Esophageal cancer arises most frequently from distal esophagus. Its surgical approach is increasingly being established as laparoscopic. In proximal esophageal cancers, the autotransplant reconstruction technique by means of a jejunum free-graft using vascular microsurgery is sometimes indicated.
The incidence of esophageal cancer has increased in recent decades, coinciding with a shift in histological type and primary tumor location. Adenocarcinoma of the esophagus is now more prevalent than squamous cell carcinoma in the United States and Western Europe, with most tumors located in the distal esophagus. The cause for the rising incidence and demographic alterations is unknown.
One of the major difficulties in allocating and comparing treatment modalities for patients with esophageal cancer is the lack of precise preoperative staging.
Among the most useful tests that we perform systematically in order to know the local situation and the possible dissemination of the illness, we include computed tomography (CT) of the chest and abdomen, and endoscopic ultrasonography (EUS). The latter appears to be the most precise of them all after our experience with the affectation of the esophageal wall and its locoregional classification. EUS-guided fine-needle aspiration (FNA) for lymph node staging is very efficient, as well as thoracoscopy and laparoscopy for esophageal cancer staging. Positron emission tomography (PET-CT), using the radiolabeled glucose analog 18-F-fluorodeoxy-D-glucose for preoperative staging of esophageal cancer, is very useful for detecting the illness in disseminated stages.
In the presence of complete esophageal obstruction without clinical evidence of systemic metastasis, surgical excision of the tumor with mobilization of the stomach to replace the esophagus has been the traditional means of relieving the dysphagia. Age alone should not determine therapy for patients with potentially resectable disease.
There are two options for esophageal resection:
- Transhiatal esophagectomy (not open thoracic esphagectomy) with cervical esophagus stomach anastomosis, especially indicated in injuries located in the proximal or distal third of the esophagus.
- Abdominal mobilization of the stomach and transthoracic excision of the esophagus with anastomosis of the stomach to the upper thoracic esophagus or the cervical esophagus.
In patients with partial esophageal obstruction, dysphagia may, at times, be relieved by placement of an expandable metallic stent or by radiotherapy if the patient has disseminated disease or is not a candidate for surgery. Alternative methods of relieving dysphagia include laser therapy and electrocoagulation to destroy intraluminal tumor.
In order to reduce the size of the tumor and improve the results, we proceed preoperatively with a simultaneous radiotherapic and chemotherapic treatment, regardless of the diagnosed histological type in patients in stages IIB, III and IVA..
The “standard” surgical technique for the cervical esophagus reconstruction includes different types of procedures such as the interposition of pedunculated cutaneous or myocutaneous tubes, or the mobilization of the stomach and colon with their corresponding vascular pedicles. The inadequate functional and esthetic results of other techniques as well as the possibility of avoiding unnecessary aggressive surgery are two strong reasons for the consolidation of an attractive alternative: the interposition of a segment of the small bowel revascularized with microsurgical techniques into cervical vascular structures, this is, an intestinal autotransplant..
This reconstructive technique has been carried out in our Department for more than ten years under the following indications:
- Pharynx and cervical esophagus malignant tumors
- Reconstruction of benign pharyngeal or cervical esophagus structures in patients in which the larynx is preserved
- Recovery of prior gastric or colic plastias is normally located via restrosternal route with a proximal stenotic component from ischemic origin.
The complexity of this procedure comes from the preservation of the graft and the vascular reconstruction. The preservation is carried out with similar procedures to those of the intestinal transplant from a cadaveric donor (preservation solution at 4ºC). Thanks to our clinic and experimental experience in over 18 years in digestive transplant, we can assure the feasibility of intestinal grafts in preservation periods longer than 4 hours.
On the other hand, this type of graft is possible thanks to the use of sophisticated and essential microsurgical techniques in vascular reconstruction for vessels with the smallest calibre at cervical level.
The functional results obtained are highly satisfactory. The patient recovers total oral intake thanks to a correct swallowing mechanism.