GastrointestinalJejunal interposition reconstruction with a stomach preserving esophagectomy improves postoperative weight loss and reflux symptoms for esophageal cancer patients
Introduction
Surgical treatments for esophageal cancer are highly invasive, and esophageal cancer often has perioperative complications [1], [2], [3]. Additionally, conventional reconstructions, such as gastric tube reconstruction, have more than a few cases with a low quality of life (QOL) and weight loss even in long-term survival cases. The low QOL cases are due to gastrointestinal symptoms such as heartburn caused by dysphagia and the back-flow of gastric acid [4]. The weight loss is due to the difficulty of oral intake [4], [5]. Furthermore, there are some cases in which complications from under-nutrition and pneumonia have caused death.
There are reports about colonic interpositions, which preserved gastric functions after an esophagectomy. Reports have shown that colonic interposition is advantageous due to a higher calorie intake and better postoperative body weight recovery [6]. It is not difficult to imagine that the small intestine can be an alternative tissue for interposition after an esophagectomy, and our team has performed this technique for middle and lower esophageal cancers called a stomach preserving esophagectomy (SPE). An SPE is a reconstruction method done by interposing the pedunculated jejunum in the posterior mediastinal route and elevating the jejunum. This surgical method interposes the jejunum so that the direct back-flow of gastric acid to the remnant esophagus can be controlled and, therefore, alleviate reflux symptoms. Compared with gastric tube reconstruction, from the point of view of gastric emptying and the capability of the stomach, this method also increases the amount of oral intake because gastric function is highly preserved. Therefore, an improvement in postoperative QOL and the preservation of digestive and absorptive functions are possible.
In this article, a detailed description of our version of the SPE surgical procedure and data obtained from the procedure are shown. Additionally, both postoperative QOL and nutritional status were compared with gastric tube reconstruction surgeries retrospectively, and the significance of SPE was examined.
Section snippets
Indication and surgical procedure for SPE
The indication of SPE is based upon the site of primary tumor, which should be below the middle of the thoracic esophagus. This limitation is because the anastomosis of the remnant esophagus to the jejunum should be lower than the aortic arch. In addition, suspicious lymph nodal metastases in the superior mediastinal area are an exclusion criterion. Obviously, cases whose tumors have massively invaded the stomach and those with stomach cancer are not candidates for SPE.
A surgical procedure for
Jejunal interposition with a stomach preserving esophagectomy preserves postoperative gastric peristalsis
A postoperative esophagogram showed that the sutured site of the residual esophagus and pedunculated jejunum is positioned at the subcarinal level. Contrast agent flowed smoothly from the pedunculated jejunum to the preserved stomach (Fig. 4A). Of note, the contrast agent temporarily pooled in the stomach and then gradually flowed to the duodenum (Fig. 4B), suggesting that the preserved stomach appeared to maintain its peristaltic action regardless of possible damage to the vagus nerve from
Discussion
Our SPE method, which is a novel technique because of the elevation of the pedunculated jejunum to the anastomosis site for reconstruction, can be good for the control of reflux symptoms. This procedure is mainly adapted for lower thoracic esophageal cancer, but is also suitable for Barrett's esophageal cancer, which is more common in North America and Europe [10], [11], [12]. In consideration of intestinal continuity after an esophageal resection, it is technically difficult to elevate
Acknowledgment
The authors appreciate Drs. Takayuki Motoki, Minoru Haisa, and Junji Matsuoka for providing useful discussions.
No biomedical financial interests or potential conflicts of interest declared.
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2019, Clinical Nutrition ESPENCitation Excerpt :However, postoperative wasting influences the entire body, including the trunk, limbs, and muscles related to eating such as the oral and pharyngeal muscles. Prolonged non-oral food intake may induce oropharyngeal muscle disuse, leading to postoperative muscle weakness in those regions; in fact, prolonged endotracheal intubation is a known risk factor of dysphagia after extubation [16] that is considered a result of oropharyngeal muscle disuse during intubation. However, evidence regarding weakness of the oropharyngeal muscles after surgery remains scarce.