EGS P11 Super-charged colonic interposition after Upper Gastrointestinal tract resections: technical considerations from both benign and malignant cases and review of literature

Abstract

Abstract Background Oesophageal reconstruction is performed after an oesophagectomy, for either malignant or benign pathology. During reconstruction, variables include choice of conduit, route of reconstruction, and site of anastomosis. The stomach is preferred for neo-oesophageal reconstruction. However, when the stomach is not viable, alternatives including colon, jejunum, skin, or anterolateral thigh (ALT) musculocutaneous flaps are considered. Of these, colon is preferred for its ability to provide long-length grafts and reliable vascular supply. However, complications remain significant problems, including ischaemia at the anastomosis. To address this, 'supercharging’ and ‘super drainage' techniques are used to enhance arterial flow and venous drainage via microvascular anastomosis. Methods Case 1 involves a 61-year-old male who underwent an oesophagectomy for GOJ adenocarcinoma. A year later he developed a strangulated diaphragmatic hernia with an ischaemic gastric conduit, which was replaced with an isoperistaltic colonic interposition using transverse and left colon with super-drainage. 3 years later, the patient presented with pancreatitis, perforated gallbladder, and duodenum. Diffuse ischaemic changes of the interposed colon were recognised. A re-do colonic interposition using right colon with an arterial graft between the right transverse cervical artery and branch of ileal artery and super-drainage via a branch of the ileal and right external jugular veins was created. Results Case 2 involves a 68-year-old female who underwent an elective hiatus hernia repair with Nissen’s fundoplication. She deteriorated shortly post-operatively where re-look surgery found early hernia recurrence causing strangulation of the distal oesophagus and proximal stomach leading to ischaemia, necrosis, and perforation. She underwent a laparotomy and resection of the ischaemic distal oesophagus and proximal stomach, oesophagostomy and feeding jejunostomy. 16 months later, she underwent interposition of the right colon between the proximal oesophagus and remaining stomach. Arterial flow was adequate and supercharging was performed between the left external jugular vein and a branch of the middle colic vein. Conclusions There is limited literature on methods of both supercharging and super-drainage, as well as the optimal choice of organ for neo-oesophageal reconstruction. Currently, no established treatment protocols exist. There is evidence that supercharging and super-drainage are associated with longer operative times. However, benefits include lower leak incidence, shorter duration to oral intake, and reduced length of stay in relation to interposition without supercharge. Associated venous congestion may contribute to anastomotic leak, and may be prevented by super-drainage. Whilst supercharging has been reported worldwide, our case series adds to the UK practice showing it improves patient outcomes in an NHS setting.