Comparative anatomical study of the anterior and posterior mediastinum as access routes after esophagectomy

Coral, Roberto Pelegrini; Constant-Neto, M.; Silva, I. S.; Kalil, Antônio Nocchi; Boose, R.; Beduschi, Thiago; Gemelle, T. F.

doi:10.1046/j.1442-2050.2003.00335.x

Cited by 39 publications

(33 citation statements)

References 3 publications

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“…A cadaver study by Coral et al indicated a shorter distance using PM compared to SR (10). In contrast, Chen et al reported that required conduit length is greater when the posterior route of reconstruction is used.…”

Section: Discussionmentioning

confidence: 90%

Substernal reconstruction following esophagectomy: operation of last resort?

Moremen¹,

Ceppa²,

Rieger³

et al. 2017

J. Thorac. Dis.

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Background:The posterior mediastinum is the preferred location for reconstruction following esophagectomy. Occasionally alternative routes are required. We examined patient outcomes of esophageal reconstruction in order to determine whether substernal reconstruction (SR) is an equivalent alternative to orthotopic placement. Methods: Following IRB approval, we performed a retrospective review of all patients who underwent an esophagectomy from 1988-2014. Only patients reconstructed with a gastric conduit and cervical anastomosis by either substernal or posterior mediastinal (PM) routes were included in the study. Endpoints assessed included anastomotic leak rate, post-operative complications, reoperation, hospital length of stay, and 30-and 90-day mortality. Results: Thirty-three patients underwent SR and 182 had a PM gastric conduit with cervical anastomosis.The SR pathology was predominantly benign while PM was mostly malignant. Sixteen SR patients had a delayed reconstruction after prior diversion. Mean hospital LOS was longer in the SR group (P<0.001).There was no significant difference in 30-and 90-day mortality. PM patients had significantly fewer respiratory complications (P<0.04), reoperations (P<0.04), and transfusions (P<0.0001) and a trend towards fewer anastomotic leaks (17.1% vs. 30.3%; P<0.09). Conclusions: This single institution experience demonstrated no significant difference in mortality between substernal and PM reconstruction following esophagectomy. However, SR was associated with significantly increased LOS and morbidity, including a trend toward increased anastomotic leaks. SR reconstruction should probably be considered an option of last resort.

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Section: Discussionmentioning

confidence: 90%

Substernal reconstruction following esophagectomy: operation of last resort?

Moremen¹,

Ceppa²,

Rieger³

et al. 2017

J. Thorac. Dis.

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“…The venous blood flow is very sensitive to mechanical obstacle and as reported in literature, venous stasis is the usual precipitating event for necrosis [17]. To prevent this event, some surgeons suggested enlarging the thoracic inlet by removing the left half of manubrium and internal third of clavicle [2][3][4]7,18,19]. The results of this present study revealed a reduction of cervical anastomotic leakage rate which statistically significant ( 10.55% vs 28.2 % ) in patients who received a substernal reconstruction with opening of the thoracic inlet ( p=0.0462).…”

Section: Discussionmentioning

confidence: 99%

“…However the enlargement of thoracic inlet did not have an impact on cervical anastomotic stricture (p=0.139). The substernal route has been considered to be inferior to posterior mediastinal approach as it was believed to be a longer route and associated with high rate of cervical anastomotic leakage [7,20]. How to reduce the incidence of cervical anastomotic leaks has always been a priority for studies in the field of oesophageal surgery.…”

Section: Discussionmentioning

confidence: 99%

“…Substernal approach is an ideal indication for esophageal palliative surgery and for caustic stricture when the scarred esophagus is left in place. The longer distance of reconstruction and the higher incidence of cervical anastomotic leakage compared with the posterior mediastinal approach have always hampered the wider use of substernal route [6,7]. Cervical anastomotic leak has always been one of the major complications associated with the anterior reconstruction approach.…”

Section: Discussionmentioning

confidence: 99%

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Esophageal Reconstruction by Substernal Route: Impact of the Thoracic Inlet Enlargement on Cervical Anastomotic Complications: Leak and Stricture

Boukerrouche¹

2016

GHOA

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Introduction: The mediastinal route is preferred four immediate reconstructions after esophagectomy however the substernal approach is used for delayed construction. The substernal route is an alternative option for reconstruction however this approach has a major disadvantage which is the potential risk of graft compression at the level of thoracic inlet .This prospective study aims to evaluate whether the enlargement of the thoracic inlet during substernal colonic interposition can influence the incidence of cervical anastomotic complications.

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“…The retrosternal route has been an alternative for oesophageal reconstruction after esophagectomy. But the longer route and the higher incidence for cervical anastomotic leakage compared with the posterior mediastinal approach have always hampered its wider use [7,8]. The biggest disadvantage of the substernal route is the potential risk for compression of the graft at the site of the thoracic inlet, which can lead to mechanical ischemia of the cervical portion of the graft causing a leakage or localized necrosis.…”

Section: Discussionmentioning

confidence: 99%

Colonic Esophageal Reconstruction by Substernal Approach for Caustic Stricture: What is the Impact of the Enlargement of the Thoracic Inlet on Cervical Anastomotic Complications?

Boukerrouche¹

2014

Surgery

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Background: The two most commonly employed options for esophageal reconstruction are the posterior mediastinal route and the substernal route. Therefore, the biggest disadvantage of the retrosternal approach is the potential risk for compression of the graft at the site of the thoracic inlet. The purpose of this study is to report our results by analysing the impact of the enlargement of the thoracic inlet by removing the left half of manubrium and internal third of clavicle on the cervical anastomotic leakage. Methods:From 2005 to 2013, 82 left colonic interpositions for oesophageal caustic stricture were performed at our institution. There were 70 women and 12 men. Ten patients had a hypopharyngeal stricture that required also reconstructive surgery. Dilation was done in 56 patients.Results: An esophagocolic anastomosis was performed in 72 patients. A gastroenteroanastomosis was performed before reconstruction in 10 patients. A pharyngoplasty was associated in 10 patients. The thoracic inlet was enlarged in 35 patients .The colonic graft was anastomosed to the posterior surface of the stomach in 69 patients. The mortality rate was 2.43 %. Graft necrosis occurred in two patients. Cervical leakage was occurred in 25 patients. Eight patients developed a cervical structure. Statistical analysis revealed that the non-enlargement of the thoracic inlet was a predictive factor of cervical leak (OR; 3.63, CI; 1.06 -12.40, P= 0.039 ) .therefore the enlargement is associate with lower rate of cervical leak. The functional results were good. Conclusion:The non-enlargement of the thoracic inlet is a predisposing factor of cervical leak in substernal colonic interposition. Therefore the enlargement seems reduce the cervical leakage.

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Comparative anatomical study of the anterior and posterior mediastinum as access routes after esophagectomy

Cited by 39 publications

References 3 publications

Substernal reconstruction following esophagectomy: operation of last resort?

Substernal reconstruction following esophagectomy: operation of last resort?

Esophageal Reconstruction by Substernal Route: Impact of the Thoracic Inlet Enlargement on Cervical Anastomotic Complications: Leak and Stricture

Colonic Esophageal Reconstruction by Substernal Approach for Caustic Stricture: What is the Impact of the Enlargement of the Thoracic Inlet on Cervical Anastomotic Complications?

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