Alternative Esophageal Conduits​

Author: Jason Muesse, MD
Institution: University of Arkansas
Date Reviewed: December 2024
Learning Domain: General Thoracic
Learning Objective: Reasons to consider alternative conduits, esophageal surgery
PowerPoint File: Alternative Esophageal Conduits​

The Stomach is the Preferred Conduit in 1st time Esophagectomy!

• Consistent and robust vascular supply
• Tough, tolerates manipulation
• Single anastomosis
• Technical ease of use compared to alternate conduits
• Decreased operating time
• Adequate length in 99% of cases

Reasons to Consider an Alterative Conduit

• Length! – Where is your tumor?
• Tumor extending from GE junction too far onto stomach (margin status)
• Previous failed esophagectomy with use of stomach as conduit 
• Tumor recurrence in gastric conduit
• Gastric radiation 
• Caustic ingestion causing damage to the stomach
• Gastric outlet obstruction from peptic ulcer disease
• Prior gastric resection or gastric cancer
• Some bariatric surgeries (esp Sleeve gastrectomy – Lap band and Roux-en-Y Gastric Bypass OK) 
   

Question: Is a PEG or G tube a contraindication to use of stomach as a conduit?

Answer: No!

• In most cases, regardless of placement, presence of a PEG or G tube does not compromise the stomach as a conduit.  
• Some surgeons feel that having a gastric feeding tube may dilate the stomach over time, due to the large amounts of liquids which are typically bolus fed, thus increasing the size of the conduit
  • Fell and Ximenes-Netto, Chapter 62, Gastric Tubes: Reversed and Nonreversed, in Pearson’s Thoracic & Esophageal Surgery, Third Edition, 2008.

Question: Is a previous hiatal hernia repair or fundoplication a contraindication to use of stomach as a conduit? 

Answer: No!

• In most cases, the stomach can still be used as a conduit.  However, the surgeon should be prepared for use of an alternative conduit.
• There is no difference in anastomotic leak rates, However,  when undergoing esophagectomy, these patients:
  • Sustain more blood loss 
  • Are more likely to require reoperation
  • Are less likely to report good to excellent swallowing function

 
What are the available alternative conduits?

• External Bypass
• Myocutaneous Flap
• Colonic Interposition Graft
• Right, Left and Transverse Colon
• Jejunal Interposition Graft
• Free graft and Pedicled Graft

External Bypass

• No longer used
• Cumbersome
• No peristalsis
• Probably better off with a spit fistula and G or J feeding tube

Myocutaneous Flap

• Preferred for short segments of esophagus
• Mainly utilized in cervical esophagus, especially following pharyngectomy or laryngopharyngectomy
• Radial forearm free flap is the workhorse
  • Can cover 8-9 cm defect
  • Good size match when tubularized
• Anterolateral free thigh flap     
  • Less of a concern for end extremity perfusion when patient is a vasculopath

In Situ Skin Flap

• Rarely used due to radiation changes in region and scar tissue from prior surgeries

Radial Forearm Free Flap

• Radial artery anastomosed to branch of external carotid artery
• Venae comitantes and cephalic vein anastomosed to external jugular vein or branch of internal jugular vein

Colonic Interposition

• Left or Right colon can be used for short or long segments as pedicled graft
• Transverse colon can be used for a shorter segment as pedicled or free graft w/ vascular anastomosis
• Can be fashioned in iso-peristaltic or retro-peristlatic fashion
• Colonoscopy, or at the least barium enema, should be performed preoperatively to rule out extensive polyps or colonic carcinoma
• Bowel prep is generally necessary preoperatively (osmotic and antibiotic)
• Mild diverticular disease is not a contraindication for usage
• CT Angiography can also be helpful in identifying anatomic variations or IMA occlusion, as well as mesenteric small vessel disease in elderly; done in all >60
• Anastomosed to stomach or gastric remnant (3 anastomoses) or in Roux-En-Y fashion with small bowel (4 anastomoses) if gastrectomy performed

Advantages of Colon As a Conduit

• Long Length
• Robust blood supply
• Preserves some function of stomach

Left Colon

• Left Colon conduit blood supply is based on ascending branch of left colic artery
• 99.7% of population has textbook left colon artery anatomy
• Get benefit of venous drainage into portal system via inferior mesenteric vein  and the systemic system via marginal vein’s connection to hemorrhoidal veins
• More diverticular disease
• Less prone to dilate than right colon
• Smaller diameter than right colon
• Probably better at propelling a solid bolus

Right Colon

• Right Colon conduit blood supply is based on the middle colic artery
• 68% percent of population has textbook right and middle colonic arterial anatomy 
• Venous drainage is less predictable
• Cecum, when placed in isoperistaltic position, is very bulky at the proximal anastomosis
• Can also anastomose to ileum, thus creating an upper esophageal sphincter using the ileocecal valve, better size match to cervical esophagus

Colon Technical Pearls

• Test clamp with bulldogs 
• Perform colon division first, prior to esophagectomy, to confirm good graft perfusion prior to anastomosis “period of observation” 
• Perform distal anastomosis to posterior body of stomach, 1/3 of the distance from the fundus to pylorus as measured from cardia
  • Try to get 10 cm of so of the graft in the intra-abdominal pressure zone, fundus then falls on this segment and serves as a flap valve
• Must be “tacked” to left crus and transect excess length
• Posterior mediastinal is preferred route, then retrosternal, then subcutaneous (last resort)
• If leave part of all of stomach intact, don’t forget gastric drainage procedure  if not performing vagal sparing esophagactomy
• Leave feeding tube in longer than you think (sometimes months)
  • takes longer to acclimate to colon than stomach, may have reflux and aspiration 
• Late redundancy is usually corrected with resection with colocolonic anastomosis
• Reflux is corrected with conversion to Roux-En-Y anatomy

How Does it Function ?

• Colon graft demonstrates episodes of contraction (avg 7.5 minutes +/- 2.4 minutes at frequency of 3.3 per minute) followed by periods of quiescence (avg 40 minutes) 
• When the colon graft is placed in antiperistaltic position, food is propelled retrograde, which could lead to patient discomfort
• Function improves over time in most patients
• In some patients, there will be no peristaltic activity

But Controversy Exists…

• Of 63 pts at 10 years:
  • 43%  had some dumping symptoms
    • 21% of those daily
    • 26% of those weekly
  • 40% reported at least one aspiration event
  • 40% had early satiety
  • 35% had diarrhea most than 3 times per day
  • 19% had heartburn
  • 16% had regurgitation

Disadvantages of Colon

• Subnormal colonic activity, which is present in 15% of cases, can be a relative contraindication to use
• Can dilate over time and larger diameter than esophagus can make it function as a reservoir instead of a conduit  leading to aspiration
• Tendency to become redundant or “sigmoidal” at distal anastomosis resulting in transient obstruction and regurgitation with aspiration
  • Up to 30% will require reoperation in lifetime, with 75% for redundancy
• Can have develop marginal ulcers at gastric suture line if anastomosed to stomach
• Left colon should not be used if prior AAA surgery
• Hemimanubriectomy usually required due to space constraints
• Can be difficult to use if obese (pericolonic fat)
• Places colonic bacteria close to lungs (theoretical)
• Potential for colon cancer in graft

Jejunal Interposition

Pedicled 

• Short segment interposition  
• Roux-en-Y esophagojejunostomy

Free graft with microvascular anastomosis

• “Supercharged” to internal mammary artery or cervical vessels for a long segment interposition

Jejunal Interposition Advantages

• Good Size Match
• Readily Available
• Relatively free from intrinsic pathology
• Hearty, predictable blood supply 
• Lower bacterial burden than colon
• Less propensity to dilate

Function of Supercharged Jejunum

• Exhibits antegrade, segmental contractions, although not necessarily coordinated – comparable to in-situ jejunum
• Effective in propulsing solids and liquids

Disadvantages of Jejunal Graft

• Tendency to become redundant
• Prolonged operating time, requiring microvascular anastomoses
• Can create large mesenteric defect, creating possibility for internal hernia
• Hemimanubriectomy and partial rib resection if “supercharging”
  • Theoretical potential for osteomyelitis, especially with leak
  • Potential for functional deficit
• Post op ileus frequent, and increased risk of NOMI (non occlusive mesenteric ischemia)
• Recurrent laryngeal nerve injury can happen due to extensive dissection for “supercharging”
  • Can be devastating if not recognized and aspiration occurs