Overview of Esophageal Reconstruction
The esophagus is a muscular tube that moves food from the back of your throat (hypopharynx) to your stomach. It’s crucial for eating and digestion. If there are problems with the esophagus, whether non-cancerous or cancerous, nutrition needs to be obtained by other methods. This can include tubes inserted directly into the stomach (gastrostomy tubes) or the small intestine (jejunostomy tubes). If the esophagus has to be removed, the next step would be to reconstruct or rebuild it.
Anatomy and Physiology of Esophageal Reconstruction
The esophagus is a long tube that is about 25 centimeters long, and it connects your mouth to your stomach. It has two special areas called the upper and lower esophageal sphincters that control the entrance and exit of food. The esophagus is divided into three sections: cervical (in the neck area), thoracic (in the chest), and abdominal (in the tummy).
The cervical part of the esophagus starts at the cricopharyngeus muscle, which is around the area of your throat, and ends at the supracervical notch, which is located just above the chest area. The thoracic segment is in the chest cavity, beginning from the notch where the chest starts and ending at the diaphragm – which is a muscle that helps in breathing. The abdominal esophagus is the smallest part; it starts from the diaphragm and ends at the gastric fundus, the top part of the stomach.
Different arteries supply these sections with blood. The cervical section gets blood from the inferior thyroid artery, which is located in the neck. The thoracic part receives direct branches of blood vessels from the esophagus itself. The abdominal part obtains its blood supply from two arteries: the left gastric artery and the left phrenic artery. Depending on the section, different veins carry away the used blood to the heart, with the superior vena cava and the azygos and inferior thyroid veins being included. The distal esophagus, which is the lower part, drains its used blood into the left gastric vein, which then pours into a larger vein called the portal vein. In some people with cirrhosis – a type of liver disease – this connection between the large systemic and smaller portal circulation can cause veins to swell up in the esophagus, causing what’s known as esophageal varices.
The primary task of the esophagus is to transfer food from the mouth to the stomach. It does this job by initiating coordinated muscular waves, known as peristalsis. The esophagus contains two types of muscles. In the neck area, the muscles are striated, meaning they have a pattern of stripes. The lower two portions – thoracic and abdominal – have smoother muscles. Each of these muscle types plays a specific role in moving food down the esophagus and into the stomach.
Why do People Need Esophageal Reconstruction
An esophagectomy, a surgery to remove or repair the esophagus, may be needed for several reasons such as removal of a tumor, healing damage caused by a severe burn, fixing radiation injuries or treating a birth defect. If someone has advanced cancer of the esophagus, such as adenocarcinoma or squamous cell carcinoma, they might need this procedure. Usually, these patients receive treatments like radiation and chemotherapy before having the surgery.
In some cases, if a person swallows a harmful substance that is highly acidic (pH less than 2) or basic (pH more than 12), it could severely injure or burn the esophagus. Depending on the seriousness of the injury, a person might need immediate esophagectomy. Also, these people have a higher risk of developing esophageal cancer, so they need to have regular check-ups.
Esophageal atresia, which is a birth defect in which part of the esophagus doesn’t develop correctly, is another reason a person might need this surgery. The condition is quite rare, occurring in 1 out of every 2500 to 4500 live births. Depending on the specific type and severity of the atresia, which might include a tracheoesophageal fistula where there’s an abnormal connection between the windpipe and esophagus, doctors might try to connect the disrupted parts of the esophagus directly. But if the gap is too large, they might need to use a piece of stomach, colon, or jejunum (part of the small intestine) to “bridge” the gap. In children, the colon is typically used for this purpose.
The esophagus removal can be done in a few different ways, including the Ivor Lewis esophagectomy, the transhiatal esophagectomy, or the Mckeown three-incision esophagectomy. Each method uses a combination of incisions in the abdomen, right chest, and left neck. The method chosen will depend on the location of the tumor, the experience of the surgeon and the health of the patient. All these surgeries can also be performed in a minimal invasive way, this is to reduce the recovery time and potential complications.
When a Person Should Avoid Esophageal Reconstruction
There might be situations when a person is too weak or malnourished to undergo a procedure called an esophagectomy, where part of or the whole esophagus is removed. These situations mean the person wouldn’t be appropriate for a surgery to reconstruct the esophagus. If someone needs this surgery, they can be given “tube feedings” – liquid food given through a tube into the stomach or a part of the small intestines (jejunum) – to complement their regular food intake.
Regarding cancer, patients who have severe esophageal cancer that has spread to other parts of the body (metastasized) or is locally advanced but cannot be removed by surgery, are best managed with comfort-focused treatments. Instead of reconstructing the esophagus, these patients might receive chemotherapy and radiation (chemoradiation), esophageal stents (small tubes to keep the esophagus open), and possibly esophageal dilations (procedures to widen the esophagus).
Equipment used for Esophageal Reconstruction
When a surgeon is doing a procedure to rebuild the esophagus, otherwise known as esophageal reconstruction, the tools required will depend on a few factors. These can include the type of esophagectomy (removal of part or all of the esophagus), how the surgeon plans to perform the procedure, and what material they plan to use to replace the esophagus.
If the surgeon plans to perform the operation using a traditional open surgery, they will need tools that can help position and secure body parts such as those in the abdomen and chest. Some of these tools include retractors, which hold back organs or tissue; staplers, used to close wounds or connect tissue; and different types of sutures (or stitches), which can be absorbable (naturally broken down by the body over time) or nonabsorbable (not broken down by the body and often need to be removed by a doctor later).
However, if the surgeon plans to use a less invasive method like laparoscopy or robotic surgery, they will need different tools. For example, ports (small tubes) are utilized to access the internal organs with minimum invasion, needle drivers (instruments for holding and guiding sutures), staplers, graspers (to hold and manipulate tissues), and drains to remove fluids.
Lastly, if the surgeon uses a method called “free flaps” for esophageal reconstruction, which involves using tissue from another part of the patient’s body, microscopes are required to clearly see the tiny vessels when connecting the tissue to its new location.
Who is needed to perform Esophageal Reconstruction?
Rebuilding the esophagus is a complex task that requires a team of medical professionals. This group includes various types of surgeons, like those who specialize in chest (thoracic), body sculpting (plastic), or belly (abdominal) surgeries. During the operation, there will also be nurses and scrub techs; these are professionals who help keep everything clean and organized in the operating room. An anesthesiologist also forms part of the team, helping you stay pain-free and comfortable during the surgery by administering anesthesia (medicine that makes you sleep or numbs pain).
After the surgery, there might be specialists like radiologists, gastroenterologists, oncologists, and radiation oncologists who will help with your recovery. Radiologists use imaging tests like x-rays or ultrasounds to check how well the surgery went and if there are any complications. Gastroenterologists are doctors who specialize in the digestive system, specifically the stomach and intestines. Oncologists and radiation oncologists are doctors who specialize in cancer treatment; they can help if the reason for your esophagus reconstruction was cancer. Together, this team will work to help you recover as safely and efficiently as possible.
Preparing for Esophageal Reconstruction
Before undergoing any surgery related to the esophagus, patients need to be cleared for heart, lung, and anesthesia-related risks. Doctors also need to evaluate the patient’s nutritional status, which includes checking blood protein levels and any weight loss prior to surgery. High blood protein levels have been linked to better long-term survival rates in patients with esophageal cancer.
To improve nutritional status, some patients may need a feeding tube inserted into their small intestine, although this is a topic of ongoing debate amongst medical professionals. Furthermore, patients need to be informed about possible complications that can occur from esophagus removal and reconstruction surgeries.
How is Esophageal Reconstruction performed
There are several ways to reconstruct the esophagus if it has been damaged or needs to be removed due to a tumor, for example. Thanks to advances in medicine, large tumors can be removed and the esophagus can be rebuilt in the same surgery. Some of the main materials or ‘conduits’ used to rebuild the esophagus are grafts from the stomach, colon, or small intestine, known as the jejunum. Other methods include using muscle from the chest or the forearm, or skin from the thigh.
Usually, the new esophagus is created in the section of the body where the heart and lungs are protected, known as the posterior mediastinum. This is the preferred spot because it can simulate the original placement of the esophagus, but if multiple surgeries have been performed, or if an alternative route is necessary, other parts of the body, like the area behind the sternum or just under the skin, can be used.
One of the most common methods for reconstructing an esophagus is called a “gastric pull-up” technique. In this procedure, the stomach is surgically moved up into the chest to replace the portion of the esophagus that has been removed. This involves removing some of the stomach while preserving a key artery along its larger curve, protecting the stomach’s blood supply. Once the stomach is reshaped into a tube-like structure, it’s pulled upward into the chest or neck where it’s attached to the remaining part of the esophagus.
However, if the stomach can’t be used, the colon can be. This involves surgically moving the colon into the place where the esophagus used to be. This procedure is more complex than the gastric pull-up because it involves three separate points of attachment or ‘anastomoses’. If the stomach and esophagus both need to be removed, a complex procedure involving the colon and small intestine might be required.
Another method involves using a section of the small intestine, known as the jejunum, to reconstruct the esophagus. This procedure, also known as a jejunal free flap, is typically used when the damage or removal is confined to the part of the esophagus in the neck. However, there are certain circumstances where this method is not recommended, such as for patients with diabetes, a history of clotting, or previous abdominal surgeries.
In the past, muscle flaps from the chest or skin flaps from around the collarbone area were commonly used to repair small areas of the esophagus. These methods are still a good choice for patients who can’t undergo the more complex procedures, for example, if they have poor heart or lung conditions or diseased blood vessels. These methods are simpler and rely on a stable blood supply, but they might not provide as much functionality as other methods.
Possible Complications of Esophageal Reconstruction
Having surgery to remove your esophagus and reconstruct it is a big, complex procedure, and complications are common. In a study of over 17,000 patients who had this surgery, about half experienced some type of complication, and about 9 out every 100 people passed away due to complications. The most frequent complications were related to the lungs (30 out of 100), digestion (15 out of 100), heart (10 out of 100), specific to the surgery (8 out of 100), and infections (7 out of 100). Hospitals that perform this surgery more often had fewer deaths.
Some specific complications linked to this surgery include leakage in the area where your surgeon joined together parts of your digestive system, insufficient blood supply to the new part of your esophagus, and narrowing in the area of the join. The likelihood of a leak happening after esophagus surgery is around 10%, with the chances being higher if the join was made in the neck area compared to behind the breastbone. This is likely because creating a longer join leads to higher rates of insufficient blood supply. When a leak is found, doctors try to make sure that the leaked fluids are removed. Patients might receive strong antibiotics, eat nothing by mouth, and receive feeding through a tube until the leak heals. If the leak doesn’t heal on its own, doctors sometimes place a tube using an endoscope to help it close.
If the leak is big and not well drained, or if the patient becomes very sick, another surgery might be needed to repair and drain the leak. If there’s a large separation in the new part of the esophagus, then the patient may need another surgery to remove the esophagus and make a new external hole for food to pass through and for feeding. 10% of patients experience insufficient blood supply to the new part of the esophagus after surgery which could be avoided by maintaining adequate blood pressure and reducing tension at the site of the join. This issue can result in a leak or narrowing in the new esophagus. Narrowing at the site of the join occurs in about 20-25% of patients and can be safely treated by gradually widening the area. Most narrowing happens within the first few months, with late occurrences possibly signaling a return of cancer and requiring further tests.
If a portion of the colon is used to replace the esophagus, a common long-term complication is excess length in the new esophagus, which can result in problems with the function of the new esophagus and lead to uncomfortable symptoms. These could develop years after the surgery and when symptoms caused by food getting stuck in the new esophagus occur, another surgery might be needed to correct it.
What Else Should I Know About Esophageal Reconstruction?
Esophageal cancer, a disease that affects the tube that transports food from the throat to the stomach, is on the rise globally. Currently, it is the 8th most common cancer around the world. Just to give you an idea of how prevalent it is, in 2018, there were nearly 17,300 new cases in the United States alone, with around 15,850 people dying from it. Esophageal cancer tends to be quite severe, necessitating surgery, including reconstruction of the esophagus.
After the surgery, care and management of the patient’s condition is often a concern, and needs to be handled carefully. This is where both your primary care doctor and any specialized surgeons come in. It is important that they fully understand how to help care and manage your condition after the surgery, because this knowledge allows them to react quickly and efficiently to any potential issues that may arise.
