Ann Thorac Surg 2002;73:1649-1651
© 2002 The Society of Thoracic Surgeons
Case report
McKeown esophagogastrectomy for esophageal carcinoma after free jejunal graft
Douglas P. MacMillan, MDa,
Ignacio G. Duarte, MDa,
Kamal A. Mansour, MDa,
Sudhir Sundaresan, MD*a
a Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
Accepted for publication September 10, 2001.
* Address reprint requests to Dr Sundaresan, 201 E Huron St, Ste 10-105, Chicago, IL 60611, USA
e-mail: ssundare{at}nmh.org
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Abstract
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Sever al well-described options exist for reconstruction after total esophagectomy for esophageal carcinoma. We present the case of a patient who was treated for squamous cell carcinoma of the esophagus; the patient had undergone treatment with neoadjuvant chemoradiation and free jejunal transfer for a cervical esophageal tumor 13 years earlier. Through a three-field approach, esophagectomy and reconstruction with a cervical gastrojejunal anastomosis were performed.
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Introduction
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The treatment of esophageal carcinoma often requires a creative approach with individually tailored treatment plans. Size, location of lesions, previous treatment, and ultimate goals of therapy are factors that should be considered for each patient. Surgical approaches described include Ivor-Lewis, left thoracotomy, transhiatal, and McKeown three-field approach [1, 2]. Reconstructive options following esophagectomy include gastric pull-up, free jejunal grafts, Roux-en-Y jejunal limbs, and colonic interposition [3–5].
A 58-year-old woman was diagnosed with limited squamous cell carcinoma of the cervical esophagus after developing dysphagia in 1986. Treated at an outside institution, she underwent neoadjuvant chemoradiation followed by resection of the cervical esophagus, total laryngectomy, thyroidectomy, and reconstruction with a free jejunal graft. She did well following this procedure and had resolution of symptoms.
In 1999, recurrent dysphagia developed in the patient; the dysphagia progressed to difficulty swallowing liquids, and she was referred to our institution. Barium swallow revealed a mass in the cervical esophagus, and fiberoptic esophagoscopy demonstrated a large, obstructing tumor in the esophagus just distal to the jejunal graft (Fig 1).
Further preoperative evaluation, including chest and abdomen computed tomographic scan and fiberoptic bronchoscopy, did not indicate any evidence of metastatic disease. Because it had been 13 years since the previous tumor, we believed this to be a true second primary malignancy. The patient was prepared for surgical intervention.
On January 10, 2001, the patient underwent total esophagectomy and gastric reconstruction through a McKeown three-field approach. We began by performing a right thoracotomy, entering the chest through the fourth intercostal space, to liberate the esophagus from the previously irradiated chest, identifying the tumor just below the distal jejunoesophageal anastomosis inferior to the thoracic inlet (Fig 2).
Next, we performed a laparotomy, freeing the lower esophagus at the level of the hiatus, and created the gastric conduit from the lesser curve of the stomach. Through a collar incision, we identified the proximal native esophagus and the proximal aspect of the jejunal graft, preserving its vascular supply. A portion of the jejunal graft was divided through the cervical exposure, and the lower segment of jejunum and intrathoracic esophagus, including the lesion, was excised. The gastric tube was then advanced along the posterior mediastinum and brought out through the collar incision, where it was anastomosed to the jejunal segment in an end-side fashion, reestablishing gastrointestinal continuity. The patient did well postoperatively, and barium swallow on the ninth postoperative day showed no leak. The patient began a liquid diet that she tolerated well, and she was advanced to a regular diet without difficulty. Final pathologic analysis of the lesion confirmed a moderately differentiated squamous cell carcinoma of the esophagus, invading the muscularis propria, with 0/6 lymph nodes positive for tumor (T2 N0).
At 6 months postoperatively, the patient continues to do well with no regurgitation or difficulty swallowing. A barium swallow performed at 3 months demonstrates a patent anastomosis (Fig 3).
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Fig 3. Barium swallow showing no leak at the new jejunogastric anastomosis (white arrow) 3 months postoperatively.
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Comment
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This patient had been treated with several well-described forms of treatment before the development of her second tumor. Each of these efforts influenced our treatment plan as much as the location and nature of the lesion.
The operative field was altered drastically by the previous radiation. This made a transhiatal procedure impossible. The cervical, thoracic, and abdominal approach pioneered by McKeown allowed the problem of an irradiated chest to be overcome.
The initial free jejunal graft was used appropriately and functioned well for almost 13 years. When a second tumor developed in the patient, the stomach became the best option for reconstructing the esophagus. The combination of these techniques has given the patient an excellent outcome.
The recurrence of dysphagia caused by a second esophageal carcinoma suggests that total laryngopharyngoesophagectomy and reconstruction with stomach or bowel in the neck should be considered in patients with a first cervical esophageal malignancy [6]. Our operation could have been avoided entirely had the patient’s thoracic esophagus been removed initially.
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References
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Lewis I. The surgical treatment of carcinoma of the esophagus with special reference to a new operation for growth in the middle third. Br J Surg 1946;34:18-31.
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McKeown K.C. Total three-stage oesophagectomy for cancer of the oesophagus. Br J Surg 1976;63:259-262.[Medline]
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Carlson G.W., Shusterman M.A., Guillamodequi O.M. Total reconstruction of the hypopharynx and cervical esophagus: a 20-year experience. Ann Plast Surg 1992;29:408-412.[Medline]
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Orringer M.B. Surgical options for esophageal resection and reconstruction with stomach. In: Baue A.E., ed. Gleen’s thoracic and cardiovascular surgery, Sixth ed. Stamford, CT: Appleton and Lange, 1996:899-922.
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Mansour K.A., Bryan F.C., Carlson G.W. Bowel interposition for esophageal replacement: Twenty-five year experience. Ann Thorac Surg 1997;64:752-756.[Abstract/Free Full Text]
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Mansour K.A., Picone A.L., Coleman J.J., III Surgery for high cervical esophageal carcinoma: Experience with 11 patients. Ann Thorac Surg 1990;49:597-602.[Abstract]
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Abstract
Introduction
