when stomach is not available - duke university · pdf filethe gastric conduit is standard of...

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When Stomach is Not Available… Shanda Blackmon, M.D., M.P.H., FACS Associate Professor, Thoracic Surgery, Mayo Clinic


Objectives

• To review options for long-segment esophageal replacement

• To review equipment and techniques

• To share our outcomes and experience


Background

• 1st successful resection of the thoracic esophagus for carcinoma was performed by Torek near the turn of the century in a patient with esophageal carcinoma1


Background

• Gastrointestinal continuity was established using an external "rubber tube" between a cervical esophagostomy and gastrostomy

• The patient survived for 13 yrs and was able to swallow liquified food


Background

• Immediate reconstruction of the gastrointestinal tract after an esophagectomy with an esophago-gastrostomy did not occur until the mid 1930s


Esophageal Replacement Options

The gastric conduit is standard of care in most circumstances…


The Dreaded Dead Conduit…


Indications for Alternate Conduits:

• Dead gastric conduit

• Injury to GE Vessel

• Cancer extending Into eso & stomach

• Recurrence of esophageal tumor1, 2

1. Schipper PH, Cassivi SD, Deschamps C, Rice DC, Nichols FC 3rd, Allen

MS, Pairolero PC. Locally recurrent esophageal carcinoma: when is re-

resection indicated? Ann Thorac Surg. 2005 Sep;80(3):1001-5; discussion

1005-6.

2. Kim MP, Brown KN, Schwartz MR, Blackmon SH. Advanced esophageal

cancer in patients who underwent radiofrequency ablation for barrett

esophagus with high grade dysplasia. Innovations (Phila). 2013 Jan-

Feb;8(1):17-22.


Esophageal Replacement Options

• Colon

• Jejunum


Esophageal Replacement Options: Jejunum

Gaur P, Blackmon SH. Jejunal graft conduits after esophagectomy. J Thorac Dis. 2014 May;6 Suppl

3:S333-40.

http://www.jthoracdis.com/article/viewFile/2526/html/16593


Congenital Variations in Jejunal Mesenteric Arcade Vascular Patterns


Reach of Jejunal Vascular Pedicle vs.

Length of Bowel (unfurled) (1:3)


Dividing the Mesentery for a Long Jejunal Graft


Dividing the Bowel for a Long Jejunal Graft


Dividing the Mesentery for a Short Jejunal Graft


Pedicled Segmental jejunal Interposition as Roux

antegastric

retrogastric


Pedicled Segmental jejunal Interposition to Stomach


SPJ


Indications

• To replace segmental esophagus (cervical)

• To reach the pharynx

• To replace entire length of esophagus when a gastric conduit is not available

Blackmon SH, Correa AM, Skoracki R, Chevray PM, Kim MP, Mehran RJ, Rice DC, Roth JA, Swisher SG,

Vaporciyan AA, Yu P, Walsh GL, Hofstetter WL. Supercharged pedicled jejunal interposition for esophageal

replacement: A 10 year experience.Ann Thorac Surg. 2012 Oct;94(4):1104-11; discussion 1111-3.


Experience

• From June 2000 to December 2010,

• 60 consecutive patients underwent SPJ

• 50 patients from MDACC (2000-2010)

• 10 patients from HMH (2006-2010)

• A database was created to evaluate patient characteristics, operative technique, and outcomes

Blackmon SH, Correa AM, Skoracki R, Chevray PM, Kim MP, Mehran RJ, Rice DC, Roth JA, Swisher SG,

Vaporciyan AA, Yu P, Walsh GL, Hofstetter WL. Supercharged pedicled jejunal interposition for esophageal

replacement: A 10 year experience.Ann Thorac Surg. 2012 Oct;94(4):1104-11; discussion 1111-3.


Results

male Age female

44 (73%) 28---------------->76 16(27%)

LOS

7----------------->575 19

57

Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement:

A 10 year experience. Annals of Thoracic Surgery 2012;94(4):1104-13.


Patient Characteristics

Timing

Primary immediate reconstruction 37 62%

Reversal of discontinuity 23 38%

Preoperative Therapy (Chemo +/-XRT) 25 42%

Histology of Primary

Adenocarcinoma 41 68%

Squamous Cell 9 15%

other 7 12%

Not cancer 3 5% Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement:



Jejunal Route

Operative Detail n %

Posterior 21 35%

mediastinum

Retrosternal 39 65%

Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal

replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4):1104-13.


Jejunal Route


Retrocolic 46 77%

Antecolic 14 23%


Results: Anastomosis


Neck Anastomosis

Hand-sewn 51 85%

Stapled side-to-side 8 13%

Circular-stapled 1 2%

Distal Connection

Jejunum to stomach remnant 29 48%

Jejunum to jejunum (Roux) 31 52%




Results: Graft Loss


Intra-operative vascular revision 16 27%

Intra-operative Graft loss 1 2%




Clinical Outcomes

SPJ

patients

n = 60

90-day/Hosp

mortality

n = 6

survivors

n = 54

Intact

n=52

Never

recon-

structed

n=2

ORAL

DIET

n=50

graft loss

n = 4

Never re-gained

nutritional

independence

n=2




Results: Operative Events

Early Event n %

Morbidity:

Leak 19 32%

Grade I 1

Grade II 9

Grade III 4

Grade IV 5




Results: Post-operative Events

Early Event n %

Morbidity:

Pneumonia 18 30%

RLN Injury 10 17%

NOMI 4 7%

Jejunal Graft loss/diversion 5 8%




Results: Post-operative Events

Late Events n %

90-day Mortality 6 10%

Later Revision 7 12%




Manometry N

orm

al S

wallo

w

Sw

allo

w a

fter

SP

J

n = 5




Conclusions

• SPJ can establish nutritional independence in a high-risk patient population when stomach is unavailable

• This is my preferred alternative for reconstruction when stomach is unavailable




How does the SPJ compare to a Gastric Conduit?


Super-Charged Pedicled Jejunal Interposition Performance Compares Favorably to a Gastric Conduit After Esophagectomy

Stephens EH,1 Gaur P,2 Hotze KO,2 Correa AM,3 Kim MP,2 Blackmon SH4

1Cardiothoracic Surgery, Columbia University, New York; 2Thoracic Surgery, The Methodist Hospital, Houston; 3MD Anderson, Houston; 4Thoracic Surgery, Mayo Clinic, Rochester


Background

• Long segment esophageal reconstruction can be accomplished with “super-charged” jejunum (SPJ), colon, or stomach

• In patients in whom a gastric conduit is not possible, SPJ has advantages:

• Does not require formal preparation

• Usually free of disease

• Similar in diameter to esophagus

• Intrinsic segmental peristalsis

• May not undergo senescent lengthening

• Challenges with SPJ: micro-anastomoses

• Previous studies have examined peri-operative and long-term outcomes of SPJ, but its functionality has not been previously assessed.

• Objective: Assess the functionality of SPJ in comparison to gastric conduits


Methods

• A conduit functionality questionnaire was

developed evaluating: • Reflux • Dumping • Dysphagia • Stricture • Zubrod score (functional status) • Post-op pain • Conduit emptying (radiography)

• Preoperative/demographic, intraoperative, and

postoperative data were prospectively collected on

the 94 living patients who underwent esophageal

reconstruction 2009-2013 at HMH.


Methods

• 45 of the 94 (48%) patients answered the

questionnaire >1 month after surgery. For

patients who completed multiple

questionnaires, the worst score for each

category was used.

• Statistical analysis was performed using SPSS

(SPSS, Chicago, IL) and included Mann-

Whitney u-test and Fisher’s Exact Test for cross

tabs with statistical significance defined as

p<0.05.


Development/Validation of Conduit Assessment Tool

• Tool was developed using three methods to establish content validity:

• 720 patient encounter records during focus groups held over a 5 year period

• formal presentations and review in multidisciplinary GI conference

• formal presentations and review in multidisciplinary esophagus tumor board meetings


Methods: Conduit Questionnaire


Methods: Conduit Questionnaire • Reflux1

• Mayo Score

• Dumping Score2

• Sigstad’s scoring method

• Dysphagia3

• Mayo Score

• Stricture4

• Blackmon et al. Score

• Zubrod score5 • 0=asymptomatically active

• 1=restricted in strenuous activity

• 2=ambulatory, self-care, >50% time out of bed

• 3=ambulatory, limited self-care, >50% time in bed

• 4=no self-care, bed-ridden

• Post-op pain (0-10)6

• Conduit emptying (radiography)7

• 0=rapid emptying w straight path

• 1=90% emptying, <2min delay

• 2=90% emptying, 2-15 min

• 3=90% emptying, 16-30 min

• 4=conduit stasis, >30min


Results Patient Characteristics and Operative Data

Gastric Conduit

(n=31, 69%)

SPJ

(n=14, 31%) p value

Male 23 (74%) 8 (57%) NS

Age (years) 63±10 55±15 0.037

Underlying Etiology: NS

Cancer 26 (84%) 13 (93%)

Benign Disease 5 (16%) 1 (7%)

Type of Resection: 0.008

Oncologic Resection for Adenocarcinoma 20 (65%) 6 (43%)

Resection for Benign Disease 2 (7%) 0 (0%)

Previous resection 1 (3%) 7 (50%)


Results Patient Characteristics and Operative Data

Gastric Conduit

(n=31, 69%)

SPJ

(n=14, 31%) p value

Location of Anastomosis: <0.001

Neck 7 (23%) 14 (100%)

Intrathoracic 24 (77%) 0 (0%)

Anastomosis Technique: 0.02

Hand sewn anastomosis 1 (3%) 2 (14%)

Stapled side-to-side anastomosis 13 (42%) 12 (86%)

Circular stapled anastomosis 17 (55%) 0 (0%)


Results Post-Operative Complications

Gastric Conduit

(n=31, 69%)

SPJ

(n=14, 31%) p value

Surgical Complications: 15 (48%) 7 (50%) NS

Pneumonia 7 (23%) 3 (21%)

Afib 4 (13%) 1 (7%)

Renal failure 1 (3%) 1 (7%)

Respiratory failure 3 (10%) 1 (7%)

UTI 1 (3%) 0 (0%)

DVT 1 (3%) 1 (7%)

Length of stay (days) 10±4 17±15 0.04

30 day mortality 0 (0%) 0 (0%) NS

Leak within 60 days 7 (23%) 4 (29%) NS

Reoperation 3 (10%) 1 (7%) NS

Afib=atrial fibrillation, NS=not statistically significant, UTI=urinary tract infection, DVT=deep vein thrombosis.


Results: Clinical Follow-Up

Gastric Conduit (n=31, 69%)

SPJ (n=14, 31%) p value

Death at last follow-up 2 (7%) 2 (14%) NS

Length of follow-up 14±11 22±14 NS


Results: Conduit Function

0

1

2

3

4

5

6

7

Gastric

SPJ

P=0.04


Discussion

• SPJ compares favorably to gastric conduit for

esophageal reconstruction in terms of

functionality.

• The groups differed significantly with SPJ

patients more likely to have had prior resection.

• Operative outcomes and peri-operative

complications were not significantly different

between groups except longer length of stay

for SPJ patients and more post-operative pain.


Discussion

• The conduit assessment is a useful tool to

compare reconstruction techniques, as well as

assess patients’ recovery and need for further

interventions.


Discussion

• Future studies involve:

• Validation of the conduit assessment tool at

other institutions

• Application of the tool to compare the outcomes

of other reconstruction techniques (ie Ivor

Lewis vs. transhiatal +/- pyloroplasty) in terms

of physiologic outcomes

• Establish expected ranges at each post-

operative time point for a given surgery,

enabling identification of patients who deviate

and may need further intervention


Limitations

• Small sample size at a single institution.

• Inherent differences in baseline characteristics of patients.

• Did not specifically examine role of conduit assessment tool in subsequent interventions and improvements in symptoms.


Jejunal Interposition Results: ROL


Colon Conduits


L Colon Interposition


Transverse Colon Interposition


R Colon Interposition


Selecting and Measuring the Colon Interposition


Passing the Colon


Delivering the Colon


Esophago-colonic anastomosis


Bringing Colon to Stomach


Colon Interposition to Stomach


Colon Interposition


Colon Interposition Results: ROL


Esophageal Replacement

• Patients who have acquired long segment esophageal discontinuity and lack stomach as a viable replacement conduit primarily have two options for reconstruction:

• jejunum

• colon



• On the contrary, shorter esophageal segmental replacement has many other options:

• free pedicled forearm skin tubes

• folded myocutaneous flaps

• Short jejunal segment



• The future may hold many other options:

• Tissue-engineered 3-dimensional scaffolds repopulated with stem cells have already been used to replace the trachea

• Esophageal stents have now given us the ability to bridge a disconnected segment of bowel and allow for regrowth of tissue and establish new continuity



• Our group has successfully reconnected a distal esophagus to jejunum with a 2 cm separation with the use of stenting alone

• The addition of antibiotics, stem cells, chemo-attractants, and other materials may enhance healing and re-growth of healthy tissue over the stent matrix


Question 1

• The “super-charged” jejunal interposition typically bases the blood supply to the superior arcade upon:

a) The axillary artery and vein

b) The internal mammary artery and vein

c) A vein loop graft off the aorta to the left subclavian vein

d) The carotid artery and jugular vein


Question 2

• The typical blood supply to the abdominal jejunal includes which purpose for each branch:

a) 1-SMA 2-LIMA 3-bridge 4-SMA

b) 1-SMA 2-SMA 3-bridge 4-SMA

c) 1-SMA 2-LIMA 3-SMA 4-SMA

d) 1-SMA 2-bridge 3-bridge 4-SMA


Question 3

• When stomach is not available for esophageal conduit, which one of the following is not an option:

a) colon

b) jejunum

c) pleura

d) skin


Thank you for your attention.


Case

• CC: cough due to aspiration

• HPI: A 17 year old woman presented with a complicated history of congenital TEF repair, chronic esophageal stricture, multiple foregut procedures, and an inability to swallow- she has been fed by a G tube for the majority of her life…


History

4/25/94

birth

TEF repair

3 m:

Nissen

&

G Tube

3 y:

Re-do

Nissen

&

G Tube

3.3 y:

Repair

Of

Vascular

ring

Dx

w

Tracheo-

malasia

Aspiration, G-tube feeding, serial dilations (>30-40)

9 y:

LLL

for

Bronch-

iectasis

13 y:

Started

propulsid

17 y.o.


She had a type C TEF:


What would you do?

• She needs entire length of esophagus replaced

• Her stomach has had previous surgeries (fundo/G tube), and one of these resulted in the G tube going through the GE vessel

• Options:

• Colon interposition

• Jejunum

when stomach is not available - duke university · pdf filethe gastric conduit is standard of...

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