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Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98111
(Email: gtsdel{at}vmmc.org).
Dr Mine and colleagues [1] present us with an interesting, retrospective review from a high-volume center (1,146 esophageal resections during a 19-year study period) that examines a particularly pertinent subpopulation of patients requiring esophageal resection for cancer, without the option for reconstruction with a gastric conduit. The authors provide us with two themes within the article. One involves the technical considerations required for esophageal reconstruction under these circumstances, and the second is the assessment of survival results in patients who also undergo extended lymphadenectomy. I believe it is the technical considerations that provide the most interesting avenue for further discussion.
The authors changed their standard technique of colon graft harvest midway through their study, and ultimately 65% of their reconstructions were done with ileocolonic grafts. They highlight the historical descriptions of the advantages of including a segment of ileum in their conduit, but they also note an overall decrease in anastomotic leakage rate and mortality during the period in which these grafts became more prevalent. Although this trend is very evident in their results, many centers have seen improvements in morbidity and mortality rates that have evolved over the last 2 decades. Many of these improvements are due to increasing surgical experience and system issues, such as anesthetic and perioperative management, including structured clinical pathways. What is also clear is that the authors carefully adapt their approach to colon harvest, according to clinical conditions and blood supply, which is equally likely to be a component of their excellent technical outcomes.
Other interesting technical details include the fact that within "recent cases" the authors harvested up to 20 cm of ileum, and used only 15 cm of colon graft. This amount of ileum is more extensive than what is used in many historic series, and considering that the esophagus typically ranges in length between 19 and 26 cm, the ileum would form the major component of the intrathoracic graft. Considering that redundancy with time has been one of the technical problems associated with colon grafts, this adaptation may be one of the reasons the authors have seen improved functional results.
The retrosternal route was used in 97% of the patients. The advantages of this route in comparison with the subcutaneous pathway are described by the authors; however, they indicate that the more standard route through the posterior mediastinum was not used because of their preference to avoid locating conduits in the "tumor bed," which has not been a significant concern in the vast majority of other esophagectomy series.
The authors also preferred their distal anastomotic technique to be in the form of a "Billroth II" method, which is, in fact, an end-to-side colojejunostomy. In the past, this anastomotic technique has been associated with increased levels of biliary reflux. The authors indicate that 24% of their postoperative population had "reflux," but unfortunately they make no attempt to subdivide this analysis between the groups that had end-to-side and Roux-en-Y colojejunostomies.
The surgical literature currently suggests that stapled anastomosis can decrease leak and stricture rate. The authors produce excellent results with the hand-sewn technique, with a leak rate of 5.4% in the second period of their study, and a very impressive overall stricture rate of only 6%. The complexity of these operations, however, is highlighted by an overall complication rate of 64%.
The authors should be congratulated on a description of a very large series of patients who typically form a small component of surgical resections, even in busy esophageal units. The results support esophageal surgeons considering using these types of ileocolonic grafts for esophageal reconstruction when the stomach is unavailable or inappropriate.
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