Innovation in surgical technique
Delayed Cervical Esophagogastrostomy: A Surgical Alternative for Patients With Ischemia of the Gastric Conduit at Time of Esophagectomy
Esofagogastrostomía cervical diferida: Una opción técnica cuando se evidencia isquemia del tubo gástrico en el momento de la esofagectomía
Enrique Lanzarini, José M. Ramón, Luis Grande, Manuel Pera
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Sección de Cirugía Gastrointestinal, Hospital Universitario del Mar, Universitat Autònoma de Barcelona, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain
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Ramón, Luis Grande, Manuel Pera" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Enrique" "apellidos" => "Lanzarini" ] 1 => array:2 [ "nombre" => "José M." "apellidos" => "Ramón" ] 2 => array:2 [ "nombre" => "Luis" "apellidos" => "Grande" ] 3 => array:4 [ "nombre" => "Manuel" "apellidos" => "Pera" "email" => array:1 [ 0 => "pera@parcdesalutmar.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Cirugía Gastrointestinal, Hospital Universitario del Mar, Universitat Autònoma de Barcelona, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Esofagogastrostomía cervical diferida: Una opción técnica cuando se evidencia isquemia del tubo gástrico en el momento de la esofagectomía" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 638 "Ancho" => 850 "Tamanyo" => 65184 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography showing the distance between the proximal end of the digestive tube and the esophagostomy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The most commonly used type of digestive tract reconstruction after esophagectomy is the ascension of the digestive tube and esophagogastric anastomosis, which can be performed at the cervical or upper thoracic level. The arterial irrigation of this “tubulized” stomach depends on the right gastroepiploic arcade, gastric arterial flow and microvasculature. This means that the most proximal end of the digestive tube can present different degrees of ischemia that may favor the development of anastomotic dehiscence and put the patient's life at risk.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An alternative, infrequently used technique has been reported that surgeons can use when ischemia of the digestive tube is detected. We present such a case.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 64-year-old male with a history of alcohol-related cirrhosis (Child–Pugh A), chronic obstructive pulmonary disease, type 2 diabetes, arterial hypertension, dyslipidemia, obesity (BMI 33<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>) and cancer of the glottis and supraglottis treated with radiotherapy in 2007. During a follow-up endoscopy of his liver disease, a depressible and friable lesion measuring 2.5<span class="elsevierStyleHsp" style=""></span>cm was observed 20<span class="elsevierStyleHsp" style=""></span>cm from the dental arches. Biopsy demonstrated the mass to be a low-grade squamous-cell carcinoma with early-stage infiltration of the lamina propria. The extension study did not identify any locoregional or distant dissemination. The case was presented to the Upper GI Tract Tumors Committee, and surgical treatment was decided. Prior to surgery, the patient underwent 6 weeks of cardiopulmonary training for functional optimization, reaching a significant increase in oxygen uptake and maximum tolerated load.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical Technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">We performed transhiatal esophagectomy in 2 stages. In the abdominal stage, the entire stomach was mobilized, freeing the greater omentum along the greater curvature, while preserving the right gastroepiploic arcade and resecting the short gastric vessels and the left gastric artery. The esophagus was mobilized until above the tracheal carina. By means of a left cervicotomy, the cervical esophagus was released, the mass was identified and the esophagus was dissected 3<span class="elsevierStyleHsp" style=""></span>cm under the cricopharyngeal muscle. The intraoperative pathology study confirmed a tumor-free resection margin of 2<span class="elsevierStyleHsp" style=""></span>cm. After tubulization of the stomach, we performed pyloroplasty and drew the digestive tube up into the neck. At this time, we observed ischemia of the digestive tube, which was more evident at the upper edge. This was ratified after a gastrotomy and visualization of the mucosa. We decided not to carry out the esophagogastric anastomosis at that time and to delay the procedure until a later date. The proximal end of the digestive tube was removed, including the gastrotomy, with a mechanical stapler. This end was secured with a stitch of non-absorbable monofilament (Prolene<span class="elsevierStyleSup">®</span> 2/0), which was exteriorized to serve as a reference point through the cervicotomy. An end esophagostomy was created and the cervicotomy was closed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In addition, a feeding jejunostomy was performed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient had a favorable recovery and was discharged from the hospital 11 days after surgery, with scheduled outpatient visits. The histopathologic study revealed a squamous carcinoma that infiltrated the submucosa surface (T1b-sm1), with no lymph node involvement and negative margins.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Eight weeks later, a thoracoabdominal computed tomography scan showed the esophagostomy in the lower left portion of the neck at a distance of 15<span class="elsevierStyleHsp" style=""></span>mm from the upper end of the tubulized stomach. There was good uptake of the intravenous contrast medium at this level (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Given these findings, the cervicotomy was re-examined to reconstruct the digestive tract. There was evidence of good irrigation of the stomach, and the esophagogastric anastomosis was performed (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The patient's evolution during the postoperative period was uneventful. The anastomosis was checked with an upper GI series using contrast and fluoroscopy, which showed proper passage of the contrast material with no stenosis or filtrations (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patients who undergo esophagectomy are frequently older and have several comorbidities (diabetes, hypertension, chronic obstructive pulmonary disease, cardiac arrhythmia) or have been treated with neoadjuvant therapies. This situation, in conjunction with ischemia of the digestive tube that has been ascended for reconstruction of the tract, can lead to anastomotic filtration, sepsis or multiple organ failure and put the patient's life at risk.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In 2009, Oezcelik et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> published a strategy for the management of patients who had undergone esophagectomy and presented with ischemia of the digestive tube before creating the esophagogastric anastomosis. The technique entails delaying the anastomosis and leaving the digestive tube closed within the neck with a Prolene<span class="elsevierStyleSup">®</span> 2/0 suture in the more proximal end of the stomach. The suture is exteriorized to serve as a guide for the esophagogastric reconstruction. In addition, a cervical esophagostomy is constructed and a jejunostomy is placed for feeding. Ninety days after esophagectomy, esophagogastrostomy is performed through the previous cervicotomy and the Prolene<span class="elsevierStyleSup">®</span> 2/0 suture is used as a guide to locate the digestive tube.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The aim of this strategy is to consolidate the irrigation of the gastric tube using a process of ischemic conditioning.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> Oezcelik et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> reported a series of 35 patients who had been treated with this technique, and all of them had good irrigation of the gastric conduit at the time of the esophagogastric reconstruction, with no dehiscence, skin infections or postoperative sepsis. Three patients had stenosis, which was treated by dilation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">More than 20 years ago, other authors described the so-called “two-staged esophagectomy” in patients with high surgical risk: initial esophageal resection and cervical esophagogastrostomy 2–3 weeks later.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The objective of this strategy was to reduce the complications associated with traditional esophagectomy in a single procedure, but without originally contemplating its application in patients with evident ischemia of the digestive tube in an attempt to recuperate its vascularization and proceed with reconstruction at a later time.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Despite the disadvantages of this strategy (2 interventions, esophagostomy and jejunostomy), its safety and effectiveness (as seen in the results of Oezcelik et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and our case report) make it a possibility versus other options, such as anastomosis in a digestive tube with doubtful viability or resection of the digestive tube and later colonic interposition, which present higher morbidity and mortality rates.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres346824" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec328486" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres346825" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec328487" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical Technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-11-19" "fechaAceptado" => "2013-11-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec328486" "palabras" => array:4 [ 0 => "Esophagectomy" 1 => "Ischemia" 2 => "Anastomotic leak" 3 => "Esophageal reconstruction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec328487" "palabras" => array:4 [ 0 => "Esofagectomía" 1 => "Isquemia" 2 => "Dehiscencia anastomótica" 3 => "Reconstrucción esofágica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ischemia of the gastric conduit after esophagectomy represents a setback that increases the risk of anastomotic leak. In order to prevent this severe complication, a surgical alternative has been proposed which consists in delaying the reconstruction until gastric perfusion improves. By adopting this strategy we can avoid two other surgical options that may significantly increase the risk of complications: (1) performing an esophagogastrostomy with a poorly perfused gastric tube and (2) resecting the gastric conduit followed by a complex reconstruction.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La comprobación de una isquemia del tubo gástrico al terminar una esofagectomía es un contratiempo que incrementa el riesgo de dehiscencia de la anastomosis esofagogástrica. Para prevenir esta grave complicación, se ha propuesto como opción quirúrgica alternativa diferir la anastomosis el tiempo necesario para que se recupere la irrigación gástrica. De este modo se evitarían otras 2 opciones quirúrgicas que acarrean graves riesgos para el paciente: 1) realizar la anastomosis esofagogástrica en un estómago con una vascularización precaria y 2) la resección del tubo gástrico con una posterior reconstrucción muy compleja.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lanzarini E, Ramón JM, Grande L, Pera M. Esofagogastrostomía cervical diferida: Una opción técnica cuando se evidencia isquemia del tubo gástrico en el momento de la esofagectomía. Cir Esp. 2014;92(6):429–431.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 682 "Ancho" => 1000 "Tamanyo" => 144519 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Esophagostomy and Prolene<span class="elsevierStyleSup">®</span> suture used to locate the upper end of the digestive tube.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 638 "Ancho" => 850 "Tamanyo" => 65184 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography showing the distance between the proximal end of the digestive tube and the esophagostomy.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 624 "Ancho" => 850 "Tamanyo" => 136965 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Intraoperative image of the esophagogastric anastomosis.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2291 "Ancho" => 1418 "Tamanyo" => 206419 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Fluoroscopy showing the esophagogastric anastomosis and proper passage of the contrast material.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delayed esophagogastrostomy: a safe strategy for management of patients with ischemic gastric conduit at time of esophagectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 17 | 3 | 20 |
| 2024 September | 46 | 2 | 48 |
| 2024 August | 35 | 4 | 39 |
| 2024 July | 37 | 4 | 41 |
| 2024 June | 16 | 1 | 17 |
| 2024 May | 15 | 4 | 19 |
| 2024 April | 22 | 7 | 29 |
| 2024 March | 52 | 8 | 60 |
| 2024 February | 57 | 5 | 62 |
| 2024 January | 34 | 2 | 36 |
| 2023 December | 42 | 2 | 44 |
| 2023 November | 54 | 2 | 56 |
| 2023 October | 54 | 5 | 59 |
| 2023 September | 31 | 4 | 35 |
| 2023 August | 22 | 0 | 22 |
| 2023 July | 26 | 3 | 29 |
| 2023 June | 49 | 1 | 50 |
| 2023 May | 85 | 6 | 91 |
| 2023 April | 65 | 5 | 70 |
| 2023 March | 65 | 3 | 68 |
| 2023 February | 41 | 5 | 46 |
| 2023 January | 42 | 2 | 44 |
| 2022 December | 56 | 2 | 58 |
| 2022 November | 50 | 13 | 63 |
| 2022 October | 44 | 5 | 49 |
| 2022 September | 55 | 8 | 63 |
| 2022 August | 43 | 8 | 51 |
| 2022 July | 32 | 6 | 38 |
| 2022 June | 30 | 9 | 39 |
| 2022 May | 40 | 5 | 45 |
| 2022 April | 41 | 5 | 46 |
| 2022 March | 71 | 6 | 77 |
| 2022 February | 70 | 5 | 75 |
| 2022 January | 116 | 5 | 121 |
| 2021 December | 47 | 10 | 57 |
| 2021 November | 73 | 9 | 82 |
| 2021 October | 72 | 11 | 83 |
| 2021 September | 51 | 9 | 60 |
| 2021 August | 53 | 9 | 62 |
| 2021 July | 30 | 7 | 37 |
| 2021 June | 32 | 12 | 44 |
| 2021 May | 59 | 10 | 69 |
| 2021 April | 107 | 11 | 118 |
| 2021 March | 45 | 8 | 53 |
| 2021 February | 46 | 10 | 56 |
| 2021 January | 45 | 11 | 56 |
| 2020 December | 43 | 3 | 46 |
| 2020 November | 43 | 11 | 54 |
| 2020 October | 31 | 3 | 34 |
| 2020 September | 31 | 7 | 38 |
| 2020 August | 31 | 6 | 37 |
| 2020 July | 20 | 3 | 23 |
| 2020 June | 24 | 5 | 29 |
| 2020 May | 31 | 14 | 45 |
| 2020 April | 39 | 5 | 44 |
| 2020 March | 50 | 6 | 56 |
| 2020 February | 23 | 5 | 28 |
| 2020 January | 32 | 7 | 39 |
| 2019 December | 32 | 11 | 43 |
| 2019 November | 28 | 7 | 35 |
| 2019 October | 20 | 8 | 28 |
| 2019 September | 12 | 12 | 24 |
| 2019 August | 13 | 5 | 18 |
| 2019 July | 24 | 14 | 38 |
| 2019 June | 25 | 20 | 45 |
| 2019 May | 122 | 41 | 163 |
| 2019 April | 63 | 24 | 87 |
| 2019 March | 20 | 6 | 26 |
| 2019 February | 10 | 9 | 19 |
| 2019 January | 13 | 1 | 14 |
| 2018 December | 14 | 5 | 19 |
| 2018 November | 25 | 8 | 33 |
| 2018 October | 28 | 7 | 35 |
| 2018 September | 13 | 4 | 17 |
| 2018 August | 9 | 2 | 11 |
| 2018 July | 12 | 3 | 15 |
| 2018 June | 9 | 2 | 11 |
| 2018 May | 7 | 3 | 10 |
| 2018 April | 9 | 2 | 11 |
| 2018 March | 13 | 0 | 13 |
| 2018 February | 24 | 1 | 25 |
| 2018 January | 9 | 0 | 9 |
| 2017 December | 14 | 1 | 15 |
| 2017 November | 11 | 1 | 12 |
| 2017 October | 19 | 0 | 19 |
| 2017 September | 10 | 5 | 15 |
| 2017 August | 28 | 3 | 31 |
| 2017 July | 24 | 0 | 24 |
| 2017 June | 28 | 0 | 28 |
| 2017 May | 43 | 2 | 45 |
| 2017 April | 26 | 6 | 32 |
| 2017 March | 30 | 21 | 51 |
| 2017 February | 114 | 1 | 115 |
| 2017 January | 46 | 1 | 47 |
| 2016 December | 37 | 6 | 43 |
| 2016 November | 51 | 1 | 52 |
| 2016 October | 99 | 17 | 116 |
| 2016 September | 165 | 9 | 174 |
| 2016 August | 58 | 9 | 67 |
| 2016 July | 33 | 3 | 36 |
| 2016 June | 31 | 10 | 41 |
| 2016 May | 35 | 11 | 46 |
| 2016 April | 35 | 33 | 68 |
| 2016 March | 55 | 20 | 75 |
| 2016 February | 29 | 9 | 38 |
| 2016 January | 40 | 14 | 54 |
| 2015 December | 43 | 10 | 53 |
| 2015 November | 33 | 6 | 39 |
| 2015 October | 34 | 7 | 41 |
| 2015 September | 38 | 4 | 42 |
| 2015 August | 65 | 7 | 72 |
| 2015 July | 43 | 3 | 46 |
| 2015 June | 28 | 2 | 30 |
| 2015 May | 41 | 3 | 44 |
| 2015 April | 61 | 12 | 73 |
| 2015 March | 27 | 12 | 39 |
| 2015 February | 28 | 9 | 37 |
| 2015 January | 31 | 8 | 39 |
| 2014 December | 43 | 21 | 64 |
| 2014 November | 62 | 12 | 74 |
| 2014 October | 68 | 18 | 86 |
| 2014 September | 25 | 7 | 32 |
| 2014 August | 0 | 1 | 1 |
| 2014 July | 0 | 1 | 1 |
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