closed. The stomach and gastroesophageal junction are mobilized, ensuring preservation of the blood supply and avoiding injury to the spleen.

♦ Extensive kocherization of the duodenum is done to allow for sufficient mobilization of the stomach as well as to help with the pyloroplasty

♦ The left gastric and short gastric vessels are divided, leaving the supply to the stomach dependent on the gastroepiploic and right gastric arteries. The omentum is separated off the stomach (Fig. 8-4).

♦ The gastroesophageal junction and distal esophagus are mobilized to the level of the carina through the esophageal hiatus. The esophagogastric junction is divided and the cardia oversewn.

♦ Once the apex of the gastric fundus can reach past the clavicles and the pylorus overlies the xiphoid process, sufficient mobilization of the stomach is completed (Fig. 8-5).

♦ A low anterior cervical incision is used to mobilize the remaining esophagus and to create the tunnel for the gastric transposition to pass. Carotid sheath and trachea are retracted laterally and the larynx and trachea medially. Care is taken to identify and protect the recurrent laryngeal nerves.

♦ The gastric transposition is best placed in the position of the native esophagus (most direct route to the cervical esophagus). A left lateral thoracotomy may facilitate positioning the stomach in the chest (Fig. 8-6).

♦ The stomach can be passed retrosternally (potentially longer and more tortuous route) or via retrohilar route. The retrohilar position requires enlarging of the esophageal hiatus and careful identification of the recurrent laryngeal nerve to prevent injury.

♦ To position the gastric conduit in the retrohilar position requires opening the diaphragm at the esophageal hiatus to allow the graft to be mobilized. A left thoracotomy is required to place the stomach in correct position behind the left lung. To create adequate space in the neck, a sternal fascial incision or removal of the clavicular head is sometimes required.

♦ Pyloroplasty is done to improve gastric emptying.

Figure 8-4

Figure 8-5

Figure 8-6