Surgical repair of refractory strictures of esophagogastric anastomoses caused by leakage following esophagectomy

Abstract

Refractory strictures of esophagogastric anastomosis caused by leakage following an esophagectomy are a severe complication, for which either repeated balloon dilations or bougies are not necessarily effective. In such a case, surgical repair is quite difficult because the esophageal substitute such as the stomach or colon is usually located in the mediastinum and severely adhesive to the neighboring organs. Furthermore, in case the resected stricture is too long for direct re-anastomosis to be performed, a free jejunal graft or a new esophageal substitute should be prepared. This paper proposes a procedure for the re-reconstruction of refractory stricture in the case of a retrosternal reconstruction with a gastric conduit, which frequently employs pull-up route. The anterior plate of the manubrium was divided medially from the notch to the symphysis with the sternal saw. The manubrium is then removed, bite by bite, like breaking up rocks, with a bone rongeur forceps, starting with the anterior plate, then the posterior plate, from upper median part to the lower and lateral part of the sternum until it reaches the symphysis and the sternoclavicular and the sternocostal joints. It is safer to destroy the manubrium little by little from the anterior side so that the posterior periosteum, which is likely to adhere tightly to the gastric conduit, can be preserved. After the manubrium is almost completely resected and the posterior periosteum of the manubrium is preserved, a median longitudinal incision is carefully made on the periosteum so as not to damage the gastric conduit that may be adhesive to the periosteum. The periosteum was gradually opened bilaterally separating the periostium and the gastric conduit. Although gastroenterological surgeons may hesitate to remove the manubrium, removing the manubrium and preserving the posterior periosteum make it possible to avoid injuring the gastric conduit and to provide a wide view around the stenosis for safely resecting the anastomotic stricture. Furthermore, this procedure allows direct re-anastomosis between the cervical esophagus and the gastric conduit without a complicated reconstruction such as a free jejunal graft. This procedure is strongly recommended as an alternative option so that a second reconstruction can be performed both safely and steadily.

Successful management of therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up: A case report

“…These results are supported by a national survey of specialist surgeons in the United Kingdom revealing that the left colon and retrosternal placement was the favored surgical approach[ 21 , 22 ]. An additional alternative of reconstruction would have been local resection of stenotic anastomosis re-anastomosis between the cervical esophagus and the gastric conduit but was withdrawn in this case due to the additional DGE[ 23 ].…”

Surgical Approach to Cervical Esophagogastric Anastomoses for Post-esophagectomy Complications

“…One published report described a tracheal approach, with a manubrium resection 6. There is also a report of an approach to the anastomotic stricture involving a manubrium resection 7. Because resection of the manubrium and the left clavicle causes depression of the anterior chest wall, this procedure is cosmetically inferior to the manubrium resection approach.…”

Temporary Use of a New Fully-Covered Self-Expanding Metal Stent for the Management of Post-Esophagectomy Strictures

“…The surgical therapies for esophageal cancer are fairly invasive procedures with substantial morbidity and mortality rates 3 . Common complications following esophagectomy include anastomotic leaks and strictures, as well as fistula formation 4,5 …”

“…3 Common complications following esophagectomy include anastomotic leaks and strictures, as well as fistula formation. 4,5 Previous studies suggest a benefit from the use of selfexpanding plastic stents (SEPS) for the management of benign, post-esophagectomy complications such as anastomotic strictures. [6][7][8][9] Despite improvements in dysphagia, SEPS in this setting are associated with a high rate of stent migration and a low rate of long-term overall benefit.…”