23: Options for Esophageal Replacement

Reestablishing gastrointestinal continuity after esophagectomy can be challenging for patient and surgeon alike. There are no perfect substitutes, since every reconstructive alternative is inferior to the native, normal esophagus. Ultimately, the goals for reconstruction include the maintenance of continuity, ability to swallow followed by adequate transit of food through the replacement conduit, provision of some barrier to reflux and aspiration, and independence from nutritional sources other than a normal oral diet. Simultaneously, every surgeon has the obligation to minimize morbidity, mortality, and long-term alterations in quality of life to the greatest extent possible. At odds to these objectives are the indications for removing the native organ and the extent to which it must be sacrificed. Clearly, situations that require complete removal of the esophagus up to the base of the tongue necessitate different reconstructive efforts compared to junctional tumors where a portion of the thoracic esophagus can remain intact. Esophageal surgeons must be adept and versatile at many different replacement options. This chapter focuses on the description of reconstructive options, emphasizing conduits other than stomach as described in foregoing chapters (Fig. 23-1). To the greatest extent possible, an attempt is made to compare our experiences with the various conduit options with the caveat that there is no level 1 data pertaining to such comparison.

Whenever a reconstruction alternative other than stomach is used, the complexity of the procedure significantly increases. Rather than a single esophagogastric anastomosis, alternative reconstructive efforts will require two to three anastomoses to reestablish continuity. Establishing adequate blood supply to the transposed reconstruction also may be more challenging in contrast to using a well-vascularized gastric conduit. For these reasons, modified whole stomach options are generally considered the first alternative to the native esophagus, despite the relative disadvantages generated by transposing the gastric reservoir into the chest, such as life-long reflux and aspiration risk (Fig. 23-2).

When the stomach is not available, however, alternative conduits for esophageal replacement become necessary. The decision to choose one option over another depends on patient and surgeon factors. The more common preferences include the colon or jejunum in variations of length and vascular supply. Prior abdominal operations or preexisting pathology may limit the use of either organ, and a thorough history is an essential part of planning for reconstruction.

The jejunum is an option for either partial or total esophageal replacement (Fig. 23-3). There are several advantages to consider with small bowel reconstruction. It generally remains free of intrinsic disease throughout a patient's life span and does not undergo senescent lengthening. Compared to the native esophagus, the size-match is excellent. There is a relative abundance of the organ, which permits reconstruction of the whole esophagus with adequate length to maintain nutritional demands. The jejunum also has a reliable blood supply with fairly consistent anatomy that does not routinely require preoperative evaluation. In the past, there were limitations on the length of esophagus that could be reconstructed with the jejunum, but this issue largely has been overcome with microvascular augmentation techniques that can accommodate grafts spanning from the base of the neck to the abdomen.

Indications

Jejunal interpositions can be tailored to any length necessary to replace the resected esophagus. We have found jejunal interpositions to be especially useful for secondary reconstruction attempts after a gastric conduit loss that has resulted in esophageal diversion. Conduit position is also determined in part by the indication requiring reconstruction. Most often placed in the retrosternal position, a supercharged jejunal conduit also may be placed in the posterior mediastinum or less often subcutaneously on the anterior chest. We believe the microvascular anastomosis and subsequent lie of the conduit are best when the conduit is in the substernal position. If local recurrence in the posterior mediastinum is a factor, or the need for radiation exists, the conduit should be placed away from this field.

Surgical Technique

Long-Segment Supercharged Jejunal Conduit

Preoperative Evaluation

Routine preoperative evaluation is necessary when planning a supercharged jejunal conduit for esophageal replacement. A complete history and physical examination should be performed, and it is important to take note of any previous abdominal, thoracic, or sternal incisions as they may alter the surgical plan and position of the conduit. In the setting of esophageal cancer, complete staging should be performed, including esophagogastroduodenoscopy/endoscopic ultrasound (EGD/EUS) and PET/CT. A CT chest/abdomen with contrast will help rule out metastatic disease, along with abnormalities of the small bowel or major abdominal vessels. Consultation with a plastic surgeon in addition to the thoracic surgeon is necessary when planning a supercharged jejunal conduit. Thorough preoperative patient education and counseling focusing on postoperative expectations, including dietary and lifestyle modifications that will be necessary ­following the procedure should be provided. In contrast to a colon interposition, there is no need for presurgical preparation of the bowel. Naturally, if one is concerned about the viability of the small bowel as a useable conduit, it is not a bad idea to have the colon prepared as another alternative.

Surgical Procedure The patient is positioned supine with a shoulder roll in place and the head turned slightly to the right. The left neck, chest, and abdomen are prepped into the field. The legs may be prepped into the field at the discretion of the plastic surgeon for possible harvest of a saphenous vein graft.

Abdomen An upper midline incision is made and the ligament of Treitz identified along with the proximal jejunum. A complete lysis of adhesions should be performed and any prior feeding jejunostomy or gastrostomy should be taken down and the bowel repaired. Transillumination of the proximal jejunal mesentery will delineate the individual jejunal vessels and their arcades (Fig. 23-4). The first vessel off of the superior mesenteric artery is generally left in place for blood supply to the fourth portion of the duodenum and proximal jejunum. The conduit is then generally based on the second to fourth jejunal vessels, but this can vary depending on the available anatomy. No vessels are divided at the outset of the case. The mesentery is dissected to expose the vessels for the transfer. Attention is then turned toward the route through which the conduit will pass. The posterior mediastinal route will not be described in detail as it is standard procedure for most thoracic surgeons to place a gastric conduit in this location; we do not often place a supercharged jejunum in this location.

Neck A collar incision is made starting at the sternal notch and proceeding upward and lateral along the anterior border of the sternocleidomastoid muscle. Before fully exposing the esophagus, the left hemimanubrium, head of clavicle, and medial aspect of the first rib are removed to increase the space available in the thoracic inlet for the conduit and microvascular anastomosis to the left internal mammary artery. This also alleviates points of bony compression on the conduit which could lead to mesenteric congestion and vascular compromise. Care must be taken when freeing the inferior aspect of the clavicle and first rib so as to not injure the internal thoracic vessels.

The esophagus is exposed by retracting the sternocleidomastoid and carotid sheath laterally and the thyroid medially. Medial retraction should be performed with great care to avoid injury to the recurrent laryngeal nerve. If the patient already is in discontinuity, the esophagostomy should be taken down and the esophagus positioned in the neck where it will lie for the anastomosis. The end of the esophagostomy must generally be trimmed back to healthy mucosa for creation of the anastomosis.

Retrosternal Tunnel We usually create a retrosternal tunnel about four fingers wide for the conduit to pass through as it traverses the chest. A measuring device is used to determine the minimum distance required for the conduit to traverse the thoracic cavity, yet allow for a tension-free anastomosis in the neck. Great care should be used for this dissection so as not to compress the anterior cardiac wall which can cause cardiovascular embarrassment. This measurement is critical because it is used to determine the location of the distal aspect of the conduit. As much as is practically possible, the conduit should lie in a straight line with no redundancy or large mesenteric loops in the bowel. The position of the conduit is critical to forming a straight, well-functioning jejunal interposition.

Conduit Creation and Passage The proximal pedicle of the jejunum, usually the second jejunal vessel, is divided close to its origin from the superior mesenteric artery (Fig. 23-5). The bowel is divided a few centimeters proximal to this point. The next jejunal vascular pedicle, usually the third, is also divided close to its origin. The mesentery that lies between these two vessels is divided toward the mesenteric border of the bowel to allow the jejunum to unfurl and straighten (Fig. 23-6). This step is key to establish a straight course through the mediastinum and a more accurate estimate of the length needed.

For a jejunogastric anastomosis, the length is measured to the posterior wall of the stomach, and the distal aspect of the jejunum is divided at the appropriate length. For a Roux limb, the distal jejunum does not require division.

After measuring and dividing the bowel and mesentery, the conduit is passed behind the colon (retrocolic) for a posterior mediastinal reconstruction, or in front of the colon (antecolic) for a retrosternal reconstruction. The conduit is placed inside a plastic bag to allow safe passage through the mediastinum. The plastic bag provides protection for small vessels as the conduit is pulled through the chosen mediastinal route. One must ensure that no twisting of the conduit occurs as it is pulled through the mediastinum. Care also must be taken to avoid excess ­traction on the conduit as this can lead to tearing of the mesentery and result in ischemic areas. Once positioned in the neck, the recipient vessels are prepared and the vascular augmentation is performed. The venous anastomosis is typically performed to the internal jugular vein. Saphenous vein grafts can be used if there is a length discrepancy. The arterial anastomosis is then performed under the operating microscope. Usually the artery can be connected directly to the carotid; if there is a length issue it can be anastomosed to a branch vessel or a short Gore-tex graft can be used.

An “indicator flap” can be created with the distal most 2 or 3 cm of jejunum. The distal 2 to 3 cm of the jejunum and its intact mesentery is separated from the main conduit and set aside to be externalized at the completion of the procedure as an indicator flap (Fig. 23-7).

Reconstruction The esophagojejunal anastomosis is performed via a hand-sewn or stapled technique. A stapled functional end-to-end anastomosis may be performed with a posterior linear staple line between the esophagus and jejunal conduit followed by hand-sewn or TA closure of the “hood” (modified Collard or Orringer technique). Alternatively the ­circular EEA device may be used, but care must be taken to avoid a blind pouch that will lead to a pseudo-Zenker's ­phenomenon.

The abdominal reconstruction is performed either by creating a “Roux” limb and distal jejunojejunal anastomosis or via a jejunogastric anastomosis low on the posterior wall of the stomach. We generally create a Roux limb as more often there is no remaining stomach for reconstruction. If stomach is chosen we advocate a prior 2/3 gastrectomy to avoid ­gastric stasis issues created by a vagotomized stomach. A feeding jejunostomy is then performed. If there is remaining stomach that is not in continuity with the conduit (i.e., a Roux limb was created), a drainage procedure at the pylorus should be performed.

When closing the neck incision the indicator flap should be positioned at the inferior aspect of the wound in a straight course so as not to compromise the blood supply. Once a drain is placed and the wound closed, one or both ends of the indicator segment should be opened to allow for drainage of secretions. This flap is left externalized as a monitor for the perfusion of the proximal bowel segment until just prior to discharge. At that point, it can be amputated at the bedside.

Complications

Most of the complications seen after a supercharged jejunal conduit are similar to those seen after esophagectomy. Bowel ischemia resulting in conduit loss is infrequent. Thrombosis or diminished flow through the vascular anastomosis may occur and if perfusion is compromised, the vascular augmentation should be revised to avoid graft loss. The indicator flap serves as a guide to the viability of the conduit and should be monitored frequently. Suspicion of conduit ischemia should prompt evaluation.

Other complications such as bleeding, aspiration pneumonia, recurrent laryngeal nerve damage, redundant bowel loop, and stricture formation are managed using standard techniques.

Results

Recently presented data update the 10-year experience from MD Anderson Cancer Center. Sixty patients received a supercharged jejunal conduit, largely for reconstruction related to esophageal cancer. Postoperative complications included 18 (30%) patients with pneumonia, 19 (31.7%) patients with an anastomotic leak (9 required major intervention, others were managed conservatively), and 4 (6.7%) patients with graft loss. The majority of patients (88%) were able to return to a regular diet after jejunal reconstruction. Thirty-day mortality, including in-hospital mortality, was 5% with a 90-day mortality of 10%. Median survival was 28 months, and the 5-year overall survival in this series is 30%. These results represent a group of high-risk patients, 42% of which were undergoing reversal of discontinuity. Given these results, we prefer a supercharged jejunal conduit for esophageal reconstruction only when the stomach is not available.

When the stomach is not available, the colon is another viable option for esophageal reconstruction (Fig. 23-8). Either the right or the left colon may be used for reconstruction and each can provide adequate length to reach the pharynx. The ­transverse colon is an integral part of the conduit whether it is based on vessels from the right or left colon. A left colon graft is based on the ascending branch of the left colic artery, whereas the middle colic vessels are the primary blood supply for a right colon graft. We prefer to use an isoperistaltic left colon conduit, as opposed to a right colon conduit, because it has a better size-match to the native esophagus and thicker wall. Some believe the colon is the best choice for reconstruction if the patient has an extended life expectancy because it is resistant to peptic strictures and provides a barrier to reflux into the proximal esophagus.

Preoperative Evaluation

The preoperative evaluation is similar to that for a jejunal conduit, which pays special attention to the colonic vessels. A CT angiogram should be obtained to identify and delineate the vascular supply to both right and left colon, including marginal arteries that connect the left and middle colic arcades. Bear in mind that the marginal artery around the splenic flexure may be inadequate or absent in approximately 5% of patients.

Previous abdominal operations or bowel resections also may limit the use of colon if the vessels already have been sacrificed or if the mesentery is scarred and foreshortened. In addition to a CT scan, a colonoscopy or double-contrast barium enema should be obtained to rule out any primary colonic lesions, diverticular disease, or vascular malformations. Patients should be placed on a liquid diet and given a mechanical bowel preparation 24 to 48 hours prior to the operation to remove bulky stool from the conduit.

Surgical Procedure

Here, we describe esophageal replacement with a left colon conduit. Begin by mobilizing the left colon completely and removing the omentum from the transverse colon (Fig. 23-9). Preserve the mesenteric vessels at all times during mobilization and identify the ascending branch of the left colic artery, as this will serve as the vascular pedicle for the conduit. Transillumination of the mesentery facilitates vessel identification. The middle colic artery also needs to be identified in the transverse colon mesentery.

An umbilical tape may be used to approximate the length needed for reconstruction. Measure the distance from a point 5 cm below the xiphoid to the ear lobe. After determining the length needed for transposition, begin vascular isolation of the pedicle. Open the transverse mesocolon on the right side of the middle colic vessels. The mesentery should be opened on both sides of the left colic artery as well. Place small bulldog clamps on the vessels that will be ligated, leaving them in place for 5 to 10 minutes to confirm graft viability. Begin ligating the vessels if the graft appears healthy after vascular isolation. Ligate the left branch of the middle colic at its origin from the middle colic, and ligate the marginal artery beyond the branches supplied by the left colic going distal in the left colon. Confirm the length needed and then transect the colon to the appropriate length. If there is a question about the viability of the segment, either intraoperative Doppler flow or fluorescein dye can be used to assure segmental viability.

The conduit should be placed retrogastric and can be passed through the posterior mediastinum, retrosternal, or via subcutaneous route to its final position in the neck. A plastic bag should again be used when passing the conduit to protect the mesentery and ensure a straight and untwisted course through the mediastinum. If using the retrosternal route, the ipsilateral hemimanubrium, clavicular head, and medial aspect of the first rib should be removed as described above for a jejunal conduit. The anastomosis is done similar to the jejunal anastomosis described above.

Complications

Some of the early complications associated with colonic conduits are secondary to vascular or anastomotic problems. There is generally no indicator flap with a colonic conduit. Therefore, one must monitor the patient carefully for any signs of conduit ischemia. Three colonic anastomoses are used with this method of reconstruction and a leak may occur from any one or more of these anastomoses if ischemia or tension is present. Leaks in the neck are generally managed by opening the neck incision and allowing for wide drainage. Managing intra-abdominal leaks may require more aggressive measures ranging from percutaneous drainage to possible reexploration if less invasive means of controlling the leak are unsuccessful. Late complications are unfortunately not uncommon secondary to senescent lengthening and dilation of the colon interpolate.

Results

The literature on colon interposition for esophageal reconstruction demonstrates good short- and long-term results. Rates of anastomotic leak, graft loss, and perioperative mortality are not significantly different than those associated with gastric pull-up procedures when reported by experienced centers. There are some disadvantages to a colon interposition. Although this is classified as an isoperistaltic graft, the peristalsis is unlikely to be functionally effective and colon interposition really represents a passive conduit. It is also somewhat difficult to avoid creating a colon interposition without introducing some degree of redundancy and angulation. Late reoperation for conduit dilation, stasis, and regurgitation has been described and is used as necessary in up to 30% of patients.

Limited functional data exist comparing swallowing function with colon compared to jejunal grafts but it is thought that jejunal conduits maintain intrinsic peristalsis after transposition that may actually assist in functional outcomes. The intrinsic peristalsis of the jejunal interposition is also a potential downside; the peristalsis is not coordinated to swallowing in any fashion. Therefore, patients will often complain of some dysphagia during meals early in the transition to peroral intake. This is part of a learning curve, and once patients recognize the symptom they are able to reprogram their swallowing to effectively “wait” until the jejunum is receptive to a bolus swallow. The high incidence of cervical anastomotic leaks in the jejunal series is also of concern.

Both the colon and augmented jejunum are acceptable options for long-segment esophageal reconstruction when the stomach is not available. There are technical aspects unique and critical to the success of each operation and surgeons will often prefer one technique over others given past experiences. Neither has been definitively proved to be superior in the literature in terms of immediate postoperative outcomes or long-term functional results. Knowledge and adeptness in both techniques are important for the frequent esophageal surgeon.

This chapter by one of the champions of the “supercharged” jejunal graft is a key component to a successful esophageal surgery practice. Knowledge of all the alternatives is crucial, in the event that either oncologic findings or technical limitations challenge the esophageal surgeon from being able to use a gastric conduit. The availability of jejunum and the ability to use the graft without a preoperative bowel preparation make this an attractive option. When possible, preoperative assessment of vascular compatibility for both jejunal and colonic conduits is preferred. Although the choice of conduit should generally depend on the location of the tumor and the level of the planned anastomosis, occasionally an alternate should be expected up front such as when there has been prior partial gastric resection or numerous prior laparotomies. The authors also mention an important technical trick, not mentioned in any of the other esophagectomy chapters. Before the esophagus is fully exposed, they recommend removing the left hemimanubrium, head of clavicle, and medial aspect of the first rib to increase the space available in the thoracic inlet for the conduit and microvascular anastomosis to the left internal mammary artery. As the authors describe, this also alleviates points of bony compression on the conduit which could lead to mesenteric congestion and vascular compromise. This trick is helpful for any type of esophagectomy where a neck anastomosis must be performed in difficult situations, such as very obese or very thin individuals.