What is the management approach for esophagojejunostomy?

Management Approach for Esophagojejunostomy

Esophagojejunostomy should be performed in high-volume centers by experienced surgeons as part of a multidisciplinary team approach to minimize morbidity and mortality. 1, 2

Indications for Esophagojejunostomy

Esophagojejunostomy is primarily indicated in the following scenarios:

• After total gastrectomy for proximal gastric tumors 1
• After esophagogastrectomy when the stomach cannot be used as a conduit 2
• For reconstruction after resection of esophageal and esophagogastric junction cancers 1, 2
• As part of immediate reconstruction after total gastrectomy with preservation of the native esophagus 1

Preoperative Assessment and Preparation

Before performing esophagojejunostomy, thorough preoperative assessment is essential:

• Evaluate cardiorespiratory function with pulmonary function tests and exercise testing 1
• Optimize treatment of comorbidities (angina, hypertension, asthma, COPD) 1
• Assess nutritional status (BMI <18.5, weight loss >20%, low albumin increase risk) 1
• Implement smoking cessation immediately 1
• Provide psychological preparation and counseling about the procedure 1
• Arrange for thromboembolic prophylaxis (antithrombotic stockings, low molecular weight heparin) 1
• Plan for broad-spectrum antibiotic prophylaxis 1
• Cross-match at least four units of blood 1

Surgical Techniques

Several techniques for esophagojejunostomy are available, with varying outcomes:

1. Conventional anvil head method - Associated with longer reconstruction time and higher risk of leakage and stricture 3

2. OrVil™ system method - Similar limitations to conventional anvil head method 3

3. Hemi-double stapling technique with anvil head - Shorter reconstruction time with lower complication rates 3

4. Side-to-side esophagojejunostomy with linear stapler (overlap method) - Shorter reconstruction time and fewer complications 3

   • The modified "esophagus two-step-cut overlap method" provides improved outcomes by:
     • Rotating the esophagus 90° counterclockwise
     • Transecting two-thirds of the esophageal diameter initially
     • Completing transection with ultrasonic scalpel
     • Creating side-to-side anastomosis at the posterior esophagus 4

5. Manual or stapled anastomoses - Both are acceptable with similar outcomes 1

Nutritional Support

Nutritional support is critical for patients undergoing esophagojejunostomy:

• A feeding jejunostomy tube should be placed at the time of operation 1, 5
• Needle catheter jejunostomy (NCJ) is effective for providing post-operative nutrition 5
• Early enteral nutrition via jejunostomy should begin within 24-48 hours post-surgery 5
• Most patients (94%) can tolerate maintenance feeding (2000ml over 20h) by day 2 post-operatively 5
• Jejunostomy feeding typically continues for a median of 15 days, but 26% of patients require prolonged feeding (>20 days) 5
• Approximately 8% of patients require home jejunostomy feeding after discharge 5

Complications and Management

Anastomotic Complications

• Clinical anastomotic leakage rate should not exceed 5% 1
• Anastomotic stricture is more common with conventional anvil head methods 3
• Patients with jejunostomy who develop anastomotic leaks have significantly lower risk for severe morbidity (Clavien-Dindo score ≥IIIb) compared to those without jejunostomy 6

Jejunostomy-Related Complications

• Minor gastrointestinal complications (diarrhea, abdominal distension, nausea) can be managed by adjusting infusion rate or medications 5, 7
• Serious complications requiring re-laparotomy are rare (1.4%) 5
• Mechanical complications include tube dislocation, obstruction, or migration 7
• Metabolic complications include hyperglycemia (29%), hypokalemia (50%), and electrolyte imbalances 7

Post-Operative Care

• Monitor for early signs of anastomotic leakage or stricture
• Gradually transition from jejunostomy feeding to oral intake as tolerated
• Oral nutrition is usually well tolerated and should be introduced as pain diminishes 1
• Expect limited oral intake at discharge (typically only 65% of nutritional requirements) 5
• Consider home jejunostomy feeding for patients who fail to thrive 5
• Schedule follow-up at 4-6 months post-procedure to assess for stricture formation 1

Key Quality Metrics

• Curative (R0) resection rates should exceed 30% 1
• In-hospital mortality should be less than 10% for total gastrectomy 1
• Clinical anastomotic leakage should not exceed 5% 1

By following these guidelines and selecting the appropriate technique based on patient factors and surgeon experience, esophagojejunostomy can be performed with acceptable morbidity and mortality rates while providing optimal nutritional support during recovery.