Reconstruction after esophagectomy in patients with [partial] gastric resection. Case report and review of the literature of the use of remnant stomach
© Dionigi et al; licensee BioMed Central Ltd. 2006
Received: 07 January 2006
Accepted: 26 April 2006
Published: 26 April 2006
Bowel reconstruction after subtotal esophagectomy represents a problem when a previous distal gastrectomy was performed: usually the colon or jejunum is used.
In a 10 year period 126 patients with primary esophageal cancer underwent esophageal resection in our Department. Surgical procedures were 57% two-phase subtotal oesophagectomy, 23% transhiatal, 9% stripping, 10 three-phase total esophagectomy and 2 endoscopic resections.
In 112 patients alimentary tract reconstruction was achieved by means of esophago-gastric anastomosis. Reconstruction was performed using colon in 10 cases and jejunum in 2. We describe the technical aspects of esophagectomy and gastric reconstruction in a patient with previous antrectomy and Billroth II reconstruction. The procedure was performed via a combined laparotomy and thoracotomy with anastomosis at the level of the azygous vein using the remnant stomach.
Few technical reports have been reported in literature about the use of remnant stomach in reconstruction for subtotal esophagectomy subsequent to distal gastrectomy. Several hypotheses are made to explain the maintenance of the gastric vascular integrity as its intramural network without micro-vascular anastomosis.
In a 10° year period between 1994 and 2004, 126 patients with primary esophageal cancer underwent esophageal resection in our Department of Surgery. Surgical procedures were: 74 (57%) two-phase subtotal oesophagectomy, 30 (23%) transhiatal, 10 (9%) stripping, 10 three-phase subtotal esophagectomy and 2 other procedures (endoscopic resections). After esophageal resection for carcinoma reconstruction of the alimentary tract can be achieved using stomach, colon or jejunum. When technically possible the stomach is the organ of choice, since esophago-gastric anastomosis has been demonstrated to present a lower incidence of complications (i.e. leakages). Colon or jejunum may be used in patients previously undergone to partial gastric resection or total gastrectomy. This is confirmed by our experience: in 112 patients (90%) with primary esophageal cancer, alimentary tract reconstruction was achieved by means of esophago-gastric anastomosis. Reconstruction was performed using colon in 10 (8%) cases and jejunum in 2 (2%). One patient had previously undergone partial gastrectomy and manifested a lower thoracic esophageal carcinoma. Two-phase subtotal esophagectomy was carried out and reconstruction was achieved using the remnant stomach without micro-vascular anastomosis. We wander why gastric remnant in patients who previously received partial gastric resection has not been widely used and if this is a surgical axiom or it is unquestionably demonstrated that it is not technically possible [1, 2].
Pathological examination revealed a squamous cell tumour of 23 mm in diameter pT3, pN0, M0, R0, G2 (Stage IIA). None coexisting neoplastic lesion was found in the resected esophagus. Evidence of areas of mild dysplasia and esophagitis of the noncancerous esophageal mucosa surrounding the cancer lesion and at the esophagogastric junction was randomly observed. None of the 15 lymph nodes dissected were involved. Postoperative course was uneventful. On follow-up, two years after operation, the patient was alive without evidence of recurrence. The patient had an improved intake of food, mainly managing a semi-solid diet with an average intake per meal was 400–500 mL. Endoscopy findings, barium meal contrast exam and angio-CT scan confirmed good vascularity of the jejunal flap and stomach.
The relationship between previous gastrectomy and subsequent occurrence of primary malignant esophageal tumour remains controversial. Maeta reported that of 129 patients surgically treated for esophageal cancer 12 (9%) had previously undergone partial gastrectomy . A possible explanation is that the development of esophageal cancer after gastrectomy is related to post-gastrectomy nutritional changes and/or post-operative gastroesophageal reflux [1, 2]. Usually the interval between gastrectomy and esophagectomy is shorter in patients who underwent gastrectomy for gastric cancer compared with those who underwent gastrectomy for peptic ulcer . Furthermore, the interval between gastrectomy and development of oesophageal cancer in patients who underwent Billroth I reconstruction is reported to be shorter compared with those who underwent Billroth II reconstruction . Reconstruction after subtotal esophagectomy could represent a serious problem when a previous gastric resection has been performed. Colon or jejunum are more frequently used. Few technical reports have been reported in literature about the use of remnant stomach in reconstruction for subtotal esophagectomy subsequent to distal gastrectomy [3, 4]. We presented a case of a patient with distal oesophageal cancer previously treated with partial gastrectomy. Reconstruction has been achieved using the remnant stomach without micro-vascular anastomosis. At the end of the procedure, the macroscopic aspect of the remnant stomach appeared to have an adequate bloody supply; thus no other options such as short segment jejunal interposition or direct Roux-y esophagojejunostomy were performed. Moreover, not infrequently, the marginal artery is found to be insufficient calibre to maintain viability of a transposed colon.
Several hypothesis can be made: the reconstituted microvascular supply from the anastomosed efferent jejunal loop with its wide gastrojejunal anastomosis contributed to the maintenance of the gastric vascular integrity as its intramural network. Vascular adaptation is a more likely hypothesis for the adequate blood supply than jejunal vessels: Reavis demonstrated that the delay effect is associated with both vasodilation and angiogenesis and results in increased blood flow to the gastric fundus prior to esophagogastric anastomosis in animals: delayed operations have less anastomotic collagen deposition and ischemic injury than those undergoing immediate resection . Clinical application of the delay effect in patients undergoing esophagogastrectomy may lead to a decreased incidence of leak and stricture formation.
At the third post-operative month, an angio-CT scan, demonstrated good vascularity of the jejunal flap and residual stomach without any vascular congenital abnormality of the aorta and its branches. The prepared stomach roll was pulled up in continuity with the efferent loop with posterior mediastinal route as it provides the shortest distance between abdomen and the thorax. A sufficient long jejunal flap must be needed. Pre-operative and intra-operative assessments revealed the stomach had an adequate length. Previous gastrectomy often causes strict adhesions between the mesocolon and the adjacent organs, making difficult the use of colon for reconstruction. The reduction in number of surgical manoeuvres beneath the transverse colon and few bowel anastomosies represent a real advantage. Chen and Lu proposed the resection of the tumour through left thoracotomy, preserving the left short gastric artery and transporting the residual stomach, the spleen and tail of the pancreas into the left thoracic cavity, and using the residual stomach to reconstruct the alimentary tract and preserve vascular integrity of the stomach . Matsubara proposed micro-vascular anastomosis . There are still some questions: first, a previous gastric procedure with additional nodal dissection might result in changing the pattern of lymph node spreading of a distal oesophageal cancer. Second, it is important to obtain adequate clear margins using the remnant stomach as an oesophageal substitute. The remnant stomach after partial gastrectomy should not be used as esophageal substitute if you pretent to perform cervical anastomosis. There is no data available in literature of the micro-vascularization of the remnant stomach and the role of the efferent stump and the length gastrojejunal anastomosis in maintaining the blood support to the stomach . Periodic surveillance is mandatory in patients who had partial gastrectomy and, if oesophageal cancer is present, its location and stage must be determined.
Finally, in the authors' experience, this technique proved to be efficient with no postoperative complication and long follow-up. The technique must be performed in Institutions with well-trained surgeons and high volume UGI procedures. We recommend further reports to verify the usefulness of the proposed technique.
The Authors are grateful to Professor S. Michael Griffin and Mr. S. Preston, Northern Oesophago Gastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne (UK) for general support, technical assistance and helpful discussion.
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