A non-randomized retrospective observational study on the subcutaneous esophageal reconstruction after esophagectomy: is it feasible in high-risk patients?

Abstract

Background: Esophageal reconstruction after esophagectomy is a complex procedure with high morbidity and mortality. Anastomotic leakage is more severe and frequent in patients with preoperative comorbidities and may present with septic conditions. Considering the possibility of an easier management of such cases, we evaluated the safety and feasibility of subcutaneous esophageal reconstruction in patients with high operative risks. Results: The mean postoperative hospital stay was longer in the subcutaneous group than the overall group. Anastomotic leakage occurred more frequently in the subcutaneous group [10 (47.6%) vs. 7 (13%), P=0.004]. Three major leakages resulted in chronic cutaneous fistula, but were successfully treated by lower neck reconstruction using radial forearm fasciocutaneous free flap (RFFF). There was no in-hospital mortality in the subcutaneous group.Conclusions: Subcutaneous esophageal reconstruction in high-risk patients showed a higher rate of anastomotic leakage. However, easier correction without fatal septic conditions could be obtained by primary repair or flap reconstruction resulting in lower perioperative mortality. Therefore, esophageal reconstruction through the subcutaneous route is not recommended as a routine primary option. However, in highly selected patients with unfavorable preoperative comorbidities or intraoperative findings, especially those with poor blood supply to the graft, graft hematoma or edema, or gross tumor invasion to surrounding tissues, esophageal reconstruction through the subcutaneous route may carefully be considered as an alternative to the conventional surgical techniques.

Robotic substernal esophageal bypass and reconstruction with gastric conduit—frequently overlooked minimally invasive option

“…Presternal/subcutaneous route confers poor cosmetic results, leads to development of epigastric incisional hernia and poor functional outcomes and currently is rarely used (22,23). It has, however, been advocated as the choice of reconstruction in frail patients, sometimes as the two staged approaches (24,25). Out of the multitude of the extraanatomic routes for esophageal reconstruction, the largest experience is accumulated with retrosternal placement of the conduit (9,12,26–31).…”

Dislocation of the gastric conduit reconstructed via the posterior mediastinal route is a significant risk factor for anastomotic disorder after McKeown esophagectomy

“…Esophageal reconstruction with a gastric conduit is typically performed via the subcutaneous, retrosternal, or posterior mediastinal (PM) route 8‐10 . Among these three routes, the PM route is considered the most physiological 11,12 .…”

“…6,7 Esophageal reconstruction with a gastric conduit is typically performed via the subcutaneous, retrosternal, or posterior mediastinal (PM) route. [8][9][10] Among these three routes, the PM route is considered the most physiological. 11,12 However, PM reconstruction carries a risk of severe morbidities such as mediastinal abscess, empyema, and tracheobronchial fistula.…”