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Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report.

Hackl C, Popp FC, Ehehalt K, Dendl LM, Benseler V, Renner P, Loss M, Dolderer J, Prantl L, Kühnel T, Schlitt HJ, Dahlke MH - BMC Surg (2014)

Bottom Line: A proximal-release stent was successfully placed by gastroscopy and the patient was discharged.Microvascular anastomoses were performed subsequently.The proximal anastomosis of the conduit was completed manually after reperfusion.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgery, University Medical Center Regensburg, Regensburg 93042, Germany. marc.dahlke@ukr.de.

ABSTRACT

Background: Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system.

Case presentation: A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion.

Conclusions: This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy.

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Related in: MedlinePlus

Diagnosis of ESSC, Esophagectomy and Esophagostomy after conduit failure. A) Workup including esophageal fluoroscopy at first presentation of the patient revealed an ESSC at 20-25 cm from the incisors. B) Status post Ivor-Lewis thoraco-abdominal esophagectomy with gastric pull-up and circular end-to-side stapled cervical anastomosis. C) Status post cervical esophagostomy and stump closure of the gastric pull-up conduit, which remained in situ within the right hemithorax.
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Figure 1: Diagnosis of ESSC, Esophagectomy and Esophagostomy after conduit failure. A) Workup including esophageal fluoroscopy at first presentation of the patient revealed an ESSC at 20-25 cm from the incisors. B) Status post Ivor-Lewis thoraco-abdominal esophagectomy with gastric pull-up and circular end-to-side stapled cervical anastomosis. C) Status post cervical esophagostomy and stump closure of the gastric pull-up conduit, which remained in situ within the right hemithorax.

Mentions: A 56 year-old caucasian female patient was referred with the diagnosis of esophageal squamous cell carcinoma (ESSC). The patient had a history of smoking (55 pack-years) and moderate alcohol consumption. Work-up including fluoroscopy, thoraco-abdominal CT scan, gastroscopy, bronchoscopy and blood works confirmed the diagnosis of a circular ESSC at 20-25 cm from the incisors (Figure 1A) with no suspect lymph nodes and no distant metastasis. After case discussion in an interdisciplinary disease management board, the patient underwent 2 cycles of neoadjuvant radiochemotherapy (cisplatin 60 mg/m2; 5-FU 1000 mg/m2; 45 Gy). A re-staging thoracoabdominal CT scan showed significant decrease in tumor size. Ivor-Lewis thoracoabdominal esophagectomy with gastric pull-up and circular end-to-side stapled cervical anastomosis (21 mm) was then performed as planned (Figure 1B). The operation included three-field lymphadenectomy, resection of the Azygos vein, cholecystectomy and insertion of a fine-needle catheter jejunostomy (FCJ) for early postoperative enteral nutrition. Histologic analysis confirmed a ypT2, ypN0, L0, V0, R0 G2 ESCC. The patient was transferred from surgical ICU to the normal surgical ward on post-operative day 5, eating strained food, supplemented by FCJ-feeding. Due to increasing CRP and leucocytosis on post-operative day 8, a thoraco-abdominal CT scan and EGD transit were performed and an anastomotic leakage with viable perfusion of the conduit was diagnosed. A proximal-release stent was successfully placed by endoscopy. After prolonged recovery from the resulting sepsis, the patient could be discharged in good clinical condition and eating regular diet on post-operative day 56. Two weeks after discharge, the patient presented with symptoms of pneumonia and was readmitted. Workup including blood-works, thoraco-abdominal CT scan, bronchoscopy and gastroscopy revealed an esophagotracheal fistula cranial to the esophageal stent, not associated with the primary cervical anastomosis. After unsuccessful tracheal stenting and no possible further interventional improvement, the fistula was resected and cervical esophagostomy was performed with tracheal reconstruction by a sternoflap. The stump of the gastric pull-up conduit was closed using 3/0 monocryl hand-sewn interrupted suture and the intrathoracic part of the conduit remained in situ within the right hemithorax (Figure 1C). The patient could be transferred from surgical ICU to the normal ward on post-operative day 4 and was discharged on post-operative day 27. At routine follow-up three months later, the patient presented in good general condition. Restaging remained without new evidence of disease and free jejunal interposition was scheduled.


Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report.

Hackl C, Popp FC, Ehehalt K, Dendl LM, Benseler V, Renner P, Loss M, Dolderer J, Prantl L, Kühnel T, Schlitt HJ, Dahlke MH - BMC Surg (2014)

Diagnosis of ESSC, Esophagectomy and Esophagostomy after conduit failure. A) Workup including esophageal fluoroscopy at first presentation of the patient revealed an ESSC at 20-25 cm from the incisors. B) Status post Ivor-Lewis thoraco-abdominal esophagectomy with gastric pull-up and circular end-to-side stapled cervical anastomosis. C) Status post cervical esophagostomy and stump closure of the gastric pull-up conduit, which remained in situ within the right hemithorax.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4202252&req=5

Figure 1: Diagnosis of ESSC, Esophagectomy and Esophagostomy after conduit failure. A) Workup including esophageal fluoroscopy at first presentation of the patient revealed an ESSC at 20-25 cm from the incisors. B) Status post Ivor-Lewis thoraco-abdominal esophagectomy with gastric pull-up and circular end-to-side stapled cervical anastomosis. C) Status post cervical esophagostomy and stump closure of the gastric pull-up conduit, which remained in situ within the right hemithorax.
Mentions: A 56 year-old caucasian female patient was referred with the diagnosis of esophageal squamous cell carcinoma (ESSC). The patient had a history of smoking (55 pack-years) and moderate alcohol consumption. Work-up including fluoroscopy, thoraco-abdominal CT scan, gastroscopy, bronchoscopy and blood works confirmed the diagnosis of a circular ESSC at 20-25 cm from the incisors (Figure 1A) with no suspect lymph nodes and no distant metastasis. After case discussion in an interdisciplinary disease management board, the patient underwent 2 cycles of neoadjuvant radiochemotherapy (cisplatin 60 mg/m2; 5-FU 1000 mg/m2; 45 Gy). A re-staging thoracoabdominal CT scan showed significant decrease in tumor size. Ivor-Lewis thoracoabdominal esophagectomy with gastric pull-up and circular end-to-side stapled cervical anastomosis (21 mm) was then performed as planned (Figure 1B). The operation included three-field lymphadenectomy, resection of the Azygos vein, cholecystectomy and insertion of a fine-needle catheter jejunostomy (FCJ) for early postoperative enteral nutrition. Histologic analysis confirmed a ypT2, ypN0, L0, V0, R0 G2 ESCC. The patient was transferred from surgical ICU to the normal surgical ward on post-operative day 5, eating strained food, supplemented by FCJ-feeding. Due to increasing CRP and leucocytosis on post-operative day 8, a thoraco-abdominal CT scan and EGD transit were performed and an anastomotic leakage with viable perfusion of the conduit was diagnosed. A proximal-release stent was successfully placed by endoscopy. After prolonged recovery from the resulting sepsis, the patient could be discharged in good clinical condition and eating regular diet on post-operative day 56. Two weeks after discharge, the patient presented with symptoms of pneumonia and was readmitted. Workup including blood-works, thoraco-abdominal CT scan, bronchoscopy and gastroscopy revealed an esophagotracheal fistula cranial to the esophageal stent, not associated with the primary cervical anastomosis. After unsuccessful tracheal stenting and no possible further interventional improvement, the fistula was resected and cervical esophagostomy was performed with tracheal reconstruction by a sternoflap. The stump of the gastric pull-up conduit was closed using 3/0 monocryl hand-sewn interrupted suture and the intrathoracic part of the conduit remained in situ within the right hemithorax (Figure 1C). The patient could be transferred from surgical ICU to the normal ward on post-operative day 4 and was discharged on post-operative day 27. At routine follow-up three months later, the patient presented in good general condition. Restaging remained without new evidence of disease and free jejunal interposition was scheduled.

Bottom Line: A proximal-release stent was successfully placed by gastroscopy and the patient was discharged.Microvascular anastomoses were performed subsequently.The proximal anastomosis of the conduit was completed manually after reperfusion.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Surgery, University Medical Center Regensburg, Regensburg 93042, Germany. marc.dahlke@ukr.de.

ABSTRACT

Background: Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system.

Case presentation: A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion.

Conclusions: This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy.

Show MeSH
Related in: MedlinePlus