Oesophageal reconstruction with a reversed gastric conduit for a complex oesophageal cancer patient: a case report

The choice of oesophageal substitute is crucial for oesophageal reconstruction. Oesophageal reconstruction with the stomach after oesophagectomy is the preferred organ and the most commonly accepted standard because of its easy access, elasticity, and comparably ample vascular supply [1, 2]. Although stomach, colon, and jejunum free revascularized grafts are available as potential conduits, a gastric conduit is used [3]. In past studies, a nongastric conduit has been associated with higher morbidity and mortality rates. Moreover, whether the blood supply of the available replacement organ is sufficient is the key to oesophageal reconstruction [4].

In oesophagectomy and reconstruction for treating middle and lower thoracic oesophageal carcinoma, a case of oesophageal cancer with a history of pylorus-preserving pancreaticoduodenectomy (PPPD) and endoscopic intestinal polypectomy placed us in a difficult situation, as follows. The right gastroepiploic artery and right gastric artery had been completely severed in the previous operation. The only supply artery that can be used for the gastric conduit for ER was just the left gastroepiploic artery. The shorter jejunum, intra-abdominal adhesions, and pathological colon forced us to choose to use the RGC to complete the oesophageal reconstruction. Although oesophageal reconstruction with RGC changed the anatomical structure of the gastrointestinal tract and the direction of gastric conduit peristalsis, there was no significant change in gut physiological function.

The patient was a 69-year-old man admitted for nearly 2 months of progressive dysphagia with histories of intestinal polyps and intraductal papillary mucinous neoplasm (IPMN) of the pancreas who underwent endoscopic surgery intestinal polypectomy and laparoscopic PPPD, respectively 9 months ago. Endoscopy showed a tumour in the middle, and lower thoracic oesophagus (29 to 35 cm from the incisors), and a biopsy revealed a squamous cell carcinoma. Further contrast-enhanced computed tomography (CT) and gastrointestinal contrast showed that the tumour was above the inferior pulmonary vein (Fig. 1A), without extraesophageal invasion. Previous gastrointestinal anastomosis of PPPD was illustrated by gastrointestinal contrast (Fig. 2A, B). No evidence of lymphadenopathy or distant metastasis was evaluated by fluorodeoxyglucose-positron emission tomography (FDG-PET). Therefore, the tumor was clinically staged as cT3N0M0 and was considered for primary resection (Ivor-Lewis oesophagectomy).

There has been an increase in the number of patients with double cancers co-occurring or metachronously in recent years. Most of them have found periampullary cancers, such as pancreatic head cancer, bile duct cancer, and cancer of the papilla Vater, after oesophagectomy for oesophageal carcinoma [5]. However, cases of oesophagectomy and reconstruction for oesophageal carcinoma after pancreatoduodenectomy or PPPD for pancreatic head cancer are rare. Pancreatoduodenectomy or PPPD is the standard surgery for resectable periampullary cancer. It involves resectioning the gastroduodenal artery and its branches, such as the right gastroepiploic artery to allow for complete dissection of lymph vessels and nodes [5]. When oesophageal cancer occurs in patients who need to reconstruct the oesophagus only by the gastric conduit because other organs are not available, the resected gastroduodenal artery or gastroepiploic artery, which is the major vessel in the greater curvature of the stomach, could lead to serious complications (such as anastomotic leakage and gastric conduit necrosis) due to insufficient blood supply to the gastric conduit [4]. Both the colon and supercharged pedicled jejunum are acceptable options for ER when the stomach is unavailable [6]. Unfortunately, a preoperative evaluation of the colon and jejunum were not available for the present case due to previous operations for colonic polyps, shortened jejunum, and intestinal adhesions. Moreover, the longer operative time required for colonic or jejunal mobilization and the additional anastomosis increase surgical stress and postoperative complications [7].

Conventional reversed gastric tube oesophagoplasty is mainly required to treat oesophageal atresia and caustic oesophageal strictures in infants and children [8]. However, a small amount was applied to failure cases in the treatment of colon, jejunum and prosthetic interpositions [9]. These gastric tubes were made of a part of the greater curvature gastric with gastroepiploic vessels and the lesser curvature gastric. Most of the gastric body still retained the original position of the abdominal cavity, and was not resected. Reversed gastric tubes are rare for oesophagogastrectomy and primary reconstruction in the treatment of oesophageal cancer. By studying the gastrointestinal contrast and reviewing the history of previous abdomen surgery, we recognised that we had no choice but just the gastric conduit, which had been pulled up reversely through the oesophageal hiatus to the oesophageal bed to complete oesophageal reconstruction. This method could also simplify surgical procedures and shorten the operative time. The patient had transient postoperative delayed thoracic gastric emptying without reflux, probably because the thoracic stomach still has weak receptive relaxation function despite the cardia, lesser curvature gastric body and vagus nerve being excised. However, no prokinetic agents were applied, and the patient recovered within two weeks. The peristaltic function of RGC was weakened after the operation; they were mainly used as conduits for transporting chyme, and other functions, such as secretion, were weakened or even disappeared. RGC could generally work without any long-term complications.

Usually, the gastric conduit is supplied by two main arteries, the right gastroepiploic artery and the right gastric artery. Cancerous, atherosclerotic or surgical involvement of the right gastroepiploic artery is a contraindication for transthoracic and transhiatal oesophagectomies [10]. However, the gastric conduit we presented was supplied mainly by the left gastroepiploic artery, which has been shown to have sufficient blood supply for the gastric conduit after ligation of the other gastric arteries intraoperatively. Procedures involving a gastric conduit or the whole stomach have become widely accepted as standard replacement organs for ER for a long time, however, the most feared complications are anastomotic leakage and gastric conduit necrosis. We successfully reconstructed the oesophagus using RGC, a nontraditional reversed gastric conduit. The only significant source of blood supply to the thoracic stomach was the left gastroepiploic artery, which was reasonably competent to supply the RGC. No long-term postoperative complications occurred, and patient was satisfied with his life after the operation. This is the first reported case of successful oesophageal reconstruction with RGC based solely on the left gastroepiploic artery to treat an oesophageal carcinoma patient.

In conclusion, oesophageal reconstruction with RGC is a feasible procedure for complex oesophageal carcinoma that can simplify complicated surgical procedures, has less influence on gut function, is less invasive, is relatively safe and is less time-consuming since no further reconstruction of the alimentary tract or the vascular system is applied.