Ann Thorac Surg 2000;69:1593-1594
© 2000 The Society of Thoracic Surgeons
Case reports
The stomach as a microvascularly augmented flap for esophageal replacement
Azim M. Valji, MDa,
Donna E. Maziak, MDCMa,
Murray W. Allen, MDa,
Farid M. Shamji, MDa
a Divisions of Thoracic and Plastic Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
Address reprint requests to Dr Maziak, Ottawa Civic Hospital, 1053 Carling Ave, CPC Room 162, Ottawa, ON, K1Y 1J8, Canada
e-mail: dmaziak{at}civich.ottawa.on.ca
 |
Abstract
|
|---|
We present a case of difficult esophageal reconstruction after total esophagectomy for iatrogenic perforation in a diseased esophagus. The stomach was used for esophageal reconstruction as a retrosternal microvascularly augmented flap; the vascular supply to the stomach had been interrupted during previous abdominal operations. The blood supply to the stomach conduit was restored by separate arterial and venous anastomosis between the right internal thoracic vessels and the left gastric vessels.
|
Introduction
|
|---|
The most common conduit used in restoring continuity of the alimentary tract, after total esophagectomy, is the stomach [1, 2]. The stomach has a consistent and identifiable blood supply, is easy to mobilize, and requires a single anastomosis. Alternative conduits include colon and free jejunal grafts [3, 4]. These conduits are used when the stomach is not available for esophageal replacement. In these situations colon interposition is preferred.
We describe a case in which only the stomach was available for reconstruction; however, its blood supply had been interrupted by ligation of the right gastroepiploic artery at the gastroduodenal junction either during previous colon resection or peptic ulcer operation. The stomach, after mobilization, was revascularized and used as a microvascularly augmented flap to successfully reconstruct the gastrointestinal tract.
An 80-year-old woman underwent an elective abdominal incisional hernia repair. Past surgical history was remarkable for diverticulitis with sigmoid resection and temporary colostomy, vagotomy, and pyloroplasty for peptic ulcer disease and closure of colostomy. Following the incisional hernia repair, she developed intestinal pseudoobstruction requiring a right hemicolectomy. During this time period a nasogastric tube was left in place for an extended period, causing stricture formation in the distal half of the thoracic esophagus. Dilatation of the stricture was carried out on three occasions and following the last dilatation the patient developed chest pain and pneumomediastinum. A diagnosis of esophageal perforation was confirmed with a gastrograffin swallow. The patient remained hemodynamically stable. She was referred for urgent operation ten hours after the perforation and was found to have a 3-cm perforation just proximal to a long esophageal stricture; the stricture itself was very fibrotic with the mucosa ischemic and necrotic. Therefore, primary repair was not possible and she underwent a total esophagectomy with cervical end esophagostomy.
The postoperative recovery was uneventful. Ten days later esophageal reconstruction was undertaken. At laparotomy the stomach was found to be normal and viable except that the right gastroepiploic vascular arcade had been ligated, near the gastroduodenal junction, during one of her previous operations; the colon was not available because of previous colectomies. A microvascularly augmented flap of the stomach was therefore contemplated. The stomach was completely mobilized in the usual fashion except that the left gastric artery and vein were exposed, but not ligated, at the origin on the celiac axis. A median sternotomy was then performed and the right internal thoracic artery and vein were prepared for microvascular anastomosis. The left gastric artery and vein were then ligated individually and divided with adequate distal length on each. An end-to-end microvascular anastomosis was performed using 9-0 nylon between the left gastric artery and vein and the right internal thoracic artery and vein, respectively.
After revascularization of the stomach tube, the reconstruction was completed. The viability of the stomach was preserved, allowing normal healing of the esophagogastric anastomosis. Oral nutrition was restored on postoperative day 8. A digital subtraction angiogram performed on day 14 showed patency of the vascular anastomosis (Fig 1). She is alive and well 31 months after the operation with no symptoms of dysphagia, delayed gastric emptying, or reflux.
View larger version (179K):
[in this window]
[in a new window]
|
Fig 1. Right subclavian angiogram showing the anastomosis between the right internal thoracic artery and the left gastric artery (arrow), providing perfusion along the lesser curvature of the stomach.
|
|
|
Comment
|
|---|
The stomach is the best conduit for replacement of the esophagus after esophagectomy [1]. When it is not available, the colon and jejunum are acceptable alternatives by various anastomoses and blood supply [5]. Previously we reported a case of esophageal replacement in which the blood supply to the retrosternally placed gastric conduit appeared to be compromised [6]. In this case an anastomosis between the left internal thoracic artery and a short gastric artery was performed with good results. To our knowledge there have been no reports of using the stomach as a microvascularly augmented flap for esophageal replacement. This procedure requires the flap to be in continuity with the gastrointestinal tract, completely devascularized of its native blood supply, and then revascularized with a systemic vessel using microsurgical techniques.
In our case the colon could not be used for esophageal reconstruction because of previous colectomies, and, due to extensive adhesions, the jejunum was not available as a free flap. The blood supply of the stomach was also found to be interrupted with only the left gastric artery and vein intact. We were able to restore adequate circulation to the stomach by microvascular anastomosis. However, to access the internal thoracic artery for revascularization of the stomach, the stomach had to be placed in the substernal position. We believe that this is an acceptable operation to restore perfusion of the stomach with good results. It presents an alternative when the stomach cannot be used as a flap based on the right gastroepiploic and right gastric arteries and the colon is also not available for esophageal replacement.
|
References
|
|---|
-
Wilkins E.W., Jr Esophageal replacement. In: Grillo H.C., ed. Current therapy in cardiothoracic surgery. Toronto: Decker, 1989:201-204.
-
Orringer M.B. Transhiatal esophagectomy without thoracotomy for carcinoma of the thoracic esophagus. Ann Surg 1984;200:282-288.[Medline]
-
Wilkins E.W., Jr Long segment colon substitution for the esophagus. Ann Surg 1980;192:722-725.[Medline]
-
Jurkiewicz M.J., Paletta C.E. Free jejunal graft. In: Grillo H.C., ed. Current therapy in cardiothoracic surgery. Toronto: Decker, 1989:206-209.
-
Hiebert C.A., Cummings G.O. Successful replacement of the cervical esophagus by transplantation and revascularization of a free graft of gastric antrum. Ann Surg 1961;154:103-106.[Medline]
-
Petsikas D., Shamji F.M. Revascularization of the ischemic gastric tube using the left internal thoracic artery. Ann Thorac Surg 1996;62:568-570.[Abstract/Free Full Text]
Accepted for publication October 28, 1999.
Top
Abstract
Introduction
