The acute management and surgical reconstruction following failed esophagectomy in malignant disease of the esophagus

Abstract

The stomach is the favored organ for reconstruction following esophageal resection for malignant disease, but has a 2% failure rate relating to ischemia. This event is associated with a high mortality, although appropriate surgical management with removal of the conduit can be life-saving. Further reconstruction is very challenging. We discuss the management options and surgical techniques for these patients. We reviewed of the surgical management of seven patients referred to a tertiary center over a 2-year period with failure of their primary esophageal reconstruction. Four patients had reconstruction with jejunum (2 free transfers and 2 'supercharged' pedicles with microanastomosis in the neck), and three with left colon. The route of reconstruction was substernal in four patients, subcutaneous in two, and through the left pleural cavity in one. There was 0% mortality, and 57% morbidity. The median intensive care unit stay was 2 days (mean 8, range 1-42). All patients tolerated full enteral nutrition, and had a satisfactory functional outcome. Failure of the conduit post-esophagectomy is a rare but serious complication, and these patients require complex surgical reconstruction. The surgical techniques described require a specialist multidisciplinary approach, but good clinical and functional outcomes are possible, even in patients with an underlying malignancy.

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

“…Many surgeons recommend to associate this procedure to the substernal esophageal reconstruction [3][4][5][18][19][20][21][22]. Statistically our study has some bias.…”

Road Map to Esophagectomy for Nurses

“…Postoperative pulmonary complications occur in 5% to 30% of patients and are a major source of morbidity. 3,4,[24][25][26]29,30 Pneumonia is the most common medical complication and alone increased the incidence of mortality by 20%. 3 Many preoperative and surgical factors may contribute to the development of the most common pulmonary complications of pneumonia and respiratory insufficiency (Table 4).…”

“…19 The most common medical complication is pulmonary related. 3,24,26,29 Three of the most serious surgical complications are anastomosis leak, chyle leak, and gastric necrosis.…”

“…This approach also allows thoracic en bloc esophagectomy (radical excision of regional mediastinal lymph nodes, surrounding tissue, and upper stomach) to be performed. 24 The en bloc resection may provide the best chance of identifying and removing potentially involved lymph nodes. 25 An incision is made in the midline abdomen from the umbilicus up to the sternal border.…”

“…Also a left cervical incision (transhiatal) might be necessary if a high anastomosis is needed. 3,24,28 Many times the surgical approach is driven by the surgeon's personal preference or dictated by the size and location of the tumor (Table 3).…”