Treatment protocol for secondary esophageal reconstruction using 'supercharged' colon interposition flaps.

Locoregional esophageal cancer is currently treated with induction chemoradiotherapy, followed by esophagectomy with reconstruction, using a gastric conduit. In cases of conduit failure, patients are temporized with a cervical esophagostomy and enteral nutrition until gastrointestinal continuity can be established. At our institution, we favor reconstruction, using a colon interposition with a 'supercharged' accessory vascular pedicle. Consequently, we sought to examine our technique and outcomes for esophageal reconstruction, using this approach. We performed a retrospective review of all patients who underwent esophagectomy at our center between 2008 and 2018. We identified those patients who had a failed gastric conduit and underwent secondary reconstruction. Patient demographics, perioperative details, and clinical outcomes were analyzed after our clinical care pathway was used to manage and prepare patients for a second major reconstructive surgery. Three hundred and eighty eight patients underwent esophagectomy and reconstruction with a gastric conduit. Seven patients (1.8%) suffered gastric conduit loss and underwent a secondary reconstruction using a colon interposition with a 'supercharged' vascular pedicle. Mean age was 70.1 (±7.3) years, and six patients were male. The transverse colon was used in four cases (57.1%), left colon in two cases (28.6%), and right colon in one case (14.3%). There were no deaths or loss of the colon interposition at follow-up. Three patients (42.9%) developed an anastomotic leak, which resolved with conservative management. All patients had resumption of oral intake within 30 days. Utilizing a 'supercharging' technique for colon interposition may improve the perfusion to the organ and may decrease morbidity. Secondary reconstruction should occur when the patient's oncologic, physiologic, and psychosocial condition is optimized. Our outcomes and preoperative strategies may provide guidance for those centers treating this complicated patient population.

Neoadjuvant chemoradiotherapy with concurrent cisplatin/5-fluorouracil is associated with increased pathologic complete response and improved survival compared to carboplatin/paclitaxel in patients with locally advanced esophageal cancer.

Trimodal therapy consisting of neoadjuvant chemoradiation followed by esophagectomy has become the standard of care in North America for locally advanced esophageal cancer. While cisplatin/5-fluorouracil has been a common concurrent chemotherapy regimen since the 1980s, its utilization has declined in recent years as the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial regimen of carboplatin/paclitaxel has become widely adopted. The efficacy of the CROSS regimen compared to alternate chemotherapy choices, however, has rarely been evaluated when each is used as a component of a trimodal treatment approach. The aim of this study is to report our institutional experience with these two concurrent chemotherapy regimens at a specialized esophageal cancer center.We performed an Institutional Review Board-approved retrospective review of a prospectively maintained institutional foregut registry from a single National Cancer Institute-designated cancer center. Esophageal cancer patients who completed trimodal therapy with a chemotherapy regimen of either carboplatin/paclitaxel or cisplatin/5-fluorouracil were identified and divided into groups based on their chemotherapy regimens. Multivariable logistic regression was used to analyze pathologic complete response rates, while the Kaplan-Meier and Cox proportional hazards models were utilized to evaluate recurrence-free and overall survival. Analytical models were adjusted for age, clinical stage, radiation dose, histologic subtype (adenocarcinoma vs. squamous cell carcinoma), and time interval from completion of neoadjuvant therapy to surgery.One hundred and forty-two patients treated between January of 2000 and July of 2015 were identified as meeting inclusion criteria. Of this group, 87 had received the CROSS regimen of carboplatin/paclitaxel, while 55 had completed cisplatin/5-fluorouracil. Multivariable analysis demonstrated that the cisplatin/5-fluorouracil.group had an increased odds of pathologic complete response (odds ratio = 2.68, 95% confidence interval, P = 0.032), as well as significantly improved recurrence-free survival (hazard ratio = 0.39, 95% confidence interval 0.21-0.73, P = 0.003) and overall survival (hazard ratio = 0.46, 95% confidence interval 0.24-0.87, P = 0.016), compared to the carboplatin/paclitaxel group.Concurrent chemotherapy with cisplatin/5-fluorouracil in locally advanced esophageal cancer is associated with higher rates of pathologic complete response and improved recurrence-free and overall survival compared to the CROSS regimen of carboplatin/paclitaxel. This suggests that, for select patients, alternate neoadjuvant chemotherapy approaches, such as cisplatin/5-fluorouracil, merit reconsideration as potential primary treatment choices in the management of this highly morbid disease.