Papel de la yeyunoplastia en la reconstrucción esofágica compleja / Role of jejunoplasty in complex esophageal reconstruction

Introducción: La reconstrucción esofágica es un proceso quirúrgico técnicamente muy complejo, gravado por una importante morbilidad. Clásicamente se han utilizado la gastroplastia y la coloplastia, aunque la yeyunoplastia ya fue descrita por Roux en 1907. Parece demostrado que la plastia de yeyuno libre es una muy buena opción en el tratamiento de la enfermedad del esófago cervical, pero no está tan claro el papel de la yeyunoplastia supercharged en la reconstrucción del esófago torácico. El objetivo de este estudio es el análisis de las reconstrucciones esofágicas realizadas en nuestra unidad y que precisaron de un injerto de yeyuno. Métodos: Estudio retrospectivo de las reconstrucciones esofágicas realizadas con yeyunoplastias en nuestra unidad entre enero de 2011 y diciembre de 2019. Se analizan datos epidemiológicos, indicaciones, técnica quirúrgica y morbimortalidad. Resultados: Se realizaron 67 procedimientos quirúrgicos de reconstrucción esofágica compleja de los que 10 fueron yeyunoplastias: 5 yeyunos libres en esófago cervical y 5 supercharged en esófago torácico con abordaje transesternal. La morbilidad, mortalidad, estancia media y tiempo de retirada de la alimentación enteral fueron menores en los yeyunos libres que en los supercharged. Conclusiones: En nuestro grupo la yeyunoplastia supercharged es la última opción para la reconstrucción del esófago torácico; el acceso por esternotomía media nos permite un excelente abordaje del mediastino anterior y los vasos mamarios internos. El yeyuno libre sería la primera elección —con indemnidad del resto de esófago— en la reconstrucción del esófago cervical. (AU)

Introduction: Esophageal reconstruction is a very complex surgical procedure, burdened by significant morbidity. Gastroplasty and coloplasty have classically been used. Free jejunal plasty has shown to be a very good option in the treatment of cervical esophagus pathology, but the role of supercharged jejunoplasty in thoracic esophagus reconstruction is still controversial. Methods: A retrospective study of esophageal reconstructions with jejunoplasties performed in our unit between January 2011 and December 2019. Epidemiological data, indications, surgical technique, and morbidity and mortality were analyzed. Results: 67 procedures of esophageal reconstruction were performed, 10 of which were jejunoplasties: 5 free jejunums and 5 supercharged. Morbidity, mortality, mean stay and withdrawal time from enteral feeding were lower in free than in supercharged jejunums. Conclusions: Supercharged jejunoplasty was the last option for reconstruction of the thoracic esophagus. Median sternotomy access provides an excellent approach to the anterior mediastinum and the internal mammary vessels. The free jejunum would be the first choice, with the indemnity of the rest of the esophagus, in the reconstruction of the cervical esophagus. (AU)

Role of jejunoplasty in complex esophageal reconstruction.

INTRODUCTION: Esophageal reconstruction is a very complex surgical procedure, burdened by significant morbidity. Gastroplasty and coloplasty have classically been used. Free jejunal plasty has shown to be a very good option in the treatment of cervical esophagus pathology, but the role of supercharged jejunoplasty in thoracic esophagus reconstruction is still controversial. METHODS: A retrospective study of esophageal reconstructions with jejunoplasties performed in our unit between January 2011 and December 2019. Epidemiological data, indications, surgical technique, and morbidity and mortality were analyzed. RESULTS: 67 procedures of esophageal reconstruction were performed, 10 of which were jejunoplasties: 5 free jejunums and 5 supercharged. Morbidity, mortality, mean stay and withdrawal time from enteral feeding were lower in free than in supercharged jejunums. CONCLUSIONS: Supercharged jejunoplasty was the last option for reconstruction of the thoracic esophagus. Median sternotomy access provides an excellent approach to the anterior mediastinum and the internal mammary vessels. The free jejunum would be the first choice, with the indemnity of the rest of the esophagus, in the reconstruction of the cervical esophagus.

Emergency esophagojejunostomy in type IV hiatal hernia: A case report.

Reconstruction of the digestive tract is a surgical challenge; we propose a novel and successful alternative using a large vascularized pedicled jejunum anastomosed to the cervical esophagus in an emergency situation. A 65-year-old female patient in follow-up due to a gigantic type IV paraesophageal hernia, whom underwent surgical hernial defect correction, had friable gastric tissue and esophageal lesions that forced an urgent esophagojejunostomy. Immediate post-operative recovery had no incidents and during the outpatient follow-up no complications were reported. This case report represents a paradigm change in the impossibility of raising the vascularized pedicled jejunum to the neck in an emergency situation.

La reconstrucción del tracto digestivo es un reto quirúrgico. Proponemos una alternativa novedosa y exitosa utilizando un gran yeyuno pediculado vascularizado anastomosado al esófago cervical en situación de emergencia. Una paciente de 65 años en seguimiento por una hernia paraesofágica tipo IV requirió corrección quirúrgica del defecto herniario; tenía tejido gástrico friable y lesiones esofágicas que forzaron una esofagoyeyunostomía urgente. La recuperación posoperatoria inmediata no tuvo incidentes y el seguimiento ambulatorio no mostró complicaciones. Este reporte de caso rompe el paradigma de la imposibilidad de ascender el yeyuno pediculado vascularizado al cuello en una situación de emergencia.

Delayed cervical esophagogastrostomy: a surgical alternative for patients with ischemia of the gastric conduit at time of esophagectomy.

Ischemia of the gastric conduit after esophagectomy represents a setback that increases the risk of anastomotic leak. In order to prevent this severe complication, a surgical alternative has been proposed which consists in delaying the reconstruction until gastric perfusion improves. By adopting this strategy we can avoid two other surgical options that may significantly increase the risk of complications: 1) performing an esophagogastrostomy with a poorly perfused gastric tube and 2) resecting the gastric conduit followed by a complex reconstruction.