Technique of Antiperistaltic Left Colonic Conduit
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CASE REPORT
Technique of Antiperistaltic Left Colonic Conduit Esha Pai 1 & Tarun Kumar 2 Received: 14 May 2019 / Accepted: 6 March 2020 # Association of Surgeons of India 2020
Abstract We describe a case of total esophagogastrectomy with colonic pull-up, in a case which was initially planned for an Ivor Lewis approach. Reconstruction was done using antiperistaltic left colon conduit based on left branch of middle colic artery. What inspired us to write this report is that, this procedure finds place in many discussions of various studies but nowhere is its detailed technique described. Gastric conduit is the workhorse of esophageal cancer surgery, but sometimes an alternative is required when primary conduit has failed or the stomach is not available due to previous surgery or disease extension. Keywords Technique of left colon pull-up . Antiperistaltic colon pull-up . Reconstruction after total esophagogastrectomy
Clinical Details A 30 years old gentleman presented with dysphagia. Upper GI endoscopy showed a non-negotiable growth from 34 cm to GE junction (GEJ), which was at 40 cm. CT scan showed growth reaching up to the fundus of stomach. Biopsy was suggestive of adenocarcinoma. After neo-adjuvant chemotherapy, though patient had improved symptomatically, radiology showed stable disease. Patient was planned for an Ivor Lewis esophagectomy. At laparotomy, the disease was extending 10 cm above GEJ, involving diaphragmatic crura and stomach up to the antrum (Fig. 1). Only option left to attempt this resection was to do a colonic conduit, as neither Ivor Lewis nor lower thoracoabdominal (Garlock’s) approaches were feasible in this setting. On reconsidering all factors like young age, no nodes, ECOG 0, we improvised and decided to go ahead with total esophagogastrectomy by a transhiatal approach with a left colonic conduit. For safe resection, the abdominal incision was extended into the sixth intercostal space cutting through the diaphragm. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12262-020-02117-x) contains supplementary material, which is available to authorized users. * Tarun Kumar [email protected] 1
Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
2
Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
Once the tumor was dissected off the aorta, the esophagus was blindly dissected as done in transhiatal esophagectomy. A modified D2 lymphadenectomy was done. A cuff of antrum was left at the pylorus after confirming a negative margin on frozen section. Our caveats for colonic pull-up were an unprepared bowel and no prior colonoscopy. Surgical steps (Figs. 2 and 3): 1. Mobilization of entire the colon. 2. Measurement of the length from pylorus to the neck, same length was marked from mid transverse colon to sigmoid colon. 3. Bifurcation of middle colic artery was identified, and a mesocolic window was made up to the mesenteric border of mid-transverse colon. 4. Inferior mesente
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