When Stomach is Not Available

Transcription

1 When Stomach is Not Available Shanda Blackmon, M.D., M.P.H., FACS Associate Professor, Thoracic Surgery, Mayo Clinic 2014 MFMER slide-1

2 Objectives To review options for long-segment esophageal replacement To review equipment and techniques To share our outcomes and experience 2014 MFMER slide-2

3 Background 1st successful resection of the thoracic esophagus for carcinoma was performed by Torek near the turn of the century in a patient with esophageal carcinoma MFMER slide-3

4 Background Gastrointestinal continuity was established using an external "rubber tube" between a cervical esophagostomy and gastrostomy The patient survived for 13 yrs and was able to swallow liquified food 2014 MFMER slide-4

5 Background Immediate reconstruction of the gastrointestinal tract after an esophagectomy with an esophagogastrostomy did not occur until the mid 1930s 2014 MFMER slide-5

6 Esophageal Replacement Options The gastric conduit is standard of care in most circumstances 2014 MFMER slide-6

7 The Dreaded Dead Conduit 2014 MFMER slide-7

8 Indications for Alternate Conduits: Dead gastric conduit Injury to GE Vessel Cancer extending Into eso & stomach Recurrence of esophageal tumor 1, 2 1. Schipper PH, Cassivi SD, Deschamps C, Rice DC, Nichols FC 3rd, Allen MS, Pairolero PC. Locally recurrent esophageal carcinoma: when is reresection indicated? Ann Thorac Surg Sep;80(3):1001-5; discussion Kim MP, Brown KN, Schwartz MR, Blackmon SH. Advanced esophageal cancer in patients who underwent radiofrequency ablation for barrett esophagus with high grade dysplasia. Innovations (Phila) Jan- Feb;8(1): MFMER slide-8

9 Esophageal Replacement Options Colon Jejunum 2014 MFMER slide-9

10 Esophageal Replacement Options: Jejunum Gaur P, Blackmon SH. Jejunal graft conduits after esophagectomy. J Thorac Dis May;6 Suppl 3:S MFMER slide-10

11 Congenital Variations in Jejunal Mesenteric Arcade Vascular Patterns 2014 MFMER slide-11

12 Reach of Jejunal Vascular Pedicle vs. Length of Bowel (unfurled) (1:3) 2014 MFMER slide-12

13 Dividing the Mesentery for a Long Jejunal Graft 2014 MFMER slide-13

14 Dividing the Bowel for a Long Jejunal Graft 2014 MFMER slide-14

15 Dividing the Mesentery for a Short Jejunal Graft 2014 MFMER slide-15

16 Pedicled Segmental jejunal Interposition as Roux antegastric retrogastric 2014 MFMER slide-16

17 Pedicled Segmental jejunal Interposition to Stomach 2014 MFMER slide-17

18 SPJ 2014 MFMER slide-18

19 SPJ 2014 MFMER slide-19

20 SPJ 2014 MFMER slide-20

21 2014 MFMER slide-21

22 SPJ 2014 MFMER slide-22

23 2014 MFMER slide-23

24 2014 MFMER slide-24

25 Indications To replace segmental esophagus (cervical) To reach the pharynx To replace entire length of esophagus when a gastric conduit is not available Blackmon SH, Correa AM, Skoracki R, Chevray PM, Kim MP, Mehran RJ, Rice DC, Roth JA, Swisher SG, Vaporciyan AA, Yu P, Walsh GL, Hofstetter WL. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-25

26 Experience From June 2000 to December 2010, 60 consecutive patients underwent SPJ 50 patients from MDACC ( ) 10 patients from HMH ( ) A database was created to evaluate patient characteristics, operative technique, and outcomes Blackmon SH, Correa AM, Skoracki R, Chevray PM, Kim MP, Mehran RJ, Rice DC, Roth JA, Swisher SG, Vaporciyan AA, Yu P, Walsh GL, Hofstetter WL. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-26

27 Results male Age female 44 (73%) > (27%) LOS > Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-27

28 Patient Characteristics Timing Primary immediate reconstruction 37 62% Reversal of discontinuity 23 38% Preoperative Therapy (Chemo +/-XRT) 25 42% Histology of Primary Adenocarcinoma 41 68% Squamous Cell 9 15% other 7 12% Not cancer 3 5% Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-28

29 Jejunal Route Operative Detail n % Posterior 21 35% mediastinum Retrosternal 39 65% Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-29

30 Jejunal Route Operative Detail n % Retrocolic 46 77% Antecolic 14 23% 2014 MFMER slide-30

31 Results: Anastomosis Operative Detail n % Neck Anastomosis Hand-sewn 51 85% Stapled side-to-side 8 13% Circular-stapled 1 2% Distal Connection Jejunum to stomach remnant 29 48% Jejunum to jejunum (Roux) 31 52% Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-31

32 Results: Graft Loss Operative Detail n % Intra-operative vascular revision 16 27% Intra-operative Graft loss 1 2% Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-32

33 Clinical Outcomes 90-day/Hosp mortality n = 6 Never reconstructed n=2 Never re-gained nutritional independence n=2 SPJ patients n = 60 survivors n = 54 graft loss n = 4 Intact n=52 ORAL DIET n=50 Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-33

34 Results: Operative Events Early Event n % Morbidity: Leak 19 32% Grade I 1 Grade II 9 Grade III 4 Grade IV 5 Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-34

35 Results: Post-operative Events Early Event n % Morbidity: Pneumonia 18 30% RLN Injury 10 17% NOMI 4 7% Jejunal Graft loss/diversion 5 8% Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-35

36 Results: Post-operative Events Late Events n % 90-day Mortality 6 10% Later Revision 7 12% Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-36

37 Swallow after SPJ Normal Swallow Manometry n = 5 Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-37

38 Conclusions SPJ can establish nutritional independence in a high-risk patient population when stomach is unavailable This is my preferred alternative for reconstruction when stomach is unavailable Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-38

39 Blackmon SH, Correa, AM, Skoracki R et al. SPJ interposition for esophageal replacement: A 10 year experience. Annals of Thoracic Surgery 2012;94(4): MFMER slide-39

40 How does the SPJ compare to a Gastric Conduit? 2014 MFMER slide-40

41 Super-Charged Pedicled Jejunal Interposition Performance Compares Favorably to a Gastric Conduit After Esophagectomy Stephens EH, 1 Gaur P, 2 Hotze KO, 2 Correa AM, 3 Kim MP, 2 Blackmon SH 4 1 Cardiothoracic Surgery, Columbia University, New York; 2 Thoracic Surgery, The Methodist Hospital, Houston; 3 MD Anderson, Houston; 4 Thoracic Surgery, Mayo Clinic, Rochester 2014 MFMER slide-41

42 Background Long segment esophageal reconstruction can be accomplished with supercharged jejunum (SPJ), colon, or stomach In patients in whom a gastric conduit is not possible, SPJ has advantages: Does not require formal preparation Usually free of disease Similar in diameter to esophagus Intrinsic segmental peristalsis May not undergo senescent lengthening Challenges with SPJ: micro-anastomoses Previous studies have examined peri-operative and long-term outcomes of SPJ, but its functionality has not been previously assessed. Objective: Assess the functionality of SPJ in comparison to gastric conduits 2014 MFMER slide-42

43 Methods A conduit functionality questionnaire was developed evaluating: Reflux Dumping Dysphagia Stricture Zubrod score (functional status) Post-op pain Conduit emptying (radiography) Preoperative/demographic, intraoperative, and postoperative data were prospectively collected on the 94 living patients who underwent esophageal reconstruction at HMH MFMER slide-43

44 Methods 45 of the 94 (48%) patients answered the questionnaire >1 month after surgery. For patients who completed multiple questionnaires, the worst score for each category was used. Statistical analysis was performed using SPSS (SPSS, Chicago, IL) and included Mann- Whitney u-test and Fisher s Exact Test for cross tabs with statistical significance defined as p< MFMER slide-44

45 Development/Validation of Conduit Assessment Tool Tool was developed using three methods to establish content validity: 720 patient encounter records during focus groups held over a 5 year period formal presentations and review in multidisciplinary GI conference formal presentations and review in multidisciplinary esophagus tumor board meetings 2014 MFMER slide-45

46 Methods: Conduit Questionnaire 2014 MFMER slide-46

47 Methods: Conduit Questionnaire Reflux 1 Mayo Score Dumping Score 2 Sigstad s scoring method Dysphagia 3 Mayo Score Post-op pain (0-10) 6 Conduit emptying (radiography) 7 0=rapid emptying w straight path 1=90% emptying, <2min delay 2=90% emptying, 2-15 min 3=90% emptying, min 4=conduit stasis, >30min Stricture 4 Blackmon et al. Score Zubrod score 5 0=asymptomatically active 1=restricted in strenuous activity 2=ambulatory, self-care, >50% time out of bed 3=ambulatory, limited self-care, >50% time in bed 4=no self-care, bed-ridden 2014 MFMER slide-47

48 Results Patient Characteristics and Operative Data Gastric Conduit (n=31, 69%) SPJ (n=14, 31%) p value Male 23 (74%) 8 (57%) NS Age (years) 63±10 55± Underlying Etiology: NS Cancer 26 (84%) 13 (93%) Benign Disease 5 (16%) 1 (7%) Type of Resection: Oncologic Resection for Adenocarcinoma 20 (65%) 6 (43%) Resection for Benign Disease 2 (7%) 0 (0%) Previous resection 1 (3%) 7 (50%) 2014 MFMER slide-48

49 Results Patient Characteristics and Operative Data Gastric Conduit (n=31, 69%) SPJ (n=14, 31%) p value Location of Anastomosis: <0.001 Neck 7 (23%) 14 (100%) Intrathoracic 24 (77%) 0 (0%) Anastomosis Technique: 0.02 Hand sewn anastomosis 1 (3%) 2 (14%) Stapled side-to-side anastomosis 13 (42%) 12 (86%) Circular stapled anastomosis 17 (55%) 0 (0%) 2014 MFMER slide-49

50 Results Post-Operative Complications Gastric Conduit (n=31, 69%) SPJ (n=14, 31%) p value Surgical Complications: 15 (48%) 7 (50%) NS Pneumonia 7 (23%) 3 (21%) Afib 4 (13%) 1 (7%) Renal failure 1 (3%) 1 (7%) Respiratory failure 3 (10%) 1 (7%) UTI 1 (3%) 0 (0%) DVT 1 (3%) 1 (7%) Length of stay (days) 10±4 17± day mortality 0 (0%) 0 (0%) NS Leak within 60 days 7 (23%) 4 (29%) NS Reoperation 3 (10%) 1 (7%) NS Afib=atrial fibrillation, NS=not statistically significant, UTI=urinary tract infection, DVT=deep vein thrombosis MFMER slide-50

51 Results: Clinical Follow-Up Gastric Conduit (n=31, 69%) SPJ (n=14, 31%) p value Death at last follow-up 2 (7%) 2 (14%) NS Length of follow-up 14±11 22±14 NS 2014 MFMER slide-51

52 Results: Conduit Function 7 P= Gastric SPJ MFMER slide-52

53 Discussion SPJ compares favorably to gastric conduit for esophageal reconstruction in terms of functionality. The groups differed significantly with SPJ patients more likely to have had prior resection. Operative outcomes and peri-operative complications were not significantly different between groups except longer length of stay for SPJ patients and more post-operative pain MFMER slide-53

54 Discussion The conduit assessment is a useful tool to compare reconstruction techniques, as well as assess patients recovery and need for further interventions MFMER slide-54

55 Discussion Future studies involve: Validation of the conduit assessment tool at other institutions Application of the tool to compare the outcomes of other reconstruction techniques (ie Ivor Lewis vs. transhiatal +/- pyloroplasty) in terms of physiologic outcomes Establish expected ranges at each postoperative time point for a given surgery, enabling identification of patients who deviate and may need further intervention 2014 MFMER slide-55

56 Limitations Small sample size at a single institution. Inherent differences in baseline characteristics of patients. Did not specifically examine role of conduit assessment tool in subsequent interventions and improvements in symptoms MFMER slide-56

57 Jejunal Interposition Results: ROL 2014 MFMER slide-57

58 Colon Conduits 2014 MFMER slide-58

59 L Colon Interposition 2014 MFMER slide-59

60 Transverse Colon Interposition 2014 MFMER slide-60

61 R Colon Interposition 2014 MFMER slide-61

62 Selecting and Measuring the Colon Interposition 2014 MFMER slide-62

63 Passing the Colon 2014 MFMER slide-63

64 Delivering the Colon 2014 MFMER slide-64

65 Esophago-colonic anastomosis 2014 MFMER slide-65

66 Bringing Colon to Stomach 2014 MFMER slide-66

67 Colon Interposition to Stomach 2014 MFMER slide-67

68 Colon Interposition 2014 MFMER slide-68

69 Colon Interposition 2014 MFMER slide-69

70 Colon Interposition 2014 MFMER slide-70

71 2014 MFMER slide-71

72 Colon Interposition 2014 MFMER slide-72

73 Colon Interposition 2014 MFMER slide-73

74 Colon Interposition 2014 MFMER slide-74

75 Colon Interposition 2014 MFMER slide-75

76 Colon Interposition Results: ROL 2014 MFMER slide-76

77 Esophageal Replacement Patients who have acquired long segment esophageal discontinuity and lack stomach as a viable replacement conduit primarily have two options for reconstruction: jejunum colon 2014 MFMER slide-77

78 Esophageal Replacement On the contrary, shorter esophageal segmental replacement has many other options: free pedicled forearm skin tubes folded myocutaneous flaps Short jejunal segment 2014 MFMER slide-78

79 Esophageal Replacement The future may hold many other options: Tissue-engineered 3-dimensional scaffolds repopulated with stem cells have already been used to replace the trachea Esophageal stents have now given us the ability to bridge a disconnected segment of bowel and allow for regrowth of tissue and establish new continuity 2014 MFMER slide-79

80 Esophageal Replacement Our group has successfully reconnected a distal esophagus to jejunum with a 2 cm separation with the use of stenting alone The addition of antibiotics, stem cells, chemoattractants, and other materials may enhance healing and re-growth of healthy tissue over the stent matrix 2014 MFMER slide-80

81 Question 1 The super-charged jejunal interposition typically bases the blood supply to the superior arcade upon: a) The axillary artery and vein b) The internal mammary artery and vein c) A vein loop graft off the aorta to the left subclavian vein d) The carotid artery and jugular vein 2014 MFMER slide-81

82 Question 1 The super-charged jejunal interposition typically bases the blood supply to the superior arcade upon: a) The axillary artery and vein b) The internal mammary artery and vein c) A vein loop graft off the aorta to the left subclavian vein d) The carotid artery and jugular vein 2014 MFMER slide-82

83 Question 2 The typical blood supply to the abdominal jejunal includes which purpose for each branch: a) 1-SMA 2-LIMA 3-bridge 4-SMA b) 1-SMA 2-SMA 3-bridge 4-SMA c) 1-SMA 2-LIMA 3-SMA 4-SMA d) 1-SMA 2-bridge 3-bridge 4-SMA 2014 MFMER slide-83

84 Question 2 The typical blood supply to the abdominal jejunal includes which purpose for each branch: a) 1-SMA 2-LIMA 3-bridge 4-SMA b) 1-SMA 2-SMA 3-bridge 4-SMA c) 1-SMA 2-LIMA 3-SMA 4-SMA d) 1-SMA 2-bridge 3-bridge 4-SMA 2014 MFMER slide-84

85 Question 3 When stomach is not available for esophageal conduit, which one of the following is not an option: a) colon b) jejunum c) pleura d) skin 2014 MFMER slide-85

86 Question 3 When stomach is not available for esophageal conduit, which one of the following is not an option: a) colon b) jejunum c) pleura d) skin 2014 MFMER slide-86

87 2014 MFMER slide-87

88 Thank you for your attention MFMER slide-88

89 Case CC: cough due to aspiration HPI: A 17 year old woman presented with a complicated history of congenital TEF repair, chronic esophageal stricture, multiple foregut procedures, and an inability to swallow- she has been fed by a G tube for the majority of her life 2014 MFMER slide-89

90 History TEF repair 3 y: Re-do Nissen & G Tube Dx w Tracheomalasia 13 y: Started propulsid Aspiration, G-tube feeding, serial dilations (>30-40) 4/25/94 birth 3 m: Nissen & G Tube 3.3 y: Repair Of Vascular ring 9 y: LLL for Bronchiectasis 17 y.o MFMER slide-90

91 She had a type C TEF: 2014 MFMER slide-91

92 What would you do? She needs entire length of esophagus replaced Her stomach has had previous surgeries (fundo/g tube), and one of these resulted in the G tube going through the GE vessel Options: Colon interposition Jejunum 2014 MFMER slide-92