Esophageal replacement: Gastric tube or whole stomach?

doi:10.1016/0003-4975(95)00411-D

The Annals of Thoracic Surgery

Volume 60, Issue 2, August 1995, Pages 261-267

https://doi.org/10.1016/0003-4975(95)00411-D Get rights and content

Background.

The stomach can be used either in its entirety or as a greater curvature tube for esophageal replacement.

Methods.

The study compares the gastric tube (group A; n = 112) to the whole stomach whose lesser curvature is denuded (group B; n = 100) in terms of technical complication and alimentary comfort. The clinical results are substantiated by assessment of the eating performance of patients and control subjects at a test meal, measurement of the gastric dimensions before and after both tailoring procedures, and intraarterial staining of the gastric wall.

Results.

Major differences between the two groups are cervical anastomosis stenoses (22.3% versus 6% [A versus B]; p = 0.008), fistulas (7.9% versus 1%; p = 0.0209), number of meals and snacks per day (4.6 versus 4; p = 0.0275), sensation of early fullness at meals (52.4% versus 17.8%; p < 0.0001), ratings given to the long-term alimentary comfort (presymptomatic condition = 10 points) (7.6 versus 8.8 out of 10 on average; p < 0.0001), and calories consumed in 1 minute at a test meal (59% [p < 0.05] versus 77% of those consumed by control subjects). The volume of the stomach is reduced by a range of 21.4% to 47.2% after tubulization (group A) whereas it increases by a range of 4.9% to 17.4% after denudation of the lesser curve (group B). Intraarterial staining of the gastric wall reveals the poor vascularity of the upper-most segment of the greater curve.

Conclusion.

Slight increase of the gastric capacity and maintenance of the submucosal vascular network account for the better results achieved with the whole stomach.

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Cited by (113)

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Reflux is one of the most common late complications after gastric tube esophageal replacement in children. Herein, we report a novel approach for safely and selectively replacing the caustic strictured thoracic esophagus with a detached reversed gastric tube (d-RGT) pedicled graft with preservation of the cardia and implementation of thoracoscopy for optimizing the mediastinal pull-through process, and its outcomes.
All children who presented to our facility with an intractable postcorrosive thoracic esophageal stricture through 2020 and 2021 were enrolled in this study. The primary operational steps were thoracoscopic esophagectomy, laparotomy for d-RGT fashioning, and cervicotomy for anastomosis after the thoracoscopically monitored mediastinal pull-through process.
Eleven children met the enrollment criteria, and their perioperative characteristics were assessed. The mean operative time was 201 min. The average duration of hospitalization was 5 days. There was no perioperative mortality. A transient cervical fistula was reported for one patient and a cervical side anastomotic stricture in another patient. A third patient developed kinking of the lower end of the d-RGT at the diaphragmatic crura level and this was treated satisfactorily by redoing the abdominal side surgery. After a mean follow-up of 8.5 months, none of the patients experienced reflux, dumping syndrome, or neoconduit redundancy.
The pattern of vascular supply of the d-RGT allowed for its total irrigation. Thoracoscopy assisted in preparing the mediastinal path for a safe and precise pull-through process. The lack of reflux seen on imaging and endoscopy in these children suggests that retaining the cardia may be beneficial.
IV.
In a Setting of Esophageal Replacement, Total Gastric Pull-Up has Fewer Complications than Partial Gastric Pull-Up
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The main indications for an esophageal replacement (ER) are unresolved complex esophageal atresia (EA) and caustic strictures (CS). The use of different organs for replacement has been described. When the stomach is chosen, there are two ways to do a gastric pull-up: a partial (PGP) or a total pull-up (TGP). Few studies have been published comparing the different techniques. The aim of this study was to compare the outcomes of patients who underwent ER by PGP or by TGT.
The medical records of all patients who underwent gastric pull-up for ER in the last 18 years at the National Pediatric Hospital Prof. Dr. Juan P. Garrahan were reviewed. The study is comparative, retro-prospective and longitudinal. Patients were divided in two groups according to the ER technique (PGP or TGP). We compared the following outcomes: duration of the operation, days of hospitalization in the intensive care unit (ICU), days of total hospitalization, time to initiation of oral feedings and rate of anastomosis dehiscence, incidence of anastomotic stenosis, need for re-operations, incidence of gastroesophageal reflux disease (GERD), incidence of tracheo-esophageal fistulas (TEF), incidence of dumping syndrome, incidence of gastric necrosis and mortality.
There were 92 patients included in the study: 70 in the PGP group (76%) and 26 in the TGP group (24%). The two groups were demographically equivalent. Patients in the TGP group had a statistically significant lower incidence of anastomotic dehiscence (22,7% versus 54,3%; p = 0.01) and dumping syndrome (13,6% versus 37,1%; p = 0.038). Patients in the TGP had lower incidence of anastomotic stenosis, although the difference was not statistically significant. There were no statistically significant differences between the groups in terms of duration of the operation, postoperative days in the ICU, time to oral feedings, GERD, TEF or overall hospital stay. There were no cases of gastric necrosis. There were 3 deaths in the PGP group and one in the TGP group.
We observed benefits in the TGP group versus the PGP approach in terms of anastomotic dehiscence and dumping syndrome, as well as a trend toward a lower incidence of anastomotic stenosis. Based on this experience, we recommend the TGP approach for patients who need an esophageal replacement by a gastric pull-up.
According to the Journal of Pediatric Surgery this research corresponds to type of study level III for retrospective comparative study.
Baseball bat-like gastric tube for end-to-side oesophageal-gastric anastomosis decreased risks of anastomotic leakage after oesophagectomy for oesophageal cancer: A retrospective propensity score matched comparative study with 613 patients
2022, International Journal of Surgery
Citation Excerpt :
The blood supply to the avascular gastric wall is primarily largely influenced by the formation because the area is supplied by the submucosal vascular network rather than the vascular arch [23]. The more distal the location in the stomach, the less blood that is supplied [19,24,25]. According to literature, approximately 20% of the blood distributed to the stomach is supplied to the avascular gastric wall [22].
To investigate the relationship between baseball bat-like gastric tubes for end-to-side oesophageal-gastric anastomosis and occurrence of anastomotic leakage after oesophagectomy for oesophageal cancer.
From July 2019 to June 2021, 613 patients with bat-like or narrow gastric tubes for end-to-side oesophageal-gastric anastomosis in oesophagectomy were retrospectively enrolled, in which 120 patients had narrow gastric tubes and 493 had bat-like gastric tubes. Clinical data including baseline characteristics, in-hospital variables and follow-up outcomes were collected.
Higher occurrence of anastomotic leak was observed in the narrow group in the unmatched cohort (14.2%, 17/120 vs. 7.3%, 36/493; P = 0.016) or the matched cohort after Propensity Score Matching (PSM) analysis (14.2%, 17/120 vs. 7.5%, 27/360, P = 0.028) when compared to the bat-like group; Multivariable analysis for risk factors of postoperative anastomotic leak in the unmatched cohort showed that the use of bat-like gastric tube was an independent protective factor (OR: 0.502, 95% CI: 0.270–0.935, P = 0.030).
Bat-like gastric tube can be used for end-to-side oesophageal-gastric anastomosis in oesophagectomy. This technique by improving blood supply to the area distal to the anastomosis decreased the incidence of anastomotic leak.
Options for Esophageal Replacement
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Esophagectomy followed by reconstruction is considered one of the most challenging interventions on the alimentary tract. Today most esophagectomies are performed for cancer of the esophagus and gastroesophageal junction. Other indications are decompensated achalasic megaeesophagus, sequelae of caustic burns, after multiple redo surgeries for reflux. The stomach, shaped into a narrow gastric tube, is the most commonly used conduit for reconstruction due to its favorable length, reliable vascular supply, the need for only one single anastomosis, and, in general, good to excellent sustainable quality of deglutition and life. However, dependent on each individual patient's particularities, reconstruction may require to choose another conduit. Colon and jejunum—sometimes to be used as an isolated loop with free vascular anastomosis or as composite grafts—are the available alternatives. Tubular skin flaps in an extremely rare situation may become the last resort option. Combined with a multitude of different access routes, including the recent minimally invasive techniques, as well as different levels of anastomosis, it is clear that there are myriad options available when planning an esophagectomy and reconstruction. A tailored approach for each individual patient guided by an experienced surgical team that is familiar with all conduits available and able to adapt to every situation in order to offer the patient the best possible type of reconstruction is the key to success. This chapter provides an in-depth description of the techniques and results of the whole spectrum of options for esophageal replacement.
Surgical treatment of the severe thoracic gastrocutaneous fistula by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma: A case report
2019, International Journal of Surgery Case Reports
Background: Thoracic anastomotic fistula (TAF) is a severe postoperative complication of oesophagectomy, and its occurrence coupled with a thoracic gastrocutaneous fistula (TGCF) and tracheostenosis is very unusual and may lead to a fatal consequence.
Case presentation: We describe a case of an old female diagnosed with mid-oesophageal carcinoma, who presented with a TAF after oesophagectomy, which was healed by an effective treatment, while a severe TGCF and tracheostenosis appeared one month postoperation. The complications were detected by gastroscopy, barium oesophagogram and thoracic computed tomography (CT). Through surgical treatments, including pedicled muscle flap filling and thoracoplasty, and a correlated corrective procedure, the patient completely recovered and was discharged six months after the admission.
Conclusion: Treatment by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma can be a curative alternative for the severe thoracic gastrocutaneous fistula.

View all citing articles on Scopus

: Presented at the Thirty-first Annual Meeting of The Society of Thoracic Surgeons, Palm Springs, CA, Jan 30–Feb 1, 1995.

View full text

Esophageal replacement: Gastric tube or whole stomach?

Background.

Methods.

Results.

Conclusion.

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Dis Esoph

L'oesophagoplastie cervicale dans le traitement du cancer de l'oesophage

Lyon Chir

Use of the stomach as an esophageal substitute

Ann Surg

Reconstruction after esophagectomy

Etude anatomo-technique avec injection vasculaire des oesophagoplasties gastriques rétrosternales chez le cadavre

Act Dig