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Original Articles: General Thoracic

Anterior Versus Posterior Routes of Reconstruction After Esophagectomy: A Comparative Anatomic Study

^a Department of Cardiothoracic Surgery, The Cancer Hospital of Fudan University, Shanghai, China
^c Department of Radiology, The Cancer Hospital of Fudan University, Shanghai, China
^b The Cancer Institute, National Healthcare Group, Singapore, Singapore

Accepted for publication November 10, 2008.

^_* Address correspondence to Dr Chen, 270# Dong'an Rd, Shanghai, 200032, China (Email: hqchen1{at}yahoo.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background: A gastric conduit is commonly used to reconstruct the alimentary tract after esophagectomy for esophageal cancer. The choice of anterior versus posterior route for reconstruction is debatable, and longer distance of the reconstructed routes may be associated with higher tension exerted on the transposed stomach. The aim of this study is to evaluate the length of both the anterior and posterior routes in a group of patients measured intraoperatively during esophagectomy for esophageal cancer.

Methods: Sixty consecutive and nonselected patients with thoracic esophageal cancer were accrued in this prospective study. Measurements of the anterior (retrosternal) and posterior routes were performed after esophagectomy but before reconstruction with gastric conduit, from the cricoid cartilage to the pyloric ring.

Results: The lengths of the anterior and posterior routes were 32.68 ± 2.67 cm and 35.48 ± 2.93 cm, respectively (p < 0.001). The anterior route is significantly shorter than the posterior route.

Conclusions: The anterior (retrosternal) route is the shorter passage for the reconstruction of the alimentary tract using the stomach after esophagectomy.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Esophagectomy is the mainstay treatment for esophageal cancer. Reconstruction of the alimentary tract is essential after esophagectomy, and the resected esophagus is most commonly substituted by the stomach [1]. Reconstruction in this circumstance is either achieved using the anterior (retrosternal) route (AR) or the posterior (prevertebral) route (PR) through the mediastinum [2]. Although both approaches have been widely used, it is debatable which one is more advantageous. Whereas AR places the gastric conduit outside the tumor bed so that digestive function will not be interfered with by local recurrence, and delivery of adjuvant radiation therapy is less complicated if needed, PR is preferred by many surgeons with a perception that it is associated with less probability of postoperative complications [2, 3]. However, these perceptions have not been supported by large-scale prospective randomized studies, and meta-analysis of randomized controlled trials on this topic revealed that both approaches yielded similar outcomes [4].

One of the commonly cited reasons for using PR is that the prevertebral route is relatively shorter than the retrosternal route, which may translate to reduced tension for the anastomosis. Previously reported postmortem analyses showed that AR is approximately 2 to 3 cm longer than PR; however, the reference points used in those studies varied, and the rationale of reference point selection was debatable [5–7]. In addition, comparison of the length of the two routes was never performed in live patients. The objective of this study is to compare the length of the different routes during esophagectomy to determine which approach is more conducive for surgical reconstruction.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Between December 2005 and October 2007, a total of 60 consecutive and nonselected patients who were diagnosed with thoracic squamous cell carcinoma of the esophagus and planned to receive esophagectomy were accrued into this institutional review board–approved prospective study. Written consents were obtained from all participating patients before their surgery. Pretreatment evaluation included a complete history and physical examination, chest roentgenogram, computed tomography of the chest and upper abdomen, complete blood counts, serum electrolyte tests, and liver, pulmonary, and kidney function tests, as well as triple endoscopy with biopsy of the esophageal lesion for pathologic diagnosis.

Esophagectomy with lymphadenectomy was routinely performed with cervical esophagogastric anastomosis. General anesthesia was administered, and the patient was positioned in the left lateral decubitus position. A standard right muscle-sparing posterolateral thoracotomy was performed through the fourth or fifth intercostal space. The right hemithorax was carefully explored to rule out any surgical contraindications before proceeding with the resection. The intrathoracic esophagus was mobilized and thoracic lymphadenectomy was performed; the esophageal carcinoma was then resected. A white inelastic polyethylene tape was attached to each end of the esophagus.

The patient was then placed in the supine position, and a midline laparotomy incision was made. The abdominal cavity was explored to rule out intraabdominal metastasis. Gastric mobilization was performed, and a gastric tube was fashioned as the conduit for esophageal replacement. The Kocher maneuver was not routinely performed as part of this operation. A space within the retrosternal mediastinum was created using a combination of blunt and sharp dissection. Before the neoesophagus was then tunneled through the retrosternal route, a blue inelastic polyethylene tape passed through the retrosternal tunnel.

An oblique cervical incision was made anterior to the left sternocleidomastoid muscle. The space between the carotid sheath and the trachea was dissected, and the cervical esophagus was identified. A single-layer hand-sewn cervical esophagogastric anastomosis was then performed at the level of the cricoid cartilage.

Careful measurements of the length of the two routes were made after the esophagus was removed but before alimentary tract reconstruction. Patients were placed in the supine position with the neck slightly extended at the time of the measurements. The cricoid cartilage was used as the proximal reference point and the pyloric ring was used as the distal reference point. The white tape was positioned in the prevertebral route, and the blue inelastic polyethylene tape was used for the retrosternal route. The two tapes were carefully aligned at the two references points, and the distances of both routes were measured (Figs 1, 2).

View larger version (103K): [in this window] [in a new window]   Fig 1. The cervical incision showing the esophagus (A), the white tape positioned in the prevertebral route (B); and the blue inelastic polyethylene tape passed through the retrosternal tunnel (C).

View larger version (117K): [in this window] [in a new window]   Fig 2. The abdominal incision showing the pylorus (A), the blue inelastic polyethylene tape passed through the retrosternal tunnel (B), and the white tape positioned in the prevertebral route (C).

	Results

Top Abstract Introduction Patients and Methods Results Comment References

All patients were diagnosed with esophageal squamous cell carcinoma in the thoracic esophagus. The number of lesions located in the upper, mid, and lower thoracic esophagus were 15, 33, and 12, respectively. All patients received esophagectomy as well as reconstruction using the gastric conduit through AR as planned.

The mean distances of AR and PR were 32.7 ± 2.7 cm and 35.5 ± 2.9 cm, respectively. Anterior route is found to be significantly shorter than PR (p < 0.001). The distances of the two routes are compared in Table 1.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

The posterior route is preferred by many surgeons because of the perception that it might be associated with fewer complications [2, 3], possibly because of a shorter distance with less anastomotic tension [6, 7]. However, this finding has not been supported by large-scale randomized studies, and a meta-analysis reported by Urschel and colleagues [4] revealed that the choice of reconstruction routes is not significantly associated with the incidences of postoperative morbidities and mortalities.

As part of the integrated treatment of esophageal cancer, reconstruction after esophagectomy should be planned with the entire treatment strategy in mind. One of the most important considerations in the management of esophageal cancer, particularly for patients with locally advanced disease, is the utility of neoadjuvant or adjuvant chemotherapy and radiotherapy. Neoadjuvant concurrent chemoradiation has been shown to improve treatment outcome for locally advanced esophageal cancer [8, 9]. Despite its efficacy, neoadjuvant or adjuvant chemoradiation is usually associated with substantial side effects and complications. Inflammation and fibrosis of adjacent soft tissues induced by combined chemoradiation will not only complicate surgical maneuvering during esophagectomy but will also adversely affect the postoperative recovery, respiratory capacity, and the functioning of the reconstructed alimentary tract, as well as increasing perioperative morbidity and mortality [10, 11]. In addition, local or regional recurrence is the most common form of treatment failure in patients with locally advanced esophageal cancer after definitive treatment [12]; thus, it is important to consider the possibility that recurrent tumors in the posterior mediastinum may cause obstruction and dysfunction of the gastric conduit when selecting the reconstruction route. With our current finding that AR is significantly shorter than PR, and the prevailing use of trimodality treatment for esophageal cancer in consideration, reconstruction by means of AR after esophagectomy should be considered as the preferable route if there are no other contraindications.

The distances of the various routes for alimentary tract reconstruction were addressed previously and most of the studies revealed that the route through the anterior mediastinum is longer than the posterior route. Orringer and Sloan [5] studied 10 cadavers and discovered that the subcutaneous route is 2 to 3 cm longer than the posterior route. They postulated that the length of AR (retrosternal route) would also be longer, as it lies between the lengths of the subcutaneous and the posterior routes. It is important to note that the reference points used for measuring the two routes were not clearly stated in the report. Ngan and Wong [6] measured the distances from the cricoid cartilage to the celiac axis, and reported that AR is 1.9 cm longer than PR after studying 20 cadavers of Asian origin. Similar conclusions were found by Coral and associates [7] using cadavers of African American and Brazilian origins, with the celiac axis and gastroduodenal artery used as the distal reference points.

The above-mentioned results seemed to differ substantially from our current findings (Table 2). We contribute these discrepancies to two major reasons. First, although all trials used the cricoid cartilage as the proximal reference point of measurement, the distal reference points used in the previous reports are different from the one we used. In previously published trials, celiac axis and gastroduodenal artery were used instead. Because the celiac axis is located in the retroperitoneal space, its distance to the cricoid cartilage would be shorter if measured through the posterior mediastinum, as the passage is relatively straight compared with the more tortuous anterior route. However, this direct distance is not clinically relevant when the stomach is used for reconstruction without the Kocher maneuver. Similarly, although the gastroduodenal artery may serve as a fixed reference point to measure the anatomic distance of anterior and posterior mediastinum, it is also not surgically relevant for postesophagectomy reconstruction using the stomach. In the current study, the Kocher maneuver was not performed as we found mobilization of the duodenum was not necessary if the anterior route is used for reconstruction; thus, an unnecessary surgical procedure can be avoided. Therefore, the pyloric ring was chosen as a superior distal reference point because of its clinical relevance. The duodenum is fixed in the retroperitoneal position without performing the Kocher maneuver, and the pyloric ring is essentially fixed in position by the duodenum. Tension to the gastric conduit is present at the pyloric ring distally and the cervical anastomosis proximally. Therefore, the length between the pylorus and the cricoid cartilage is much more representative of the actual distance used for reconstruction. The finding of AR being the shorter route can be further explained using our knowledge of gross anatomy. As the pyloric ring is situated more anteriorly in the normal anatomic position (Fig 3), it is clear that using AR (retrosternal route) for transposing the stomach while the duodenum is fixed in position should be more direct and straight.

View larger version (119K): [in this window] [in a new window]   Fig 3. The pyloric ring is situated more anteriorly in the normal anatomic position.

Although we discovered that the anterior route is shorter for postesophagectomy reconstruction using the stomach, whether this route is associated with fewer postoperative complications remains unanswered. Urschel and colleagues [4] reported that no significant differences could be found in the postoperative morbidity and mortality comparing the two procedures in their meta-analysis; however, all studies included in that analysis were completed before the trimodality era, and neoadjuvant treatments were not used for most patients. As neoadjuvant chemoradiation is currently considered part of the standard treatment for locally advanced esophageal cancer, avoiding the tumor bed within the radiotherapy field during reconstruction may be crucial for reducing posttreatment complications of the gastric conduit. However, this probability cannot be sufficiently addressed without a well-designed prospective clinical trial. Esophageal cancer is relatively common in Asia, and most of the cases are treated in tertiary-care hospitals specializing in cancer management. A multicenter randomized clinical trial is currently under development to study the outcome, complications, and quality of life associated with the routes of alimentary tract reconstruction in patients with esophageal carcinoma undergoing trimodality therapy.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

1. Akiyama H, Miyazono H, Tsurumaru M, et al. Use of the stomach as an esophageal substitute Ann Surg 1978;188:606-610.[Medline]
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This article has been cited by other articles:

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Haiquan Chen John Tam Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chen, H. Articles by Tam, J. Search for Related Content PubMed PubMed Citation Articles by Chen, H. Articles by Tam, J. Related Collections Esophagus - other