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98 R. Rajaram and M. M. DeCamp
RGEA. If an injury to the RGEA is sustained intraoperatively, or excessive stretch of this vessel
is a concern, the use of “supercharging” as an adjunct may salvage use of the gastric conduit. It is
worth noting that no studies have systematically
looked at use of this technique in the context of a
damaged or injured RGEA. Nevertheless, awareness and consideration of “supercharging” may
prove timely when an injury does occur and few
other options are available to supplement blood
flow to the conduit.
Venous Drainage
The importance of alleviating stagnant venous
drainage, as done in “supercharging, ” has been
addressed by other means as well. One example
of this is by transient bloodletting from the short
gastric vein. In one study, the authors found that
30 min of bloodletting after creation of the gastric tube resulted in a significant increase in tissue
blood flow at the esophagogastric anastomosis
shortly afterwards. Flow remained elevated from
baseline after bloodletting ceased although this
was not significant [26]. Nonetheless, in a patient
with a compromised RGEA, it is necessary to attenuate venous congestion as much as possible
and allow for appropriate inflow to the proximal
region of the stomach. Transient venous bloodletting, while technically cumbersome, may help
in achieving this and should be considered a tool
in the surgeon’s armamentarium during esophagectomy.
Conclusion
Esophageal reconstruction with use of the gastric conduit has become an established method
of preserving alimentary continuity following
esophagectomy. Although the risk of esophageal
leak or necrosis is not insignificant following
this surgery, techniques may be employed to improve postoperative success. These techniques
center primarily upon preserving and augmenting the bloody supply the RGEA provides to the
gastric tube. A detailed medical and surgical history with consideration of dedicated preoperative vascular imaging in high-risk patients is a
necessary first step. Intraoperatively, early identification of this vessel with meticulous dissection is required to ensure that this vessel is kept
intact. Transposition of the gastric conduit to
the chest or neck should be done carefully with
particular attention given to avoiding excessive
twisting of this vessel and creating a tension-free
reach. Finally, the surgeon should consider the
use of novel procedures such as “angleplasty”
or “supercharging” if there is persistent concern
for a tenuous blood supply. With deliberate use
of the steps outlined in this chapter, the likelihood of an injury to the RGEA is minimized and
the resulting success of the operation optimized
postoperatively.
Five Key Points: Avoiding Injury to the Right Gastroepiploic Artery
1. After gaining exposure, identify the right gas-
troepiploic artery early in the course of the op-
eration and determine if any aberrant anatomy
is present.
2. Ensure a buffer zone of at least 2.0 cm from
the visible, palpable, or “dopplerable” right
gastroepiploic artery when separating the
greater omentum from the greater curvature
of the stomach.
3. Ensure careful separation of the gastrocolic
ligament, omentum, and transverse mesoco-
lon as you approach the pylorus during the
greater curvature dissection to avoid a proxi-
mal pedicle injury.
4. Delicate care should be taken when mobiliz-
ing or repositioning the gastric conduit into
the chest or neck to prevent excessive longitu-
dinal tension, kinking, or torsion on the right
gastroepiploic arcade.
5. After mobilization, evaluate the right gastro-
epiploic artery at the diaphragmatic hiatus to
assess for excessive impingement that may re-
sult in vascular compromise.
999 Injury to the Right Gastroepiploic Artery
Five Key Points: Diagnosing and/or
Managing the Complication Intraoperatively or Postoperatively
1. If concerned about vascular compromise,
make liberal use of the Doppler to evaluate
the pedicle and fundic region of the stomach
to assess appropriate blood flow.
2. Consider additional intraoperative techniques
in the conduit with a tenuous, but viable, right
gastroepiploic arterial supply such as “angleplasty” to relieve tension or “supercharging”
to improve inflow and/or venous drainage.
Consider revising the operative plan
3.
to allow a
shorter conduit if oncologically feasible, e.g.,
an intrathoracic versus cervical anastomosis.
Consider converting to a pedicled jejunal
4.
or
colonic interposition graft if irreparable damage has been done to the right gastroepiploic
artery.
Avoid perioperative alpha agonists and vaso
5.
pressors that may decrease splanchnic outflow
in the setting of an already tenuous right gastroepiploic artery.
References
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Briel JW, T
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al. Revascularization using
Intra-Operative Solutions for Ischemic Gastric Conduit
Robert E. Merritt
10
Gastric Esophageal Replacement Conduit
The stomach has supplanted the colon and the
small intestine as the esophageal replacement
conduit of choice. The stomach has a constant
blood supply, which includes the right and left
gastroepiploic arteries and veins, the left and
right gastric artery and veins, and the short gastric vessels. The stomach is easily be mobilized
by dividing the gastro-colic, gastro-hepatic, and
gastro-splenic ligaments (See Fig. 10.1). The
stomach can easily be used to replace the esophagus for both transthoracic esophagectomy and
transhiatal esophagectomy. The stomach can be
constructed into a tubular conduit and an esophagogastric anastomosis can be performed in the
upper thorax, which is typically done as part of
an Ivor Lewis esophagectomy. The esophagogastric anastomosis should be performed at the
level of the azygous vein or higher. The stomach
can also be transposed into the neck for a cervical
esophagogastric anastomosis as described in the
transhiatal esophagectomy. There are four major
factors to consider when mobilizing the gastric
conduit, which have significant ramifications for
gastric conduit ischemia or necrosis [1].
R. E. Merritt ()
Department of Surgery, Division of Thoracic Surgery,
The Ohio State University Wexner Medical Center,
Columbus, OH, USA
e-mail: robert.merritt@osumc.edu
1. The right gastroepiploic artery is the main
arterial blood supply to the gastric conduit and
should be preserved in every case. The gastoepiploic vein is equally important and any
direct manipulation of the gastroepiploic vascular arcade should be avoided. The adequacy
of arterial blood flow within the artery can be
tested with a Doppler probe intraoperatively
if there are concerns about an injury to the
arcade.
2. The intraoperative surgical margins on the
gastric conduit should be assessed prior to
the esophagogastric anastomosis. This can be
a particular challenge for large GE (gastrointestinal junction) junction tumors that extend
into the gastric fundus. The gastric conduit
should not be narrower than 4 cm in diameter.
3. The gastric fundus should be maintained in
order to provide adequate length of the gastric
conduit. This principle becomes very important when the esophagogastric anastomosis
needs to be performed in the cervical neck,
where adequate length of the gastric conduit is
essential to avoid tension on the anastomosis.
4. The shape and diameter of the conduit is an
important consideration in terms of gastric
emptying. The conduit should ideally be
4–5 cm in diameter. Large and patulous gastric conduits may not empty well, which results in delayed gastric emptying. Large and
dilated gastric conduits may result in venous
congestion and may possibly contribute to
conduit ischemia.
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_10,
© Springer Science+Business Media New York 2015
101
102 R. E. Merritt
Fig. 10.1 The gastro-colic ligament is divided with a li-
gasure device along the greater curvature of the stomach.
The right gastroepiploic arteriovenous arcade should be
preserved during the dissection. Injury to the gastroepiploic arteriovenous arcade would result in immediate gastric conduit ischemia
The preservation of the right gastroepiploic
ateriovenous arcade is sufficient to sustain the
gastric conduit after mobilization [2]. The left
and right gastric artery arcades can be routinely
divided without increased risk for ischemia because approximately 60 % of the blood supply
comes from the right gastroepiploic arteriovenous arcade [3]. The ideal width of the gastric
conduit should be 4–5 cm in diameter. The gastric conduit is created by dividing the mobilized
stomach along the lesser curvature with a linear
endo-mechanical stapler (See Fig. 10.2). Gastric
conduits that are too narrow can result in gastric
tip necrosis due to the poor collateral circulation
in the submucosa of the gastric fundus [4]. The
gastric conduit is typically passed through the
esophageal hiatus and the intrathoracic anastomosis is performed at the level of the azygous
vein. The esophageal hiatus should be widened
enough to avoid compression of the esophageal
conduit and subsequent venous stasis.
The incidence of gastric conduit ischemia
and necrosis depends largely on the technique
that was used to mobilize the stomach. The occurrence of an anastomotic leak and/or stricture
is largely related to the incidence of ischemia of
Fig. 10.2 The gastric conduit is created by dividing the
stomach along the greater curvature with a linear endomechanical stapler. A tubular gastric conduit is created,
which should measure 4–5 cm in diameter for maximal
conduit perfusion and functional emptying
the gastric conduit. The incidence of anastomotic complications varies in the reported studies
with a range of 0–24 % [5–8]. Kassis et al. recently reported an overall anastomotic leak rate
of 12.3 % for cervical anastomoses and 9.3 %
for intrathoracic anastomosis in a large series of
7595 esophageal resections from the Society of
Thoracic Surgeons (STS) database [9]. Orringer
et al. reported a large series of 1085 transhiatal
esphagectomies, which reported an anastomotic
leak rate of 13 % and a gastric conduit necrosis
rate of 2.6 % [10]. The higher rate of gastric conduit ischemia/necrosis encountered with the cervical esophagogastric anastomosis is thought to
be related to the possible compression from the
mediastinum and/or the thoracic inlet. The overall incidence of gastric conduit necrosis ranges
from 0.5 to 10.4 % [10–15]. The reported series
are summarized in Table 10.1.
The predisposing factors for gastric conduit
necrosis include direct injury to the gastroepiploic
ateriovenous arcade, external compression of the
gastric conduit, low perioperative blood pressure,
and excessive manipulation of the gastric conduit. The risk of gastric conduit necrosis can be
minimized with meticulous operative technique
Tab le 10 .1 Esophagectomy series reporting the incidence of esophageal conduit necrosis
Series # Patients Mortality (%) Anastomosis leak (%) Conduit ischemia (%)
Orringer [10] 1085 4 13 2.6
Peracchia [11] 242 0.8 5.8 1.2
Davis [12
Shuchert [13
Briel [14
Moorehead [15
]
]
]
959 10.6 3.9 0.5
222 1.4 – 3.2
230 3.5 14.3 10.4
760 3.8 – 1.0
]
10310 Intra-Operative Solutions for Ischemic Gastric Conduit
for mobilization of the stomach and creation of
the gastric tube. The gastroepiploic arcade should
be identified intraoperatively with gentle palpation or by Doppler probing. The localization of
the primary blood supply to the gastric conduit
should minimize the risk of direct injury. In addition, the author recommends checking for twisting of the gastric conduit prior to the anastomosis
and ensuring that the esophageal hiatus is not
compressing the gastric conduit.
Diagnosis of Gastric Conduit Ischemia
The early recognition and diagnosis of gastric
conduit necrosis is critical to minimizing the risk
of perioperative mortality. The clinical signs and
symptoms of gastric conduit necrosis depend
on the degree of ischemia and the extent of the
esophagogastric leak. Patients often develop
tachycardia, leukocytosis, metabolic acidosis,
and altered mental status. The patients can potentially develop florid sepsis and respiratory failure
requiring intensive care unit (ICU) admission,
mechanical ventilation, and vasopressor support.
The contrast esophagogram should demonstrate
extravasation of the contrast consistent with an
anastomotic leak (See Fig. 10.3a, b). An upper
endoscopy can be performed with minimal insufflation to assess the esophagogastric anastomosis
and the mucosa of the gastric conduit can be evaluated for ischemia or frank necrosis. A computed
tomography (CT) scan of the thorax can also be
obtained to evaluate for the evidence of an anastomotic leak, such as pneumomediastinum, pleural effusion, or disruption of the esophagogastric
anastomosis. For patients with cervical anasto-
moses, the neck incision can be opened directly
to inspect for drainage from the anastomosis and
assess the fundus for ischemia or necrosis.
The appropriate management and treatment
of gastric conduit ischemia/necrosis is crucial
to the survival of the patient. In cases in which
the ischemia is mild and the manifestation is an
anastomotic leak that is contained, the patients
can be managed with bowel rest, intravenous
antibiotics, and drainage. In patients with anastomotic leaks and associated mediastinitis and
empyema, a reoperation is necessary to drain any
purulent fluid and to debride the mediastinum
and the intrathoracic cavity. The disrupted area of
the esophagogastric anastomosis can be repaired
primarily if the gastric conduit has adequate arteriovenous perfusion. The necrotic material of
the edges of the esophagus and gastric conduit
should be debrided before embarking on the primary repair. The author prefers to use interrupted
nonabsorbable suture to re-approximate the anastomosis. A pleural flap or intercostal muscle flap
can be used to cover the repaired anastomosis. In
certain cases, the gastric conduit will be found to
be severely ischemic, and there is a tissue necrosis present. In this situation, the gastric conduit
cannot be preserved and an esophageal diversion
should be performed. The gastric conduit should
be dissected down to the esophageal hiatus and
divided with a linear stapler. The staple-line
should be over-sewn to minimize the risk of a bile
leak into the thorax. The esophageal anastomosis
is also resected and a cervical esophagostomy
is fashioned below the level of the left clavicle.
This location is better for the placement of an ostomy bag and for the concealment of the ostomy
under clothing. The placement of a functioning
104 R. E. Merritt
Fig. 10.3 a A contrast esophagogram demonstrates con-
trast extravasation consistent with an esophagogastric
anastomotic leak. b A contrast esophagogram demonstrates contrast collecting in the mediastinum consistent
with a large anastomotic leak
jejunostomy tube is essential for adequate enteral nutrition and hydration during the period of
esophageal diversion. After the patient has recovered from the operation, a staged reconstruction
can be planned for 3–6 months after esophageal
diversion. The author prefers to utilize the supercharged pedicled jejunal interposition technique for reconstruction of the gastrointestinal
tract [16]. During this procedure, a Roux-en-y
limb of jejunum is harvested and passed through
a substernal tunnel. The left clavicle head and
hemi-manubrium are resected to provide space
for the jejunal limb and avoid compression. The
ateriovenous pedicle of the jejunal limb is then
anastomosed to the left internal mammary vein
and artery to provide “super-charged” perfusion.
A two layer hand-sewn esophago-jejunostomy is
performed to restore gastrointestinal continuity.
Blackmon et al. reported a series of 60 patients
who underwent super-charged pedicled jejunal interposition for esophageal replacement in
which 83 % of the patients were able to achieve a
return to a regular diet [16].
There have been a number of techniques that
were proposed for the prevention of gastric tube
ischemia/necrosis. Urschel hypothesized that
ischemic conditioning of the gastric fundus could
be achieved by dividing the left gastric arteriovenous pedicle prior to a planned esophagectomy
[17]. Patients would undergo a staging laparoscopy 1–4 weeks prior to the esophagectomy. The
left gastric pedicle would be divided at the time
of laparoscopy to “pre-condition” the gastric
fundus for ischemia. This concept has not been
proven to be effective in preventing gastric conduit necrosis. Similarly, Sekido et al. reported the
results of performing microsvascular augmentation for the gastric conduits that appeared ischemic immediately after the gastric mobilization
[18]. Two patients underwent a venous—venous
anastomosis and one patient underwent an arterial augmentation with improved gastric conduit
outcome.
10510 Intra-Operative Solutions for Ischemic Gastric Conduit
Summary
The occurrence of gastric conduit ischemia/necrosis after esophagectomy remains the most
challenging postoperative complication to manage. The incidence of this complication is relatively low; however, the impact on perioperative
mortality is significant when the gastric conduit
necrosis occurs. In the postoperative period, surgeons should be attuned to recognizing the early
clinical signs of conduit necrosis, such as new
onset tachycardia, respiratory failure, or mental
status changes. The diagnosis can be determined
with contrast esophagography and/or direct inspection of the gastric mucosa with endoscopy.
In cases of frank gastric conduit necrosis, a takedown of the esophagogastric anastomosis and
resection of the ischemic gastric conduit is indicated. The esophageal diversion procedure is
completed by creating a cervical esophagostomy.
Patients can be reconstructed with either a jejunal interposition graft or a colonic interposition
graft after 3–6 month recovery period. The best
strategy to minimize the risk of the gastric conduit necrosis is prevention. Meticulous dissection
of gastric conduit and preservation of the right
gastroepiploic arteriovenous arcade will help ensure excellent conduit function and healing. In
addition, careful patient selection is important to
avoid postoperative cardiopulmonary dysfunction that directly impacts the vascular perfusion
to the gastric conduit during the postoperative
period. Clearly, more research needs to be conducted to better predict which patients are at high
risk for the gastric conduit ischemia/necrosis and
to improve intraoperative assessment of the gastric conduit perfusion.
Key Points for Avoiding Gastric Conduit Necrosis
• Avoid direct injury to the gastroepiploic
ateriovenous arcade.
• Ensure that there is no external compression
of the gastric conduit as it passes through the
esophageal hiatus.
• The diameter of the gastric conduit should be
4–5 cm.
• Preserve the gastric fundus for maximal gas-
tric conduit length.
• Avoid perioperative hypotension and hypox-
emia to minimize decreased arteriovenous
perfusion to the gastric conduit.
Key Points for Managing Gastric Conduit Necrosis Postoperatively
• Recognize the early signs of conduit necrosis,
such as tachycardia, hypotension, leukocyto-
sis, respiratory dysfunction, and altered men-
tal status.
• Patients with gastric conduit necrosis and
anastomotic dehiscence require an esophageal
diversion with formation of an esophagos-
tomy.
• A functional jejunostomy tube is essential for
nutritional support and hydration after esoph-
ageal diversion.
• A supercharged jejunal interposition or colon
interposition can be used for esophageal
reconstruction after the esophageal diversion.
• Ischemic preconditioning or vascular aug-
mentation have limited evidence of efficacy
in the prevention of gastric conduit necrosis.
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al. Supercharged ped
al. Use of “superchar
al. Preva-
R, Chevray
of the stomach
ge”
-
Jejunal Feeding Tube Complications
Sidhu P. Gangadharan
11
Introduction
Adequate nutrition in patients undergoing treatment for esophageal pathology is crucial. Dysphagia and odynophagia may lead to malnutrition
at presentation. Treatment, whether chemoradiation or surgery, may also lead to impaired ability to take adequate nutrition. While this is typically temporally limited, at times it may be more
chronic. Malnutrition increases the risk of postoperative complications in patients undergoing
surgery for esophageal cancer [1–4]. Intensive
nutritional support has been found to improve
outcomes of esophagectomy, particularly in patients who undergo neoadjuvant chemoradiation
[5]. Weight gain is improved and the incidence of
severe postoperative complications is decreased
in patients in whom nutrition is optimized. A
randomized trial of nutritional supplementation
noted that patients who received preoperative
supplementation and patients who received both
preoperative plus postoperative supplementation
with a formula enriched with arginine, omega-3
S. P. Gangadharan ()
Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185
Pilgrim Rd, W/DC 201, Boston, MA, USA 02215
e-mail: sgangadh@bidmc.harvard.edu
Harvard Medical School, Boston, MA, USA
fatty acids, and RNA revealed similar levels of
significant improvement when compared with a
control group with no supplemental nutrition [6].
However, in some patients, oral intake is
not sufficient to realize these benefits, and tube
feeding must be used to supplement or replace
food by mouth. In cases where this might be
thought to be transient, a nasally placed enteric
tube may suffice. However, for longer-term use,
a feeding tube that accesses the bowel directly
may be preferable, especially with a high rate
of dislodgement of a nasally-placed tube [7]. At
esophagectomy, the standard practice is to place
a feeding tube to allow more rapid resumption
of enteric nutrition if a pre-esophagectomy tube
had not already been placed. Recent studies have
questioned whether this routine practice is necessary, noting that a benefit with regard to length
of stay, infectious complications, or anastomotic
leak has not been definitively demonstrated [8].
Nevertheless, given the minimal additional time
needed to place feeding jejunostomy tubes, and
the hedge against future issues such as anastomotic stricture or delayed gastric conduit emptying leading to poor oral intake, most surgeons
still believe in this practice. Dependence on tube
feeding outside of the initial postoperative period
(> 3 weeks) has been reported in over 10 % of patients undergoing esophagectomy [9].
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_11,
© Springer Science+Business Media New York 2015
107