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Intraoperative Solutions for the Gastric Conduit that Will Not Reach
Ali Aldameh
8
Colon as an Alternative Conduit
The stomach is the preferred conduit for esophageal replacement in majority of the cases for its
reliable blood supply, low intraluminal bacterial
burden, and the need for only a single anastomosis. Occasionally, the stomach is not available because of previous abdominal or gastric surgery or
involvement with tumor [1–5]. The esophageal
surgeon should be equipped with the knowledge
and skills to use alternative conduits for reconstruction. Most surgeons will then utilize the
colon as a second option for an alternative conduit. The left colon in particular has an advantage
over the right colon in that its lumen is smaller
and more closely approximates that of the esophagus. The vascular anatomy on the left is more
consistent than on the right; however, involvement by atherosclerotic disease of the inferior
mesenteric artery is more common than in any
other mesenteric vessel. Preoperative evaluation
is crucial in all cases where colon is anticipated
as a conduit. Complete surgical history including
knowledge of prior abdominal surgery that may
have interrupted either the arterial blood supply
or venous drainage of the colon that may render a
segment of the colon unusable is important. The
inferior mesenteric vein drains into the splenic
vein, and prior severe pancreatitis or other causes
A. Aldameh ()
Department of Surgery, Harvard Medical School,
Boston, MA, USA
e-mail: aalmadeh@partners.org
of splenic vein thrombosis may render the left
colon unusable as a conduit because of inferior
mesenteric vein thrombosis. Colonscopy and CT
angiography are performed in the preoperative
evaluation to rule out colonic disease or vascular anomalies including neoplasia, stricture, or
extensive diverticulosis. Mechanical and antibiotic bowel preparations are administered prior to
surgery.
A midline laparotomy is performed, and the
abdomen is explored for metastatic disease. The
peritoneal attachments of the left colon to the
retroperitoneum are divided along the white line
of Toldt. We use an umbilical tape from the proposed proximal line of transection of the esophagus through the proposed route of placement of
the conduit to the point of proposed anastomosis to the stomach. The umbilical tape length is
used to estimate the conduit length that is needed
and can then be used to measure an appropriate
length of colon.
The vessels supplying the left colon are visualized by transillumination and the middle colic
artery is test clamped. A palpable pulse should
still be present in the marginal artery. If there is
any question, a Doppler probe is used to assess
the quality of the pulse, a clamp is then left in
place, and the conduit inspected for adequate perfusion. Once the conduit is deemed of satisfactory quality, we proceed with the esophagectomy.
The left colon is then prepared. The omentum is
separated from the left colon and splenic flexure
that is to be used as a conduit. The middle colic
artery is divided, and the mesentery is divided
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_8,
© Springer Science+Business Media New York 2015
87
88 A. Aldameh
as close as possible to the root, away from the
marginal artery of Drummond. The colon is reanastomosed with a single interrupted 3.0 silk
anastomosis and the mesenteric defect is closed.
The proximal anastomosis is then constructed;
this allows better determination of conduit length
and ensures that the conduit will sit properly
in the neck. The proximal end of the conduit is
retrieved into the neck by use of an endoscopic
camera bag attached to suction tubing. We prefer the posterior mediastinal (in situ) route as this
is the shortest route between the stomach and
esophagus (Fig. 8.1 ). The surgeon should be pre-
pared to accept that in some cases the posterior
mediastinal route is unavailable because of prior
infection and prior gastric conduit leak with subsequent scarring. In these cases, the substernal
is preferred. If a substernal approach is used, we
resect the manubrium or a portion of the manubrium to prevent obstruction, prevent angulation,
and to allow adequate space for the colon. The
proximal anastomosis is typically constructed
with a single- or two-layer hand-sewn anastomosis of the end of the esophagus to the side of the
antimesenteric taenia. The anastomosis is constructed over a nasogastric tube with its tip positioned in the center of the stomach. The conduit
should be monitored for arterial insufficiency or
venous engorgement. We then complete the gas-
trocolic anastomosis with a large EEA stapler or
in a side-to-side functional end-to-end stapled
manner. Finally the conduit is sutured to the crus
to prevent migration of the colon into the chest
or herniation of abdominal viscera into the chest.
In cases where the left colon is involved with
extensive diverticular disease or atherosclerotic
occlusion of the inferior mesenteric artery, and
splenic vein thrombosis with thrombosis of the
inferior mesenteric vein, it is unusable as a conduit. The right colon is an acceptable conduit and
is used as an alternative conduit that will reach
the esophagus in the neck.
The right colon is inspected and its retroperitoneal attachments are dissected and lysed. The
mesentery of the right colon is transilluminated
and the ileocolic, right colic, marginal, and middle colic arteries identified. Clamps are placed on
the ileocolic and right colic arteries, and the right
colon is inspected for adequate perfusion through
the marginal artery. The right colon is then harvested, leaving the marginal artery intact. An appendectomy is performed. Appropriate lengths of
right colon are divided with a GIA 75-mm stapler,
and the colocolonic anastomosis is performed in
a single layered interrupted fashion. The proximal end is drawn up into the neck carefully to
prevent trauma or injury to the harvested colon.
The proximal anastomosis is then completed cre-
Fig. 8.1 We prefer the posterior mediastinal (in situ) route as this is the shortest route between the stomach and esopha-
gus
898 Intraoperative Solutions for the Gastric Conduit that Will Not Reach
ated via a single-layer end of esophagus to the
side of the colon along the taenia. Finally we construct the cologastric anastomosis with either an
EEA staplers or a side-to-side stapled technique.
Jejunum as an Alternative Conduit
Replacement of the esophagus with jejunum is
indicated when the stomach is not suitable because of prior surgery or involvement with disease. Jejunum is then used to replace a portion of
the esophagus as a free graft, pedicled graft, or
Roux-en-Y replacement Fig. 8.2. Replacement
of a distal esophageal peptic stricture should be
performed with colon or jejunum in preference
to stomach. Interposition of an isoperistaltic segment of intestine is preferable to gastric pull-up,
which has a very high incidence of recurrent severe reflux. Roux-en-Y jejunal replacement may
be used to replace the stomach and distal esophagus after total gastrectomy including distal
esophagectomy. Free jejunal graft is indicated in
limited reconstruction of the cervical esophagus.
However, total esophageal replacement cannot be
accomplished with jejunum alone as the length is
insufficient to reach the neck. Important detailed
history to exclude patients with disease of the
small bowel due to inflammatory bowel disease
or previous surgery is crucial in the preoperative
preparation. Mechanical bowel preparation is
not necessary for jejunal interposition; however,
if the jejunum is found to be unacceptable as a
conduit or if the blood supply to the jejunum is
inadvertently damaged during harvest, rendering
it unusable as a conduit, the colon should be readily available and prepared for reconstruction.
After total gastrectomy and distal esophageal
resection, Roux-en-Y replacement may be used
for reconstruction. Main indications include
proximal gastric tumors or esophageal resection
into the upper chest. With meticulous preparation, Roux-en-Y configuration will reach the
neck, but this is variable; however, it will not reliably reach the cervical esophagus. When it is
used after total gastrectomy, jejunum is divided
approximately 30 cm beyond the ligament of
Treitz. The jejunum is elevated outside the abdomen, and the vascular arcade is transilluminated.
The proposed point of division is identified, and
the line of division of the mesentery is identified along with the proposed division of several vessels of the mesentery, which will allow
transposition of the jejunum up into the chest.
The feeding vessel is identified and preserved.
The serosal surface of the mesentery is scored,
and the vessels to be transected are momentarily
clamped and the conduit observed for few min-
Fig. 8.2 Jejunum is then used to replace a portion of the esophagus as a free graft, pedicled graft, or Roux-en-Y
replacement
90 A. Aldameh
utes for evidence of ischemia or congestion. A
window in the transverse mesocolon is created
to the left of the middle colic vessels for the jejunum and its mesentery to pass through. In cases
of total gastrectomy, the proximal anastomosis
is to distal esophagus in the upper abdomen. If
distal esophagectomy is performed as for tumors
of the cardia that extend to the gastroesophageal
junction, the abdominal incision must be brought
across the costal margin into the left sixth or seventh interspace.
A stapled or hand-sewn technique is used
for the esophagojejunal anastomosis. We prefer
a 33-mm EEA stapler. A pursestring suture is
placed in the distal esophagus, and the shaft of
the EEA stapler is introduced through the stapled
end of the proximal jejunum. After removal of
the EEA stapler, the jejunal end is closed with
a TA 60-mm stapler. To prevent herniation of
abdominal contents into the chest and minimize
tension on the esophagojejunal anastomosis, the
jejunum is tacked to the hiatus at several points
with interrupted silk sutures. The defect in the
colonic mesentery should be closed to prevent
an internal hernia. The distal anastomosis can be
hand sewn or performed by a side-to-side functional end-to-end stapled technique.
is then hand sewn in two layers with interrupted
3.0 silk sutures.
Free Jejunal Interposition
In certain circumstances, a free jejunal graft may
reach portions of the upper esophagus that pedicled grafts may not. There is a significant risk
of life-threatening graft ischemia and necrosis.
In addition, two anastomoses are required, increasing the morbidity risk of anastomotic leaks.
A short segment of jejunum is harvested and a
left cervical incision is made. The esophagus
and carotid and jugular vessels are isolated. The
jejunal vessels are dissected and isoplated and
sharply divided. The artery and vein are flushed
with heparinized saline. The proximal hand-sewn
anastomosis is constructed first, an operating microscope and fine 9 -0 or 10 - 0 suture are used
to anastomose the jejunal vessels to the carotid
and jugular vessels, and the distal anastomosis
is then constructed. Finally the graft is covered
with a meshed split-thickness skin graft to allow
monitoring of graft viability in the postoperative
period.
Pedicled Jejunal Interposition
This is best performed via a left thoracoabdominal incision along the left seventh interspace
across the costal margin and the rectus muscle.
The jejunum is transilluminated, and an appropriate length of jejunum is selected from a point
20 cm distal to the ligament of Treitz. A single
large vessel is used as a feeding vessel for the
conduit (Fig. 8.2 ). The jejunum is transected
proximally and distally with a GIA stapler, and
the mesentery is divided on each side. The remaining jejunum is reconnected by a side-to-side
functional end-to-end standard stapled technique.
The pedicled jejunum is tunneled through the
mesocolon and brought into the left chest. The
proximal anastomosis is then constructed in a
similar fashion to the Roux-en-Y esophagojejunal anastomosis. The jejunogastric anastomosis
Summary
Various possible operative techniques for esophageal conduit replacement exist to treat patients
with esophageal carcinoma in whom the stomach
will not reach the neck due to disease or malignancy. The skilled esophageal surgeon should be
a master of the anatomy of the neck, chest, and
abdomen and prepared to use all routes and methods available. We have described our methods for
alternative reconstruction in this chapter. The references below are included for further reading.
Key Points
1. The colon and jejunum are alternate conduits
for the case where the stomach will not reach.
2. When using the colon, the left colon is preferred over the right, partly due to a better size
918 Intraoperative Solutions for the Gastric Conduit that Will Not Reach
match with the esophagus. The posterior mediastinal route is preferred over the substernal
route.
3. Careful assessment and preservation of the
vascular supply, especially the marginal artery, to the colon must be performed when
considering a colonic conduit.
4.
A jejunal conduit can be used as a free graft
or a pedicled
graft. The vascular supply must
be carefully assessed and preserved as well,
similar to when using a colonic conduit.
References
1. Ginsberg R. Selection and placement of conduits:
Comments and controversies. In: Pearson FG, Cooper
JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson
GA, Urschel HC Jr, editors. Esophageal surgery. London: Churchill Livingstone; 2002. p.
Hiebert C, Bredenber
2.
conduits. In: Pearson FG, Cooper JD, Deslauriers J,
Ginsberg RJ, Hiebert CA, Patterson GA, Urschel HC
Jr, editors. Esophageal surgery. New York: Churchill
Livingstone; 2002. p. 794–801.
3.
Coleman J, Searless J, Jurkiewicz M, et al. T
experience with the free jejunal autograft. Am J Surg.
1987;154:394–8.
4. Marks JL1, Hofstetter WL. Esophageal reconstruction with alte
2012;92(5):1287–97.
Blackmon SH, Correa
5.
Kim MP, Mehran RJ, et
nal interposition for esophageal replacement: a 10-year
experience. Ann Thorac Surg. 2012;94(4):1104–11.
g C. Selection and placement of
rnative conduits. Surg Clin NA
AM, Skoracki R, Chevray PM,
al. Supercharged
800–1.
en years
pedicled jeju-
Injury to the Right Gastroepiploic Artery
Ravi Rajaram and Malcolm M. DeCamp
9
Introduction
The right gastroepiploic artery (RGEA) has
played an important role clinically for the general and cardiothoracic surgeon for many years.
While this vessel was frequently used in previous
years for revascularization in cardiac surgery, its
current significance stems primarily from its role
as the principal blood supply to the gastric conduit in an esophagectomy. Consequently, careful
dissection and preservation of this artery is paramount in ensuring adequate blood supply for alimentary reconstruction. This chapter is a review
of the importance of technique and meticulous
dissection of this vessel. Furthermore, we will
describe important considerations in anticipating
and avoiding injury to this artery, management
options when an injury to RGEA is identified,
and procedures to augment blood flow to the
tenuous gastric conduit.
M. M. DeCamp ()
Division of Thoracic Surgery, Northwestern Memorial
Hospital, 676 North Saint Clair Street, Suite 650, 60611
Chicago, IL, USA
e-mail: mdecamp@nmh.org
R. Rajaram
Department of Surgery, Northwestern University Feinberg School of Medicine, 251 E. Huron St.,
Galter 3-150, 60611, Chicago, IL, USA
e-mail: Ravi-Rajaram@northwestern.edu
Anatomy of the RGEA
The RGEA most often arises as a terminal branch
of the gastroduodenal artery which itself is a
branch of the common hepatic artery (Fig. 9.1 ).
This vessel traverses from the patient’s right to
left along the greater curvature of the stomach
and is encased within the greater omentum. Because the left gastric, short gastric, and left gastroepiploic arteries (LGEA) are ligated during a
standard esophagectomy, the blood supply to the
stomach relies primarily on the RGEA with some
contribution from branches of the right gastric
artery.
The gastric fundus is the region most distant
from its arterial inflow and venous drainage and
thus particularly susceptible to ischemia. Blood
flow to the fundus was initially thought to rely
on the RGEA communicating directly with the
LGEA. However, studies on this topic differ and
have suggested that a direct RGEA anastomosis with the LGEA only occurs approximately
23–70 % of the time [1–5]. In a cadaver study
by Liebermann-Meffert et al., the authors found
that the RGEA contributed approximately 60 %
of the total blood supply to the gastric tube with
the remaining portion distributed among collaterals from the LGEA (20 %) as well as a smaller,
submucosal network of collaterals (20 %). Of
note, they also reported that direct communication between the RGEA and LGEA is minute and
that while the right gastric artery is often preserved in esophagectomy, its contribution to the
vascularity of the gastric tube is negligible [6].
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_9,
© Springer Science+Business Media New York 2015
93
94 R. Rajaram and M. M. DeCamp
Fig. 9.1 Anatomy of the right gastroepiploic artery
These findings underscore the importance of the
RGEA in the success of the gastric conduit during esophagectomy.
Vascular Considerations in Esophagectomy
Studies have demonstrated that use of a gastric
conduit, as opposed to jejunal or colonic, for
esophageal replacement following esophagectomy is associated with similar, if not lower, rates
of ischemia. However, this highly morbid complication still occurs with use of stomach, with
estimates ranging from 0.5% to 10.4% of cases
[7–9]. Research has shown that mobilization of
the gastric fundus during esophagectomy is associated with a greater than 50 % decrease in gastric tissue oxygen tension and that this resulting
degree of oxygenation is correlated with subsequent success of the esophagogastric anastomosis [10, 11]. Consequently, while some loss of
tissue perfusion and oxygenation is unavoidable
during this surgery, optimizing conditions for
blood flow is critical for a successful anastomosis and good postoperative outcomes. These studies highlight the importance of careful, gentle
manipulation and handling of the whole gastric
conduit throughout the entirety of the operation
to minimize local trauma, vascular torsion/kink-
ing, or conduit tension or compression. From a
physiologic perspective, it is also important to
avoid worsening perioperative splanchnic hypoperfusion by minimizing the use of vasopressors
and alpha agonists. Communication with the anesthesia team intraoperatively and critical care
team postoperatively regarding the significance
of avoiding these medications is key to maximizing oxygen tension in the newly mobilized gastric conduit.
Preoperative Evaluation of the RGEA
A detailed past medical and surgical history is
critically important prior to esophagectomy.
Known aorto-iliac occlusive disease or peripheral vascular disease, as well as any prior vascular
intervention whether transabdominal or catheter-based, should raise concern for adequacy of
gastric conduit perfusion after mobilization. An
associated history of diabetes, given its known
impact on both macro and microvascular disease,
may also warrant a more focused evaluation. A
dedicated computed tomography (CT) scan of
the chest, abdomen, and pelvis is often part of the
preoperative evaluation of the esophageal cancer
patient. In addition to reviewing the tumor and
nodal morphology and ruling out metastases, the
surgeon should also evaluate the visceral aorta
959 Injury to the Right Gastroepiploic Artery
for extensive calcification. In the setting of the
aforementioned comorbid conditions, evaluation
of celiac and mesenteric arterial integrity may be
achieved through modalities such as CT or magnetic resonance (MR) angiography or aortography.
Currently, patients who have a planned esophagectomy, do not routinely undergo any form of
preoperative screening to ensure an appropriate
diameter or size of the RGEA. Evidence from
cardiac surgery has shown that preoperative
evaluation of this vessel in the form of transabdominal ultrasound or multidetector CT is feasible and may be worthwhile in operative planning for coronary artery bypass revascularization
[12, 13]. For example, in a study by Minakawa
et al., the authors used preoperative sonography
to evaluate the RGEA and identify patients with
a threshold artery diameter of 2 mm for subsequent revascularization. All individuals that met
this criterion preoperatively were found intraoperatively to have arteries sizeable enough for subsequent anastomosis. Furthermore, comparison
of preoperative ultrasound measurements with
postoperative angiography of this vessel was
highly correlated and confirmed acceptability of
this screening approach. Unfortunately, data regarding the use of preoperative evaluation of the
RGEA in esophagectomy are lacking. However,
in patients who may have a history of foregut surgery, previous exploratory laparotomy, prior cardiac surgery with an unknown graft, or aberrant
or incomplete anatomic visualization on routine
preoperative imaging, the use of either of these
modalities with special attention to the RGEA
may prove useful in operative planning.
inferior to the pylorus and traverses along the
greater curvature, its relationship with the LGEA
is subject to change as described above [1]. As
such, to avoid accidental injury, it is advantageous to locate and establish the RGEA’s anatomic relationship and path early upon entering
the abdomen prior to proceeding further in the
course of the operation. This is especially true
during any abdominal reoperation as adhesions
may distort or obscure the precise anatomy of the
omentum, transverse colon, and greater curvature
of the stomach.
During the preparation of the gastric conduit,
the greater omentum is separated from the greater
curvature of the stomach. At this point in the operation, the surgeon should be extremely mindful
of the previously identified course of the RGEA.
Accidental injury, or excessive manipulation, of
this vessel during dissection of the omentum can
cause irreparable vascular compromise and subsequently result in an inability to use the stomach as a conduit for esophageal replacement [15].
Consequently, it is recommended that a minimum
of 2.0 cm clearance be given between the RGEA
and the omentum to be divided to avoid accidental mechanical or thermal injury (Fig. 9.2 ) [16].
Additionally, particular attention should be given
when the dissection approaches the pylorus as
the RGEA courses deep and posterior to the duodenal bulb to its origin from the gastroduodenal
artery. The gastrocolic ligament and omentum
are often fused with the transverse mesocolon in
this location. Careful separation of these planes
Preparation and Mobilization of the Gastric Conduit
Given the infrequency with which dedicated imaging of the RGEA is obtained preoperatively,
it is important that soon after entering the peritoneal cavity and establishing exposure that the
RGEA is identified. There is tremendous known
variability in the celiac and hepatic arterial system and thus the location and path of the RGEA
[14]. While this vessel reliably originates just
Fig. 9.2 Greater curvature dissection
96 R. Rajaram and M. M. DeCamp
is required to avoid traction injury to the RGEA
or its accompanying veins. This dissection also
promotes easier passage of the conduit cephalad
while decreasing subsequent anastomotic tension.
Esophagectomy with the use of a gastric conduit involves a delicate balance of obtaining appropriate reach of the conduit while preserving
vascularity to the esophagogastric anastomosis.
Ensuring an appropriate length of conduit is key
not only for achieving a tension-free anastomosis but also for minimizing reflux in the patient
postoperatively [15]. Transferring of the conduit
cephalad into the chest or neck is a critical step in
the course of the operation. During this time, it is
important to avoid excessive stretch, torqueing,
or twisting that may result in stenosis, dissection,
or a traction injury to the RGEA. Maintaining
collinear movement of the conduit with its vascular pedicle will help to safeguard against inappropriate twisting or rotation during mobilization.
Additionally, after the tubularized stomach
has been relocated to the chest, the surgeon
should inspect the conduit to ensure that there is
no excessive compression at the diaphragmatic
hiatus. In recognition of this, we routinely open
the hiatus anteriorly to the pericardial reflection,
ligating the crossing phrenic veins. Omitting
these safeguarding steps may result in significant
vascular compromise to the conduit with identification after it is too late. Arterial compromise
typically presents early postoperatively with
acidosis and evidence of a systemic inflammatory response syndrome (SIRS) due to conduit
necrosis. Venous compression is more insidious
with full thickness necrosis often delayed until
postoperative days 5–7.
Techniques for Improving Tissue Oxygenation
Tension-Free Anastomosis
particularly in the relatively oxygen-deprived
fundic region of the stomach. A generous Kocher
maneuver and careful separation of the gastrocolic ligament from the transverse mesocolon aid
in facilitating appropriate length.
Additionally, novel techniques have been described to address this issue of tension on the
conduit and to allow for sufficient reach [17]. For
example, noting the relative redundancy of the
greater curvature in comparison with the strained
lesser curvature, some authors have advocated
for the use of a lengthening procedure termed
“angleplasty.” In this technique, the point of tension at the angle of the lesser curvature is divided
transversely through the seromuscular layer for a
distance of 4 cm exposing the submucosa. This
is followed by a longitudinal incision for approximately 4 cm through the gastric wall with
subsequent closure of the incision using vertical
seromuscular Lembert sutures [18]. By lengthening the gastric tube, this procedure may allow
for a tension-free anastomosis and as a result improved arterial flow and reduced venous congestion in the proximal portion of the stomach.
Finally, as long as a cancer-free esophageal
resection margin can be achieved, another simple technical maneuver to reduce tension when
conduit length is limited is to change the level
of the planned anastomosis from cervical to intrathoracic. Multiple studies have consistently
demonstrated lower anastomotic leak rates for
intrathoracic reconstructions [19, 20]. Thus, although an unanticipated change in the operative
plan is not ideal, it is often preferable to a dubious anastomosis.
During any esophagectomy, but particularly in
the context of a tenuous RGEA, creating a tension-free anastomosis is critical to a successful
patient outcome. Use of a generous Kocher maneuver, “angleplasty,” and alterations to the anastomotic level are techniques the surgeon may employ to mitigate this concern as best as possible.
Achieving appropriate length of the gastric conduit can often be an issue, especially for cervical
anastomoses. The stretch placed on the stomach
when attempting to reach the cervical esophagus may result in compromised blood flow,
“Supercharging”
The territory most vulnerable to ischemia in the
gastric conduit is the proximal portion of the
979 Injury to the Right Gastroepiploic Artery
stomach in the area of the fundus. This is primarily attributed to the unfortunate fact that after
mobilization and transposition of the stomach
into the chest or cervical region, this portion of
the conduit is farthest away from its nutrient arterial inflow and venous drainage. This area is
also where the esophagogastric anastomosis occurs. Thus, a potentially ill-fated situation occurs,
whereby the area most susceptible to ischemia is
also the region most in need of a robust blood
supply for healing.
With this in mind, a technique that has received considerable attention for patients requiring esophagectomy is “supercharging.” The use
of this method was first reported in 1947 and
has increasingly been reported in the literature
[15, 21]. “Supercharging” involves creating additional microvascular anastomoses to increase
blood flow to the gastric conduit or, in some
cases, the pedicled jejunal or colonic substitutes.
While some surgeons may routinely use this procedure, more often it is selectively implemented
to augment blood flow. In this context, the use of
“supercharging” may prove invaluable as a salvage technique, particularly in the case of a tenuous conduit or compromised RGEA. The value
of this procedure lies in its potential to not only
increase arterial flow but also enhance venous
drainage from the conduit. The latter is often a
concern following esophagectomy, in particular
when there is marked gastric distention at either
the thoracic inlet or the diaphragmatic hiatus, or
when the conduit is on tension or has a particularly long cephalad reach.
“Supercharging” has been described for many
kinds of esophageal reconstructions including the
use of gastric, jejunal, and colonic conduits. In a
series reported by Sekido et al., 82 reconstructions of all types were performed with use of “supercharging” selectively in situations where the
conduit appeared ischemic or had areas of poor
perfusion. They most commonly used the superior thyroid artery in the neck and the internal thoracic artery in the chest as the recipient arteries.
Venous drainage was achieved with use of the internal or external jugular veins in the neck or the
internal thoracic vein in the chest. In the case of
gastric conduits, the graft artery was the RGEA
and the graft vein was a transferred gastroepiploic vein. The majority of patients had both an
arterial and venous anastomosis performed. Of
the 82 reconstructions, only two had leaks, none
requiring reoperation, and only two patients had
conduit necrosis with one requiring reoperation
[22]. Of note, thrombosis in the anastomosis did
occur in three patients intraoperatively, and in
each case, redoing the anastomosis was successful.
In another series, nine patients had “supercharging” performed and seven of these involved
a gastric conduit. In preparing the stomach, the
LGEA was ligated proximally, close to its origin
from the splenic artery. Subsequently, the LGEA
was anastomosed to the transverse cervical artery
in an end-to-end fashion using 9
operative
blood flow measurements were taken
-0 nylon. Intra-
at the fundus of the stomach and, in each case,
flow increased after this microvascular anastomosis. None of the nine patients experienced a
leak postoperatively [23].
In a study by Murakami and colleagues, they
evaluated “supercharging” for use in total esophagectomy with pharyngogastrostomy. In this series of 11 patients, none experienced a leak or
conduit necrosis postoperatively. Additionally,
they found that performing only a venous anastomosis increased mean blood flow to the gastric
fundus by 19
% using laser Doppler flowmetry,
whereas performing both an arterial and venous
anastomosis resulted in a 43 % increase in flow
to this same region [24]. In a subsequent study
,
the authors found that performing a microvascular anastomosis procedure in subtotal esophagectomy was associated with a significantly lower
likelihood of postoperative leak compared to a
control group which did not have any microvascular anastomoses [25].
While the target and choice of recipient and
graft vessels vary considerably in different descriptions of “supercharging,” the basic tenets
of augmenting blood flow to an area of relative
ischemia remain consistent. Although these studies were all associated with increased operative
times, serious consideration should be given to
performing additional microvascular anastomoses in the presence of a questionably viable