conduits after esophagectomy for esophageal reconstruction

Conduits for Esophageal Reconstruction

Dr Shahbaz Khan Panhwer

Postgraduate trainee (R1)

Surgical Unit-IV

Criteria for Choosing conduits?

• Normal Esophagus ??

• Superior to any potential substitute

• Criteria???

• Living viscus

• Adequacy of its blood supply

• Freedom from intrinsic disease and

• length of resected esophagus that it is capable of bridging.

• No.of anastomosis/Expertise???

So What to Choose?

• Stomach???

• Advantages:

• Reliable Blood supply

• Gastric function preserved

• Excellent length

• Single anastomosis

• Relatively simple

• Disadvantages:

• Reduced Reservoir function

• Reflux

• Regurgitation

• Increased risk of anastomotic leak

Colon

• Right sided/Left sided Colon?

• Advantages:

• Excellent length

• Reservoir function of stomach

• Resistant to reflux

• Disadvantages:

• Blood supply tenuous

• Redundancy

• Most prefer Left Colon ??

Diameter smaller

Less prone to dilate

More reliable blood supply

Excellent length

Jejunum

• Advantages:

• Peristaltic tube

• No acid/alkaline reflux

• Disadvantages:

• Limited length

• Size

• Vascularity

• Need of revascularization

Anatomy of Colon

Colon ( Short segment/Long segment)

Right colon interposition

Left Colon Interposition

Transverse colon interposition

Preparation & Workup

• Preoperative angiogram

• Colonoscopy

• Bowel Preparation

Surgical Steps

• Supine,abdomen,chest &neck draped.

• Midline incision

• Assessment & Preparation of Long segment interposition graft

Step-1

• Proper identification of the fusion line between the colon and the peritoneum of the posterior abdominal wall avoids entering the wrong plane and encountering bleeding when the colon is being freed.

• The sigmoid colon is freed from the retroperitoneum toward the midline and can also be brought out of the abdominal wound.

Step-02

• The splenic flexure is similarly mobilized, taking care not to damage the spleen, as this incurs significant additional morbidity.

Step-03

• The transverse colon is prepared by detaching the greater omentum from its antimesenteric border.

• The omentum is first detached left of the midline to enter the lesser sac; further separation can then proceed more readily.

Step-03• Tentatively pick point of division of

right transverse &descending colon, then measure the length of colon graft with umbilical tape (5cm below xiphiod--- angle of jaw)

• Appropriate feeding vessel is identified via transillumination.

• Temporary vascular isolation is obtained by placing bulldog clamps on vessels that will be divided,observe graft for 5-10min for signs of ischemia/venous congestion

Step-04• Transverse colon divided with help

of linear stapler just right middle colic artery.

• Descending Colon is divided just below bifurcation of left colic into ascending & descending branches.

• The mesocolon,which has no other branches between middle & left colic is incised.

Step-05

• To aid delivery of graft into neck Penrose drain/chest tube is attached to the proximal end of the conduit.

Step-06

• The lower end of the conduit is anastomosed to a convenient part of the upper gastrointestinal tract, whether this be the stomach, duodenal stump, or upper jejunum (if gastrectomy had been performed previously)

• If the stomach is intact, the conduit is placed in the retrogastric position.

Right ColonInterposition

• Right colon and the terminal segment of the ileum are mobilized.

• As mobilization proceeds proximally, the duodenum is encountered and care must be taken not to damage the head of the pancreas; in this region the main right colic vessel may be encountered as it courses over the uncinate process of the pancreas.

• The parietal peritoneum is gradually transected starting from the iloecolic region next to the large bowel and continuing until the right flexure of the colon,attachment released.

Biological trialof graft

• Trunks of the ileocolic and right colic vessels are clamped with vascular clamps, thus leaving the selected part of the colon supplied only by the middle colic vessels.

• If biological trial is positive and no disturbances in the blood supply to the isolated fragment of the colon are observed, mobilization of the graft may be initiated.

Ligation & division of vessels

• Greater omentum is removed in the area of the mobilized colon segment, and next the vascular trunks, which had been clamped in vascular clamps, are ligated and transected.

• Next the transverse colon should be transected in the middle of its length.

Mobilization of graft & Anastomosis

• The efferent stump of the transverse colon is closed with a double-layer manual suture, or stapled.

• On the other hand, the afferent stump, which forms the caudal segment of the mobilized graft, is closed with a temporary suture until it is anastomosed with the stomach/jejunum.

• Transection of the ileum in the caecal region completes mobilization of the graft.

Jejunal conduits

Jejunal Conduits

• 3RD choice as conduit

• Resistant to acid/Bile

• Abundant length

• Pedicled graft ----- Supercharging ??

• FREE Graft with Microvascular anastomosis

• The abdominal cavity is approached from upper midline incision reaching from the xiphiod process of the sternum to the umbilicus

Surgical steps

• The DJ junction is identified, and the proximal jejunum is brought out of the abdomen and placed on a large gauze pack over the abdominal wall so that the mesentery is easily visualized.

• The vascular pattern of the mesentery is then examined for completeness of arterial and venous arcades.

• In patients with a thick mesentery, transillumination by a strong light from behind is helpful; in obese patients, the fat in the mesentery has to be removed before the arcades can be delineated

• If vascular system appears adequate, the next step is to evaluate the efficacy of vascular anastomosis by means of a biological trial.

Efficient----natural color & peristalsis

Inefficient----intense peristalsis,Cyanosis,marble like appearance & lack of visible pulsations

• Dissection is begun in the upper jejunum, at a point approximately halfway between the edge of the intestine and the root of the mesentery, proximal to the branching of the main Jejunal arteries.

Steps• The jejunum is transected 20 cm

from the DJ flexure and in the caudal portion beyond the vascular trunk which forms graft pedicle.

• The arterial and venous branches are mobilized separately, then divided and ligated with fine ties.

• When a sufficient length of mesentery has been prepared for cervical anastomosis, there is an excess of jejunum in relation to the mesenteric length, with concertina of the intestine.

• Although moderate excess is harmless, too much redundant jejunum can result in kinking of the conduit, which may lead to obstruction.

• To prevent this complication, a part of this excessive segment of jejunum can be resected, and an end-to-end anastomosis made

Abdominal anastomosis • The conduit is then placed in the retrocolic,

retrogastric position (when appropriate) before being delivered to the right chest or neck

• Next continuity of the gastrointestinal tract within the abdominal cavity should be restored by anastomosing the jejunal stumps remaining after mobilization of the graft.

• If a gastrectomy has been performed and a jejunal conduit is used, a Roux-en-Y configuration of the long jejunal conduit is satisfactory and an end-to-side jejunojejunostomy is carried out in the abdomen.

• Alternatively, the duodenum can be selected as the site of anastomosis.

Indicator graft

• 4-6cm of proximal jejunum is separated from graft maintaining continuity with vascular arcade.

• Exteriorized as indicator graft to monitor patency of vascular anastomosis.

• Ligated & excised on 6th

POD

Jejunum Free Graft

Identification of segment

Division of free graft

Anastomosis & Revascularization

Complications

• Intraoperative complications

Hemorrhage

Injury to tracheobronchial tree

RLN injury

Pneumothorax

Postoperative complications

• Delayed haemorhage

• Anastomotic leak

• Mediastinitis

• Pulmonary complications

• Arrythmias,MI,Pericardial temponade

• Delayed gastric emptying

• Chylothorax

• Herniation of abdominal visceras through hiatus

Functional Complications of esophageal replacement

• Anastomotic stricture

• Redundancy & impaired emptying

• Obstruction at thoracic inlet or diaphragmatic hiatus

• Reflux esophagitis

• Ulceration of esophageal substitute

• Postvagotomy dumping