Conduit necrosis following esophagectomy: An up-to-date literature review

Abstract

Esophageal conduit ischaemia and necrosis is an uncommon but devastating complication of esophagectomy and remains one of the most challenging issues in surgical practice. The incidence, time interval to develop symptoms, and clinical presentation are highly variable with no predictable pattern. Evidence comes from case reports and case series rather than randomized controlled trials. We describe the issues surrounding conduit necrosis affecting the stomach, jejunum and colon as an esophageal replacement and the advantages, disadvantages and challenges of each type of reconstruction. Diagnosis is challenging for the most experienced surgeon. Upper gastrointestinal endoscopy and computed tomography thorax with both oral and intravenous contrast is the gold standard. Management, either conservative or interventional is also a difficult decision. Management options include conservative treatment and more aggressive treatments such as stent insertion, surgical debridement and repair of the esophagus using jejunum, colon or a musculocutaneous flap. In spite of recent advances in surgical techniques, there is no reliable strategy to manage esophageal conduit necrosis. Our review covers the pathophysiology and clinical significance of esophageal necrosis while highlighting current techniques of prevention, diagnosis and treatment of this life-threatening condition.

Indocyanine Green (ICG) fluorescence angiography of gastric conduit after transhiatal thoracic esophagectomy with proximal gastrectomy for esophagogastric junction adenocarcinoma: A case report and initial experience at a tertiary government hospital in the Philippines

“…Optimal perfusion of the esophageal replacement, whether stomach, colon or jejunum, is an important determinant of esophageal surgery outcomes. Ischemia-related complications of the conduit can range from subclinical to ischemia-related anastomotic leakage to frank necrosis [ 8 ]. The impact of anastomotic leakages on long-term recurrence and survival of esophageal cancer patients following surgery remains debatable [ 9 , 10 ].…”

“…When creating the gastric conduit, the right gastroepiploic artery (RGEA) and, when possible, the right gastric artery (RGA) are preserved along with their corresponding veins [ 18 , 19 ]. However, blood supply of the gastric conduit is mainly through the RGEA [ [6] , [7] , [8] , 15 , 20 , 21 ]. The gastric conduit remains viable even with just single arterial supply and drainage due to its extensive intramural arterial and venous vascular network [ 18 ].…”

“…Intraoperative assessment of the viability and perfusion of the gastric conduit that depends on the pulsations of vessels, color of the gastric serosa, peristalsis, bleeding from the cut edge, visualized connection of the right and left gastroepiploic vessels, and temperature are subjective and dependent on surgeon experience. [ 5 , 8 , 13 , 16 ] These parameters may also be affected by several factors such as tissue damage, cardiopulmonary instability, and inotropic support [ 5 , 16 ].For this case, potential site of anastomosis was initially identified and marked using traditional intraoperative assessment by the surgeon.…”

“…An early study by Shimada, et al failed to demonstrate reduction in incidence of anastomotic leakage with the use of ICG fluorescence angiography despite its ability to evaluate the blood supply and detect microvasculature of the gastric conduit [ 17 ]. However, majority of the succeeding studies have demonstrated its usefulness in predicting the risk of anastomotic leakage [ 8 ]. Visualized evaluation of blood flow to the conduit by ICG fluorescence angiography significantly reduced risk of anastomotic complications compared to when it is not used [ 11 , 16 ].…”

“…Use of ICG fluorescence angiography can lead to modifications in intraoperative decisions such as resection of ischemic areas at the tip of the gastric conduit [ 15 ], choice of different area for anastomosis in the conduit [ 8 , 19 ], use of alternative conduits such as the colon or jejunum, and additional procedures such as supercharging or superdrainage whereby additional microvascular anastomoses between the conduit vessels and vessels in the neck in case of cervical anastomosis are performed [ 11 , 17 , 25 ]. In one study, 23 % of cases deviated from the anastomosis site chosen by usual visual assessment [ 19 ].…”