Colonic Reconstruction Research Articles

OGC O05 Linear stapled technique for robotic assisted minimally invasive oesophagectomy and gastrectomy: technique, stepwise introduction, reproducibility and outcomes

Abstract Background Robotic-assisted surgery (RAS) for oesophagectomy and gastrectomy is gaining in popularity. Compared to open oesophagectomy and conventional minimally invasive techniques, RAS is associated with decreased rates of complications, increased harvested lymph nodes and shorter length-of-stay. However, high anastomotic leak rates (20-27%) have been seen within randomised trials and case series, with up to 50% early in some published series. We present our technique for a linear anastomosis and the results of its staged introduction. Methods Initially developed by a single surgeon at open surgery, it was adapted to thoracoscopic procedures and then reproduced during RAS by several surgeons across two centres. Using a prospectively maintained database we reviewed the first sixty-three cases utilising a modified linear anastomosis technique for oesophageal anastomosis. Outcomes, with particular focus on the anastomosis were reviewed. We also describe in detail the technical steps involved in our technique for a side-to-side linear semi-mechanical stapled anastomosis using a tri-stapler with a 2-layer V-lock closure of the common enterotomy, during robotic surgery (video). Results Sixty-one patients had a two-stage oesophagectomy (one for benign disease), one with colonic reconstruction and two total gastrectomy. Median age was 63 (range 47-85). 89% (55/62) were adenocarcinomas, the remainder squamous cell carcinomas. The anastomosis was performed via an open approach initially in 11, thoracoscopically in 4, then robotically in 48 (including the gastrectomies). The first 20 anastomoses were performed by one surgeon, who then proctored four others. Two Type I anastomotic leaks (3.2%) and two Type I conduit necrosis occurred. There was no in hospital mortality. Non-anastomotic complications occurred in 28/63 (44.4%) of patients, most commonly respiratory (15/63, 23.8%). Conclusions We report a reproducible technique for semi-mechanical linear stapled anastomosis and its safe introduction into oesophageal and gastric resections including RAS, with anastomotic leak rates below the internationally reported rates, even in the early phase of its introduction in open, thoracoscopic and RAS. This technique, combined with training and mentorship may help more centres safely introduce a RAS oesophago-gastric programme, and improve patient outcomes.

450. LINEAR STAPLED TECHNIQUE FOR ROBOTIC ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY AND GASTRECTOMY: TECHNIQUE, STEPWISE INTRODUCTION, REPRODUCIBILITY AND OUTCOMES

Abstract Background Robotic-assisted surgery (RAS) for esophagectomy and gastrectomy is gaining in popularity. Compared to open oesophagectomy and conventional minimally invasive techniques, RAS is associated with decreased rates of complications, increased harvested lymph nodes and shorter length-of-stay. However, high anastomotic leak rates (20–27%) have been seen within randomised trials and case series, with up to 50% early in some published series. We present our technique and results of the staged introduction of a linear anastomosis. Methods The technique was initially developed by a single surgeon at open surgery; then adapted to thoracoscopic surgery and finally reproduced at RAS by several surgeons across two centres. Using a prospectively maintained database we reviewed the first forty-two cases utilising a modified linear anastomosis technique for oesophageal anastomosis. Outcomes, with particular focus on the anastomosis were reviewed. We also describe in detail the technical steps involved in our technique for a side-to-side linear semi-mechanical stapled anastomosis using a tri-stapler, with a 2-layer V-lock closure of the common enterotomy, during robotic surgery (video https://www.dropbox.com/s/ljf3zmuy68qry7b/Anastomosis%20technique_Short_Sound.mp4?dl=0). Results Forty patients had a two-stage esophagectomy, one with colonic reconstruction, and two, total gastrectomy. Median age was 62 (range 47–85). 93% (39/42) were adenocarcinomas, the remainder were squamous cell carcinomas. The anastomosis was performed via an open approach in the initial 11, thoracoscopically in 4, then robotically in 27 (including the two gastrectomies). The first 20 anastomoses were performed by one surgeon, who then taught four others. Two grade I anastomotic leaks occurred (4.7%), both were treated conservatively. There was no 30-, 90-day, or in hospital mortality. Non-anastomotic complications occurred in 14/42 (33.3%) of patients, most commonly respiratory (5/42, 11.9%). Conclusion We report a reproducible technique for semi-mechanical linear stapled anastomosis and its safe introduction into esophageal and gastric resections, including RAS. Anastomotic leak rates are below the internationally reported rates, even in the early phase of its introduction in open, thoracoscopic and RAS. With good training and mentorship this may help more centres safely introduce a RAS esophago-gastric programme, improve patient outcomes and reduce length of stay.

Surgical treatment of thoracic esophageal diverticula.

Thoracic esophageal diverticulum (TED) is a rare benign disease associated with motility disorders of the esophagus. Surgical management is usually the definitive treatment, with traditional excision of the diverticulum via thoracotomy and minimally invasive techniques being comparable and associated with a mortality rate of between 0 and 10%. To present the results of surgical treatment of patients with thoracic diverticula of the esophagus in a 20-year period. The study presents a retrospective analysis of the results of surgical management of patients with the thoracic esophageal diverticulum. All patients underwent open transthoracic diverticulum resection with myotomy. Patients were evaluated for the degree of dysphagia before and after surgery, associated complications and overall comfort after surgical treatment. Twenty-six patients due to diverticula of the thoracic part of the esophagus underwent surgical treatment. Resection of the diverticulum with esophagomyotomy was performed in 23 (88.5%) patients, anti-reflux surgery was performed in 7 (26.9%) and in 3 (11.5%) patients with achalasia, the diverticulum was left unresected. Among the patients operated on, 2 (7.7%) patients developed a fistula, and both required mechanical ventilation. In 1 patient the fistula closed spontaneously, and the other patient required esophageal resection and colon reconstruction. Two patients required emergency treatment due to mediastinitis. There was no mortality in the perioperative period of hospital stay. Treatment of thoracic diverticula is a difficult clinical problem. Postoperative complications pose a direct threat to the patient's life. Esophageal diverticula is characterized by good long-term functional results.

Safety and efficacy of double-tract reconstruction with remnant stomach conservation in esophagectomy for patients with a history of distal gastrectomy.

Total gastrectomy with jejunum or colon reconstruction after esophagectomy is commonly performed in patients with esophageal cancer who have a history of distal gastrectomy. In this study, we examined the safety and effectiveness of double-tract reconstruction (DTR) with preservation of the remnant stomach for said patient population. Twenty-seven esophageal cancer patients with a history of distal gastrectomy who underwent transthoracic esophagectomy between 2010 and 2020 in our institution were retrospectively analyzed; 15 of these patients underwent DTR, whereas 12 underwent completion gastrectomy with jejunal Roux-en-Y reconstruction (RYR). Short-term outcomes, postoperative nutritional indexes, and ghrelin levels were evaluated. Moreover, abdominal lymph-node metastasis and recurrence, which were removed by total residual gastrectomy, were examined to determine the oncological validity of residual stomach preservation. There was no metastasis and recurrence in abdominal lymph nodes, such as #4sa or #11d, which were removed by total residual gastrectomy. Total operation time did not differ between the groups (P = 0.4247). The blood loss for the DTR group was 495 ± 446mL, whereas that for the RYR group was 844 ± 575mL (P = 0.0168). Clavien-Dindo grade III or higher complications were not significantly different between the groups (P = 0.7063). The rates of serum total protein values at 6months in the DTR and RYR groups were 112% ± 12.2% and 102.6% ± 10.7% (P = 0.0403), respectively. The prognostic nutritional indexes at 6months in the DTR and RYR groups were 108.6% ± 14.5% and 83.2% ± 42.6% (P = 0.0376), respectively. DTR in esophagectomy is safe and effective for patients with a history of distal gastrectomy.

A biodegradable magnesium surgical staple for colonic anastomosis: In vitro and in vivo evaluation.

Staplers have been widely used in the clinical treatment of gastrointestinal reconstruction. However, the current titanium (Ti) staple will remain in the human body permanently, resulting in some adverse effects. In this study, we developed a type of biodegradable staple for colonic anastomosis using 0.3 mm diameter magnesium (Mg) alloy wires. The wire surface was modified by micro-arc oxidation treatment (MAO) and then coated with poly-l-lactic acid (PLLA) to achieve a moderate degradation rate matching the tissue healing process. The results of tensile tests on isolated porcine colon tissue anastomosed by Mg and Ti staples showed that the anastomotic property of Mg staples was almost equal to that of Ti staples. The in vitro degradation tests indicated the dual-layer coating effectively enhanced the corrosion resistance and maintained the tensile force of the coated staple stable after 14-day immersion in the simulated colonic fluid (SCF). Furthermore, 24 beagle dogs were employed to conduct a comparison experiment using Mg-based and clinical Ti staples for 90-day implantation by ent-to-side anastomosis of the colon. The integrated structure of Mg-based staples was observed after 7 days and completely degraded after 90 days. All animals did not have anastomotic leakage and stenosis, and 12 dogs with Mg-based staples fully recovered after 90 days without differences in visceral ion levels and other side effects. The favorable performance makes this Mg-based anastomotic staple an ideal candidate for colon reconstruction.

Comparing the short-term results of the improved triangular anastomosis technique for complete laparoscopic radical resection of sigmoid colon cancer and laparoscopic-assisted small incision colon reconstruction: A CONSORT study.

The laparoscopic approaches using the triangular anastomosis technique for sigmoid colon cancer (SCC) are rare. This CONSORT study explored the short-term effects of laparoscopic radical resection of SCC with modified triangular anastomosis technique and laparoscopic-assisted small incision colon cancer reconstruction surgery. From April 2019 to January 2021, a total of 86 patients with SCC who were admitted to Luopu County People’s Hospital were selected and received radical resection. Patients were divided into 2 groups using a random number table method: in the control group, patients underwent laparoscopic-assisted small-incision reconstruction surgery, and patients in the observation group underwent complete laparoscopic surgery with modified triangular anastomosis technique. The 2 groups were compared in perioperative related indicators and postoperative complications. After 3 months follow-up, local tumor recurrence and metastasis, abdominal wall puncture and implantation, and death were observed. Compared to the control group, shorter operation time, gastrointestinal reconstruction time, postoperative exhaust time, hospitalization time, and less intraoperative blood loss, and lower probability of complications were observed in the observation group (P < .05). However, there was no significant difference in the number of lymph node dissections between the 2 groups (P > .05). After 3 months of follow-up, no local tumor recurrence, distant tumor metastasis, abdominal wall puncture implantation, and death were found in the 2 groups of patients. It is indicated that the improved triangular anastomosis technique for complete laparoscopic radical resection of SCC is effective in treatment for SCC.

339. RESULTS OF LEFT COLON RECONSTRUCTION FOR ESOPHAGECTOMY IN A LOW VOLUME HOSPITAL IN JAPAN

Abstract Our hospital is a low volume hospital that performs about 5–10 esophageal cancer surgeries per year in Japan. We aimed to evaluate the results of colon reconstruction in our hospital and the appropriateness of performing this procedure in a low volume hospital. We retrospectively examined complications such as suture failure, conduit necrosis, and anastomotic stenosis in colon reconstruction cases performed at our hospital from 2012 to 2022. Five cases were performed. In all cases, we have confirmed arterial supply of colon by dynamic CT before surgery, and have chosen to posterior mediastinal reconstruction using the left-sided colon. Esophageal-colon anastomosis was performed, with hand-sewn in 2 cases and triangulating stapling in 3 cases. Although a plastic surgeon was always waiting in case of poor blood supply of conduit, none of the cases needed microvascular anastomosis. Recurrent nerve palsy in 1 patient, ileus in 1 patient, and pneumonia in 2 patients were detected. The median operative time was 654 minutes, and the median blood loss was 260 mL. We believe that our cautious preparations make it acceptable to perform esophageal cancer surgery with colon reconstruction even in low volume hospitals.

Feeding jejunostomy following esophagectomy may increase the occurrence of postoperative small bowel obstruction.

This study aimed to clarify the characteristics and treatment of bowel obstruction associated with feeding jejunostomy in patients who underwent esophagectomy for esophageal cancer. In this single-center retrospective study, 363 patients underwent esophagectomy with mediastinal lymph node dissection for esophageal cancer at the Wakayama Medical University Hospital between January 2014 and June 2021. All patients who underwent esophagectomy routinely underwent feeding jejunostomy or gastrostomy. Feeding jejunostomy was used in the cases of gastric tube reconstruction through the posterior mediastinal route or colon reconstruction, while feeding gastrostomy was used in cases of retrosternal route gastric tube reconstruction. Nasogastric feeding tubes and round ligament technique were not used. Postoperative small bowel obstruction occurred in 19 of 197 cases of posterior mediastinal route reconstruction (9.6%), but in no cases of retrosternal route reconstruction because of the feeding gastrostomy (P < .0001). Of the 19 patients who had bowel obstruction after feeding jejunostomy, 10 patients underwent reoperation (53%) and the remaining 9 patients had conservative treatment (47%). The cumulative incidence of bowel obstruction after feeding jejunostomy was 6.7% at 1 year and 8.7% at 2 years. Feeding jejunostomy following esophagectomy is a risk factor for small bowel obstruction. We recommend feeding gastrostomy inserted from the antrum to the jejunum in the cases of gastric tube reconstruction through the retrosternal route or nasogastric feeding tube in the cases of reconstruction through the posterior mediastinal route.

Operative outcomes and long-term survival of patients undergoing colon interposition after esophagectomy for cancer.

BackgroundThe first choice of an esophageal substitute after esophagectomy for cancer is the stomach. However, the colon must be considered for reconstruction in specific situations. The purpose of this study was to clarify the frequency and clinical features of patients who underwent colon interposition in thoracic esophagectomy and to investigate the postoperative complications and survival.MethodsWe conducted a retrospective case–control study in the National Cancer Center Hospital East, Japan. Patients who underwent colon interposition after esophagectomy for cancer between 2010 and 2020 were analyzed.ResultsEighty‐eight patients underwent esophagectomy with colon interposition; 53.2% received preoperative treatment and 52.3% underwent thoracoscopic surgery. Clavien–Dindo grade >III postoperative complications occurred in 42% of the patients; anastomotic leakage was the most common complication, occurring in 26.1% of the cases. Univariate analysis of the factors associated with Clavien–Dindo grade <III complications showed that the period 2015–2020 and totally mechanical Collard anastomosis were significant factors, with odds ratios (OR) of 0.264 and 0.267 (p = 0.00327 and p = 0.00335), respectively. Totally mechanical Collard anastomosis was associated with a lower risk of anastomotic leakage by univariate and multivariate analysis (OR, 0.257, p = 0.00566 and OR, 0.285, p = 0.133, respectively). Three‐year overall survival was 54.2%. Univariate and multivariate analysis of overall survival showed that older age was a risk factor (OR, 1.08) for complications.ConclusionIn colon reconstruction after esophageal cancer resection, totally mechanical Collard anastomosis for cervical anastomosis may reduce the risk of Clavien–Dindo grade >III complications.

Ileo-right colonic reconstruction preserving all four colonic vessels after esophagectomy for cancer.

When colonic graft is used as an esophageal substitute after esophagectomy, one or two feeding vessels of the colon are cut to obtain sufficient length, the graft is passed via the subcutaneous route, and microvascular anastomosis is often used to avoid fatal complications. Sixteen consecutive ileo-right colonic reconstructions via the posterior mediastinal or retrosternal route with preservation of all four colonic vessels were performed in the past eight years. We presented the surgical technique and evaluation of this surgical method. In 15 out of 16 consecutive cases, the graft could be pulled up to the neck through the posterior mediastinal or retrosternal route while preserving all four colonic vessels. Reconstruction was not possible in one patient because of ileocolic vessel injury during colonic mobilization. Anastomotic leakage occurred in three patients, but all were minor and were treated conservatively. There were no patients with graft necrosis resulting from insufficient blood supply. Ileo-right colonic reconstruction with preservation of all four colonic vessels through the posterior mediastinal or retrosternal route is a safe and feasible procedure and is considered the first choice for colonic reconstruction as an esophageal substitute.

A Template-Based 3D Reconstruction of Colon Structures and Textures From Stereo Colonoscopic Images

This article presents a framework for 3D reconstruction of colonic surface using stereo colonoscopic images. Due to the limited overlaps between consecutive frames and the nonexistence of large loop closures during a normal screening colonoscopy, the state-of-art simultaneous localization and mapping (SLAM) algorithms cannot be directly applied to this scenario, thus a colon model segmented from CT scans is used together with the colonosocopic images to achieve the colon 3D reconstruction with high accuracy. The proposed framework includes 3D scan (point cloud with RGB information) reconstruction from stereo images, a visual odometry (VO) based camera pose initialization module, a 3D registration scheme for matching texture scans to the segmented colon model, and a barycentric-based texture rendering module for mapping textures from colonoscopic images to the reconstructed colonic surface. A realistic simulator is developed using Unity to simulate the procedures of colonoscopy and used to provide experimental datasets in different scenarios. Experimental results demonstrate the good performance of the proposed 3D colonic surface reconstruction method in terms of accuracy and robustness. Currently, the framework requires a pre-operative colon model as the template for colon reconstruction and can reconstruct 3D colon maps when the colon has no large deformation and the colon structure is clearly visible. The datasets used in this article and the developed simulator are made publicly available for other researchers to use (https://github.com/zsustc/colon_reconstruction_dataset).

Microvascular grafting to enhance perfusion in colonic long-segment oesophageal reconstruction.

Oesophagectomy with long-segment colon reconstruction is the first-line treatment when the stomach is not available. Supercharging of the newly formed conduit can improve vascular function utilizing intraoperative perfusion imaging system, following thoracoscopic oesophagectomy for distal-oesophageal and gastroesophageal junction cancer. The purpose of this study is to examine the safety and efficacy of microvascular augmentation of left colonic interposition following oesophagectomy for oesophageal cancer. A retrospective analysis of 156 consecutive oesophagectomies between January 2016 and July 2018 was performed. All oesophagectomies involving left colon interposition with microvascular augmentation were included in the study. In all cases, oesophageal mobilization was performed thoracoscopically in prone position and the left colon was used as neo-oesophagus in an isoperistaltic fashion. Conduit perfusion was assessed with the Spy system and neck supercharging was performed using microsurgical technique. A total of n = 5 (3.2%) patients were identified. Two cases had delayed and 3 had immediate reconstruction. The conduit was microsurgically augmented in 3 cases with both venous and arterial anastomoses (supercharging) and in 2 cases with venous anastomosis only (superdrainage). No anastomotic leak was identified. One case developed left recurrent laryngeal nerve palsy with associated aspiration pneumonia. Supercharged colonic interposition is a safe way of oesophageal reconstruction when long-segment interposition graft is needed. In oesophageal cancer and in the absence of a viable stomach with intact gastroepiploic arcade, it should be considered a feasible option with favourable outcomes, when the expertise and facilities are available. Use of intraoperative perfusion imaging reveals improved conduit blood supply post-supercharging.

Comparison of outcomes of pedicled jejunal and colonic conduit for esophageal reconstruction

BackgroundAt present, the gastric tube is the first choice for esophageal reconstruction after esophagectomy for various benign and malignant diseases. However, when the stomach is not available, a pedicled jejunum or colon is used to reconstruct the esophagus. The present study aimed to compare the postoperative outcomes and quality of life of patients receiving jejunal and colonic conduits.MethodsIn the present retrospective study, the clinical data of 71 patients with esophageal carcinoma, who received jejunal reconstruction (jejunum group, n = 34) and colonic reconstruction (colon group, n = 37) from 2005 to 2015, were compared.ResultsCompared with the colon group, the jejunum group had a lower incidence of postoperative anastomotic leakage, lesser duration of postoperative drainage, and faster recovery. Furthermore, the scores were better in the jejunum group than in the colon group, in terms of short-term overall quality of life, physical function and social relationships. Moreover, the jejunal group had a significantly lower frequency of pH < 4 simultaneous reflux time > 5 min (N45) and the longest reflux time (LT) at 24 weeks after surgery.ConclusionIn esophageal cancer, when gastric tube construction is not feasible, a pedicled jejunum may be preferred over a colonic conduit due to lower incidence of acid reflux, anastomotic leakage and higher postoperative short-term quality of life, and rapid postoperative recovery.

PROSPECTIVE AND RETROSPECTIVE STUDY OF COLONIC INTERPOSITION IN BENIGN AND MALIGNANT ESOPHAGEAL LESION.

The Retrospective and prospective study entitled "Prospective and Retrospective study of Colonic Interposition in Benign and Malignant Esophageal Lesion" will be conducted in the Department of Surgery of MGM Medical College and M.Y. Hospital, Indore over a period of 2 year.&#x0D; The above table shows the distribution of patients according to presenting complains. 1 (3.3%) patient presented with liquid dysphagia, 23 (76.7%) patients presented with solid and liquid dysphagia and 6 (20.0%) patients presented with solid dysphagia. Majority of the patients had solid and liquid dysphagia. the distribution of patients according to diagnosis. 6 (20.0%) patients had carcinoma esophagus and 24 (80.0%) patients had esophageal strictures. Majority of the patients had esophageal strictures. Comparison of wound site infection. At 2 weeks, 2 (6.7%) patients had wound site infection, which was still present at 1 month and decreased to 1 (3.3%) at 3 months. After 3 months, none of the patients had wound site infection.&#x0D; The colon interposition is an alternative option for esophageal reconstruction when the stomach is unavailable the quality of life after colonic transposition compared at postoperative 1 month and 2 year using specially designed QOL questionnaire for coloplasty patients. Our disease specific questionnaire performs well in relation to previously published study which was used same questionnaire asses the quality of life. in post coloplasty patients According to the selected colon graft (left or Right) route of reconstruction, direction of graft various surgical procedures can be considered for colonic reconstruction in present study left colic artery based left colonic graft is used. Regardless of the situation, blood supply of colon graft directly affect the outcome of the surgery.&#x0D; Keywords: Colonic, Interposition, Esophageal &amp; Lesion.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.Case presentationIn case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.ConclusionsThe causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

Efficacy of preserving the residual stomach in esophageal cancer patients with previous gastrectomy.

There is no consensus concerning whether the residual stomach should be preserved after esophagectomy for thoracic esophageal cancer patients with previous distal or segmental gastrectomy. The purpose of this retrospective study was to assess the efficacy of preserving the residual stomach after esophagectomy in patients with previous gastrectomy. Between 2000 and 2015, 45 consecutive thoracic esophageal cancer patients with previous distal or segmental gastrectomy underwent esophagectomy followed by colon reconstruction. Patients were assigned to two groups according to how the residual stomach was treated (preservation group, n = 11; resection group, n = 34). We compared surgical outcomes and alterations of nutrition status, including the skeletal muscle area, between the two groups. In addition, we investigated the distribution of abdominal lymph node metastases in the resection group. Operative time and blood loss tended to be lower in the preservation group compared to the resection group. However, the difference did not reach statistical significance. The rate of patients decreasing skeletal muscle area after surgery was significantly higher in the resection group (88% vs 50%, P = 0.03). There were no patients with metastatic abdominal lymph nodes when the previous gastrectomy had been performed for gastric cancer and the esophageal cancer was located at the upper or middle esophagus in the resection group. Preservation of the residual stomach after esophagectomy in esophageal cancer patients with previous gastrectomy may influence the postoperative nutrition status and can be selectively approved.

RA05.07: ESOPHAGEAL RECONSTRUCTION BY PEDICLED TERMINAL ILEUM AND RIGHT COLON WITH PRESERVED ILEOCOLIC VESSELS

Abstract Background In the case of esophageal cancer patient whose stomach is not available for reconstruction, we had been using pedicled jejunum for lower esphageal cancer or right colon reconstruction as an alternative. However, high incidence of postoperative anastomotic leakage regarding insufficient blood supply was a great distress. We started the unique reconstruction technique using terminal ileum and right colon with preserved ileocolic vessels in 2011. Based on our experience, we considered benefits of our method. Methods After esophagectomy and lymphadenectomy, the ascending colon was mobilized. The mid colic, right colic (if exist) and ileocolic vessels, as well as marginal vessels of terminal ileum, were preserved, the ileum was cut at the point approximately 20–30cm from the ileum end. The final ileal artery and vein may be ligated and cut, if necessary. The pedicled ileo-colon was, then, carefully lifted isoperistaltically via subcutaneous route. Esophagoileostomy was usually performed by functional end to end anastomosis. Additional anastomoses were performed by Billroth II or Roux en Y method. Results In total of 383 patients who were underwent transthoracic esophagectomy between 1998 and 2017, 15 pedicled jejunum (J), 4 traditional right colon (C) and 6 ileo-colon preserved ileocolic vessels (IC) were used for reconstruction. The incidence of esophagoileostomy-related complications were 6.7% (1/15) in J, 50.0% (2/4) in C and 33.3% (2/6) in IC. One in IC showed ileal necrosis caused by sclerotic obstruction on the root of ICA, then remained right colon was used for free flap salvage reconstruction. Two in C suffered from pneumonia at early post-operative days, probably because of microaspiration of colic bacterium, interestingly, there was no caces of pneumonia in IC. In addition, the subcutaneous space was occupied only with the ileum, therefore the antesternal skin bloating was not bulky. Conclusion The advantages of our technique are; i) less anastomotic complications, ii)possibility of less aspiration pneumonia, iii) better cosmetic appearance, and iv) no microvascular surgery required. Our technique could be used as the standard method of reconstruction after esophagectomy for patients in whom stomach is not available. Disclosure All authors have declared no conflicts of interest.

Pelvic Exenteration Put into Therapeutical and Palliative Perspective: It Is Worth to Try.

Pelvic exenteration (PE) is one of the most drastic operations in surgical oncology, associated with severe morbidity and mortality. The objective of our study was to review our experience of PE in terms of surgical characteristics, complications, and overall survival. All patients who had PE surgery between January 1999 and December 2015 were identified. Patients with verified distant metastatic disease were excluded. Patients with advanced pelvic tumors experiencing incapacitating postradiation severe damages were included. The following parameters were recorded: age, sex, indication for surgery, tumor histology, type of exenteration, urinary tract and colon reconstruction methods, operative time, blood transfusion, intensive care unit admissions, length of hospital stay and readmissions, and characteristics of perioperative morbidity and mortality. A total of 25 patients were submitted to PE by our surgical team. Most of the patients suffered from cervical cancer followed by bowel cancer. There was no perioperative mortality. Early postoperative complications ensued in 56% of the patients. Most complications involved the urinary system. Five years survival was estimated at 38%. Most patients (n = 9, 36%) died due to their primary disease, 5 (20%) died because of complications following operation, and 2 (8%) died because they denied oral feeding, which was associated with depression. Patients with a variety of malignancies can benefit from PE. Meticulous surgical technique, perioperative care, counseling, and nutritional support play an important role.

Colon reconstruction after the Hartmann procedure. Laparoscopy or laparotomy?

The Hartmann procedure - primarily - was introduced for the treatment of cancerous diseases of sigmoid colon and rectum. In the last few years it was performed in cases with complicated inflammation of the left colon, colon cancers with bowel obstruction or perforation, or in the case of insufficiency of the anastomoses, or in urgent operations after traumatics bowel injuries, when making the anastomosis is at very high risk. Later on the restoration of the continuity of the GI tract can be done traditionally (by laparotomy) or laparoscopically. We present our experiences with the above technique, and also compare our results with traditional open surgeries in our patients.

Colon Reconstruction and Esophageal Reconstructive Surgery

Esophageal reconstruction using colon graft was investigated in this review. Since the first use of the colon for esophageal reconstruction by Kelling and Vulliet, the colon reconstruction became a reliable surgical option to reconstruct partially or totally the esophagus. Over the time, the efficacy of colon graft has been thoroughly evaluated and definitively attested by competent surgeons during the past three decades. The mortality has been significantly improved however the early morbidity is still slightly higher compared to gastric reconstruction. Despite the increased operative time and number of anastomoses, the advantages of a colon graft become apparent including its relatively straight mesentery, its status as an enough long graft to be pulled up to the neck, its low incidence of disease, its resistance gastroesophageal reflux and its long-term good functional results. Compared to right colon, the left colon has less variation in blood supply and a smaller lumen diameter which matches perfectly with esophageal lumen. Colon reconstruction in an isoperistaltic fashion is the standard in order to prevent regurgitation and improve food transit. The posterior mediastinum and the substernal route are the most commonly route used in esophageal reconstruction. However in case of substernal colon reconstruction, as recommended by authors, the thoracic inlet should be enlarged by the partial remove of the manubrium and the left clavicle to ensure there is no compression on the transposed graft at the level of the thoracic inlet. The selection of appropriate colon graft should be based on the adequacy of blood supply and the length of reconstruction. Thereafter microvessel anastomosis should be added in cases where graft ischemia might occur.