Conduits When Stomach Fails
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1 Conduits When Stomach Fails Shanda Blackmon, M.D., M.P.H., FACS Associate Professor, Thoracic Surgery, Mayo Clinic Disney Duke Masters of Minimally Invasive Thoracic Surgery Orlando, 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 Disclosure I have no relevant disclosures related to this presentation & will not be discussing off-label device or medication usage 2014 MFMER slide-3
4 Outline History Replacement options for esophagus SPJ technical features SPJ Outcomes Case Review Conclusions 2014 MFMER slide-4
5 Esophageal Replacement is a bit like swimming with sharks 2014 MFMER slide-5
6 >100 Years of work MFMER slide-6
7 Conduit Alternatives for Esophagus Dickinson KJ & Blackmon SH. Management of conduit necrosis following esophagectomy. Thoracic Surgery Clinics 25(2015) MFMER slide-7
8 Jejunal Interposition Results: ROL 290 pts, RS route, 1-11% mortality, 0-36% Leak, 0-11% graft loss Gaur P & Blackmon SH. Jejunal graft conduits after esophagectomy. J Thorac Dis 2014;6(S3):S MFMER slide-8
9 Colon Interposition Results: ROL 2014 MFMER slide-9
10 Skin Conduits Microvascular augmentation 2014 MFMER slide-10
11 Musculocutaneous flap replacement 2014 MFMER slide-11
12 This is typically reserved for patients who do not have a colon or jejunal option left 2014 MFMER slide-12
13 Esophageal Replacement Options The gastric conduit is standard of care in most circumstances 2014 MFMER slide-13
14 The Dreaded Dead Conduit KJ, Blackmon SH. Management of Conduit Necrosis Following Esophagectomy. Thorac Surg Clin Nov;25(4): MFMER slide-14
15 Dead conduit is worse situation 2014 MFMER slide-15
16 Indications for Alternate Conduits: Recurrence of esophageal tumor1, 2, 3 Dead gastric conduit 2 Injury to GE Vessel or prior surgical alteration Cancer extending Into eso & stomach 1. Schipper PH, Cassivi SD, Deschamps C, Rice DC, Nichols FC 3rd, Allen MS, Pairolero PC. Locally recurrent eso ca: when is re-resection indicated? Ann Thorac Surg Sep;80(3):1001-5; discussion Kim MP, Brown KN, Schwartz MR, Blackmon SH. Advanced eso ca in patients who underwent RFA for barrett esophagus with HGD. Innovations (Phila) Jan-Feb;8(1): KJ, Blackmon SH. Management of Conduit Necrosis Following Esophagectomy. Thorac Surg Clin Nov;25(4): MFMER slide-16
17 Long Segment Esophageal Replacement Options Stomach Jejunum- +SC Colon- +/- SC 2014 MFMER slide-17
18 Background Full-length esophageal reconstruction using a pedicled jejunal flap augmented by cervical or thoracic vascular microanastomosis a longsegment supercharged pedicled jejunum, (SPJ) to recreate esophageal continuity after resection represents decades of surgical evolution 2014 MFMER slide-18
19 Colon Conduit 1988 Demeester et al., Ann Surg, Oct MFMER slide-19
20 Mayo Clinic Experience: pts, colon, 65% L colon, 9% mortality 2014 MFMER slide-20
21 K Mansour: Jejunal Conduits: patients 133 conduits Mansour KA et al. Ann Thorac Surg, 1997;64: MFMER slide-21
22 25 yrs of bowel interposition- Mansour et al. 85 R colon 18 L colon 4 transv colon 23 jejunal interpositions 3 free jejunal interpositions Mansour KA et al. Ann Thorac Surg, 1997;64: MFMER slide-22
23 Joe Miller: Jejunal Experience Cooper WA & Miller JI Jejunal Interposition for Esophageal Replacement. Operative Tech in Thorac & CV Surg, Vol 4, (3), 1999; MFMER slide-23
24 Jejunal Arterial Anatomy Vasa recta Marginal artery Arcades Jejunal Branches SMA 2014 MFMER slide-24
25 Esophageal Replacement Options: Jejunum Gaur P & Blackmon SH. Jejunal graft conduits after esophagectomy. J Thorac Dis 2014;6(S3):S MFMER slide-25
26 VSE Also called the Merendino procedure Advantage of having intact Vagi Motility of bowel interposition Cannot do full dissection of lymphatics More difficult to perform Gaur P & Blackmon SH. Jejunal graft conduits after esophagectomy. J Thorac Dis 2014;6(S3):S MFMER slide-26
27 Pedicled Segmental jejunal Interposition as a Roux 2014 MFMER slide-27
28 Pedicled Segmental jejunal Interposition to Stomach Dickinson KJ & Blackmon SH. Management of conduit necrosis following esophagectomy. Thoracic Surgery Clinics 25(2015) MFMER slide-28
29 How do I do SPJ? 2014 MFMER slide-29
30 Indications for SPJ To reach the pharynx To replace entire length of esophagus when a gastric conduit is not available Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-30
31 Background Long segment esophageal reconstruction can be accomplished with super-charged 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 Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-31
32 Background Adequate length can be obtained to replace the entire esophagus when cervical microvascular augmentation is performed as part of the reconstruction 2014 MFMER slide-32
33 Esophageal Reconstruction SPJ = pedicled segment of jejunum is transposed to the neck and the superior arcade of the bowel is connected to chest/neck vessels while the inferior arcade is left attached to the native SMA branches 2014 MFMER slide-33
34 1. Positioning and Pre-op head feet 2014 MFMER slide-34
35 2. Incisions 2014 MFMER slide-35
36 3. Abdominal Exploration & J Tube 2014 MFMER slide-36
37 2014 MFMER slide-37
38 4. Bowel Trans-illumination 2014 MFMER slide-38
39 2014 MFMER slide-39
40 4. Bowel Trans-illumination 2014 MFMER slide-40
41 4. Bowel Trans-illumination 2014 MFMER slide-41
42 5. Neck Dissection Regardless of the route, the thoracic inlet is typically enlarged with a hemi-manubriectomy & resection of the head of the clavicle and first rib; occasionally the 2 nd rib is also removed, as was done in this case MFMER slide-42
43 SPJ Blackmon SH & Hofstetter WL. Long Segment Reconstruction with jejunum. Esophageal Surgery- Luketich, 2015 Wolters Kluwer 2014 MFMER slide-43
44 5. Neck Dissection 2014 MFMER slide-44
45 6. LIMA Preparation 2014 MFMER slide-45
46 7. Creating the Tunnel for Conduit head feet 2014 MFMER slide-46
47 7. Creating the Tunnel for Conduit 2014 MFMER slide-47
48 SPJ Blackmon SH & Hofstetter WL. Long Segment Reconstruction with jejunum. Esophageal Surgery- Luketich, 2015 Wolters Kluwer 2014 MFMER slide-48
49 8. Jejunal Testing & Ligation 2014 MFMER slide-49
50 Blackmon SH & Hofstetter WL. Long Segment Reconstruction with jejunum. Esophageal Surgery- Luketich, 2015 Wolters Kluwer 2014 MFMER slide-50
51 Blackmon SH & Hofstetter WL. Long Segment Reconstruction with jejunum. Esophageal Surgery- Luketich, 2015 Wolters Kluwer 2014 MFMER slide-51
52 SPJ Blackmon SH & Hofstetter WL. Long Segment Reconstruction with jejunum. Esophageal Surgery- Luketich, 2015 Wolters Kluwer 2014 MFMER slide-52
53 8. Jejunal Testing & Ligation 2014 MFMER slide-53
54 Jejunal Route 2014 MFMER slide-54
55 9. Delivering the Jejunum to Neck 2014 MFMER slide-55
56 Microscopic Anastomoses 2014 MFMER slide-56
57 SPJ Blackmon SH & Hofstetter WL. Long Segment Reconstruction with jejunum. Esophageal Surgery- Luketich, 2015 Wolters Kluwer 2014 MFMER slide-57
58 10. Microscopic Venous Anastomosis 2014 MFMER slide-58
59 11. Microscopic Arterial Anastomosis 2014 MFMER slide-59
60 12. Resecting Redundant Bowel 2014 MFMER slide-60
61 13. Creating the Proximal Bowel Anastomosis in the Neck 2014 MFMER slide-61
62 Blackmon SH & Hofstetter WL. Long Segment Reconstruction with jejunum. Esophageal Surgery- Luketich, 2015 Wolters Kluwer 2014 MFMER slide-62
63 14. Making the Monitoring Flap 2014 MFMER slide-63
64 Blackmon SH & Hofstetter WL. Long Segment Reconstruction with jejunum. Esophageal Surgery- Luketich, 2015 Wolters Kluwer 2014 MFMER slide-64
65 15. Closing the Neck 2014 MFMER slide-65
66 16. Creating the Roux (Distal Bowel Anastomosis) 2014 MFMER slide-66
67 17. Closing the Mesenteric Defect 2014 MFMER slide-67
68 18. Feeding Jejunostomy 2014 MFMER slide-68
69 19. Closing the Diaphragmatic Defect 2014 MFMER slide-69
70 20. Abdominal Closure head feet 2014 MFMER slide-70
71 Post-Operative Management No IV pressors (give volume for hypotension) Hourly doppler examination No pressure on the flap/monitoring segment 2014 MFMER slide-71
72 20 Steps to SPJ 1. Positioning & pre-op 2. Incisions 3. Abdominal exploration 4. Bowel trans-illumination 5. Neck dissection 6. LIMA Prep 7. Creating the tunnel for the conduit 8. Selecting jejunal route, testing the blood flow, and ligation of 3 rd arcade 9. Delivering the jejunum to the neck 10. Microscopic venous anastomosis 11. Microscopic arterial anastomosis 12. Resecting redundant bowel 13. Creating the bowel neck anastomosis 14. Making the monitoring flap 15. Closing the neck 16. Creating the roux 17. Feeding jejunostomy 18. Closing the mesenteric defect 19. Closing the diaphragmatic defect 20. Abdominal closure 2014 MFMER slide-72
73 2014 MFMER slide-73
74 What about Technical Outcomes? 2014 MFMER slide-74
75 MDACC- HMH Experience 2014 MFMER slide-75
76 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, & outcomes Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-76
77 Results male Age female 44 (73%) > (27%) LOS > Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-77
78 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, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-78
79 Jejunal Route Operative Detail n % Posterior 21 35% mediastinum Retrosternal 39 65% Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-79
80 Jejunal Route Operative Detail n % Retrocolic 46 77% Antecolic 14 23% Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-80
81 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, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-81
82 Results: Graft Loss Operative Detail n % Intra-operative vascular revision 16 27% Intra-operative Graft loss 1 2% Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-82
83 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, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-83
84 Results: Operative Events Early Event n % Morbidity: Leak 19 32% Grade I 1 Grade II 9 Grade III 4 Grade IV 5 Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-84
85 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, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-85
86 Results: Post-operative Events Late Events n % 90-day Mortality 6 10% Later Revision 7 12% Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-86
87 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-87
88 Conclusions SPJ can establish nutritional independence in a high-risk patient population when stomach is unavailable This is our preferred alternative for reconstruction when stomach is unavailable Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-88
89 Blackmon SH, et al. Supercharged pedicled jejunal interposition for esophageal replacement: A 10 year experience.ann Thorac Surg Oct;94(4): ; discussion MFMER slide-89
90 How does the SPJ functionally compare to a Gastric Conduit? 2014 MFMER slide-90
91 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-91
92 Background Objective Assess the functionality of SPJ in comparison to gastric conduits Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-92
93 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. Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-93
94 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<0.05. Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-94
95 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 Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-95
96 Focus Groups Esophagus Support Group 2014 MFMER slide-96
97 Methods: Conduit Questionnaire Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-97
98 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 Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-98
99 Results Patient Characteristics and Operative Data Gastric Conduit (n=31) SPJ (n=14) p value Male 23 (74%) 8 (57%) NS Age (years) 63±10 55± Underlying Etiology: Cancer 26 (84%) 13 (93%) NS Type of Resection: Oncologic Rsxn for Adenoca 20 (65%) 6 (43%) Rsxn for Benign Disease 2 (7%) 0 (0%) Previous Rsxn 1 (3%) 7 (50%) Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-99
100 Results Patient Characteristics and Operative Data Gastric Conduit (n=31) SPJ (n=14) 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%) Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-100
101 Results Post-Operative Complications Gastric Conduit (n=31) SPJ (n=14) 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%) Afib=atrial fibrillation, NS=not statistically significant, UTI=urinary tract infection, DVT=deep vein thrombosis. Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-101
102 Results Post-Operative Complications Gastric Conduit (n=31) SPJ (n=14) p value 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 Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-102
103 Results: Clinical Follow-Up Gastric Conduit (n=31) SPJ (n=14) p value Death at last follow-up 2 (7%) 2 (14%) NS Length of follow-up 14±11 22±14 NS Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-103
104 Results: Conduit Function 7 P= Gastric SPJ Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-104
105 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. Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-105
106 Discussion The conduit assessment is a useful tool to compare reconstruction techniques, as well as assess patients recovery and need for further interventions. Stephens ES, Blackmon SH. SPJ Performance compares favorable to a gastric conduit after esophagectomy. Annals of Thoracic Surgery 2015; 2014 MFMER slide-106
107 Current Mayo Experience Alternative conduits 1/1985 to 12/2015: Cervical replacement w skin = 17 Colon Interpositions = 141 Jejunal Interpositions = 45 Other = 60 Gastrectomy jejunum = MFMER slide-107
108 More Mayo data here*** 2014 MFMER slide-108
109 Discussion Future studies involve: Validation of the conduit assessment tool at other institutions and in more patients Application of the tool to compare the outcomes of other reconstruction techniques Establish expected ranges at each postoperative time point for a given surgery, enabling identification of patients and cutpoints where deviation may trigger further intervention 2014 MFMER slide-109
110 2014 MFMER slide-110
111 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-111
112 It Takes Teamwork 2014 MFMER slide-112
113 If we have time, cases;;; 2014 MFMER slide-113
114 2014 MFMER slide-114
115 Questions? 2014 MFMER slide-115
When Stomach is Not Available
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