Colonic Interposition for Salvage Esophagectomy with Supercharging

This video shows a case in which a colonic interposition is performed to restore enteric continuity after a failed Ivor-Lewis esophagectomy in a sixty-one-year-old male. This initial surgery was performed to treat distal esophageal cancer. Because of a leak after the index esophagectomy, the patient required a cervical diverting esophagostomy. The video authors demonstrate the reconstruction technique utilizing a retrosternal approach for passage of an isoperistaltic segment of transverse colon, followed by supercharging the conduit with additional arterial inflow and venous outflow.

To begin, an exploratory laparotomy was performed, followed by mobilization of the transverse colon after identification of the middle colic vessels. Next, the existing cervical esophagostomy was taken down, followed by left sternoclavicular joint resection. After creation of a retrosternal tunnel, the conduit was passed from the abdomen into the neck, where a hand-sewn coloesophageal anastomosis was performed. The anastomosis was “supercharged” via a microvascular anastomosis between the left internal mammary artery and middle colic artery, in addition to microvascular venous anastomosis using a portion between the left internal mammary vein and colonic recipient vein (1, 2). Subsequently, an end-to-side stapled cologastric (distal conduit) anastomosis with pyloroplasty was performed, followed by an end-to-side stapled colocolonic anastomosis to restore intestinal continuity. 

In conclusion, a colonic interposition using isoperistaltic transverse colon via retrosternal passage is a viable technique for a salvage esophagectomy when complications arise from a standard esophagectomy. It may be possible to consider supercharging the conduit with additional arterial inflow and possibly venous outflow to decrease risk of anastomotic complications.

References

1. Yasuda T, Shiraishi O, Iwama M, Makino T, Kato H, Kimura Y. Novel esophageal reconstruction technique via transmediastinal route from posterior to anterior mediastinum after esophagectomy. J Thorac Cardiovasc Surg. 2018;156(2):859-866.
2. Schraufnagel DP, Ahmad U, Raja S. Supercharged through a tunnel, is it an action movie? No, it’s a novel esophageal reconstruction! J Thorac Cardiovasc Surg. 2018;156(2):867-868.

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