Minimal access surgery of corrosive and thermal strictures of the foregut : Journal of Minimal Access Surgery

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Review Article

Minimal access surgery of corrosive and thermal strictures of the foregut

Baskaran, Vasudevan1; Banerjee, Jayant Kumar2; Ghosh, Sita Ram3; Kumar, Sukumar Santosh4; Dey, Santosh Kumar5; Kulkarni, Shrirang Vasant6; Bharathi, Ramanathan Saranga7,

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Journal of Minimal Access Surgery 19(1):p 1-19, Jan–Mar 2023. | DOI: 10.4103/jmas.jmas_140_22
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Abstract

INTRODUCTION

Ingestion of corrosives and hot liquids culminates in foregut strictures of varying degree and extent.[1,2] If severe, strictures render alimentation impossible, thereby, endangering life.[1,2] Hence, its remedy aims at restoring alimentary continuity by either resecting or bypassing the affected gut segment.[3-7] Conventional surgery for corrosive/thermal strictures (CS/TS) proves considerably traumatic owing to the large expanse spanning three body compartments, namely, neck, thorax and abdomen.[3-7] Minimal access surgery (MAS) can restrict trauma in the latter two of these compartments.[1,8-51] However, the experience with its use in CS/TS is both heterogeneous and limited, which prompted this review.

METHODS

PubMed, Scopus, Google, Google Scholar, Cochrane and Web of Science were systematically searched for articles from 1990 to Dec 2021, as per the guidelines,[52] employing the following MeSH terms and truncated words-corrosive/caustic/thermal/oesophageal/gastricstrictures, laparoscopy, thoracoscopy, minimalaccess/minimallyinvasivesurgery. Articles pertaining to MAS of CS/TS were identified and their full texts obtained. Articles unavailable in full text, in foreign languages, containing insufficient information and duplicates were excluded [Figure 1]. Amidst diverse strictures, surgical approaches, routes, conduits, instruments and techniques, added to the articles being case reports and case series, only a narrative review was possible.

F1
Figure 1:
Schematic diagram depicting the methodology of literature search and review

RESULTS

The search revealed 1988 articles out of which 52 pertained to the review. Another 5 articles were identified by manual cross referencing. Of these 57 papers, seven met the exclusion criteria [Supplement 1] and 50 articles were reviewed [Figure 1]. This review summarises the MAS treatment of over 200 patients with CS/TS, over 3 decades. The salient findings gleaned from them are summarised in Tables 1-3. Figure 2 depicts an algorithmic approach to the problem.

F2
Supplement 1
T1
Table 1:
Demographics, affected organs, pre-operative parameters, procedures, operative ergonomics, anaesthesia and access
T2
Table 2:
Operative and outcome parameters
T3
Table 3:
Classification of minimal access surgery procedures for caustic/thermal strictures
F3
Figure 2:
Schematic diagram depicting the minimal access management options

Narration

Background

Concentrated alkalies and acids used for household cleaning are the commonest causative agents for CS worldwide, with alkalies being more common in the West and acids in the East.[1,2,8-25,27-41,43-49] Uncommon, yet equally damaging, are zinc chloride and hot coffee.[26,42] Ingestion of caustics exhibits bimodal age distribution. Children consume them accidentally, especially solids, in smaller quantity (<30 ml) whereas young adults (<40 years) consume them in larger quantities (>30 ml), because of suicidal intent, inebriation or bravado.[1,2,8-49] As a thumb rule “acid licks the esophagus and bites the stomach” while converse holds true for alkalies, albeit with enough exceptions to this rule.[1-3,19,32,34,43,48] Stricturing occurs wherever there is holdup of corrosives, which usually correspond to anatomical luminal narrowing viz. cricopharynx, crossing of bronchi, gastro-oesophageal junction (GEJ) and pylorus [Table 1].[1-3,32] Quantity, concentration, viscosity of the corrosives and duration of contact with tissues determine the extent and severity of stricturing.[1,2,13-16,21,23,25,29,32,34,37]

Oesophagus is most commonly involved followed by stomach, hypopharynx and larynx [Table 1].[2,19,32] Mid-thoracic oesophagus is affected the most, followed by lower, upper thoracic and cervical parts [Table 1]. Distal gastric strictures are more common than proximal ones due to dependent stasis and pyloro-spasm [Table 1].[2,4,7]

Endoscopy is pivotal for stricture assessment.[1-49] Once formed, the narrow strictures prevent distal luminal examination, hence, early assessment of the distal oesophagus/stomach is essential to choose apt surgery and conduit, subsequently.[11] Contrast swallow and computerised tomogram delineate the anatomy offering a roadmap to surgery.[2,19,20,23,26,28,29,32,34,37-43] Computerised tomogram performed during the acute phase also predicts subsequent stricture formation.[53] It is, however, difficult to accurately assess the stricture extent, luminal distensibility, mucosal health, motility and gut fixity as mucosal edema and strictures restrict the quantity of contrast that can be consumed.[54] Pre-operative radiologic assessment of colonic length and vasculature is recommended, but often omitted in the young as atherosclerotic obliteration of vessels is uncommon.[6,12,19,23,32,34,41,55,56] Most patients undergo repeated endoscopic dilatation/bouginage [Table 1] to maintain adequate lumen (>14 mm for 4 weeks) for nutrition.[6,8-51] Unfortunately, repeated interventions create diverticulae and micro-ruptures which perpetuate inflammation and fibrosis.[13,25,30,40] Hence, the 3-6 months period prescribed for subsidence of inflammation may prove inadequate for definitive surgery [Table 2].[53] Longer time lag renders resection easier and safer.[28] Though nasoenteral feeds suffice, most need surgical feeding access [Table 1] for adequate nourishment (2500 Kcal, 1–2 g N/kg body weight) to attain >10 gm% hemoglobin and >3 gm% albumin, lest the anastomoses leak.[3,32,41,57] It may be augmented with parenteral nutrition prior to surgery.[43]

Surgical basics

Stomach and colon are common conduits for oesophageal replacement [Table 2].[1,2] Whole stomach may be used, based on right gastric and right gastro-epiploic vessels [Table 2]. This is possible in children due to short thorax, but exigent in adults, where greater curvature based gastric tube is preferred for effective length and drainage.[10,13,16,19,21,28,29,38-40,50,51] Reversed anisoperistaltic conduit, pedicled on left gastro-epiploic vessels, is used exclusively in children. It entails no organ sacrifice and is less prone to tortuosity.[31] Stomach may also be used after proximal gastrectomy, but such conduits are found wanting in length.[25] Stomach is sturdy, quick to mobilise, easy to form a conduit on a dependable vasculature and entails a single anastomosis.[3,15,22,27] Gastric tube has a long intra-thoracic staple line and its cranial most portion carries only intra-mural blood supply. Hence, the anastomosis constructed there is prone to leaks, strictures and fistulae (detailed later) [Table 2].[14,31,51]

Colon and ileo-colon are interposition conduits [Table 2].[12,19,23,24,26,34,36,41] Most are isoperistaltic, based on left colic vessels (especially its ascending branch), favored owing to its unvarying anatomy, optimal luminal diameter, presence of marginal arcade and robust blood supply.[12,19,23,32,35,36,41,55,56] Long conduits, including distal 15 cm of ileum, can be based on left colic vessels.[26,32,56] Ileo-colic valve prevents reflux proving advantageous.[26] Some prefer middle colic vessels as the pedicle and few employ anti-peristaltic conduits, but, with suboptimal results.[6,34] Colon is more versatile, acid resistant, longer and thinner, so more easily accommodated in the chest, but entails 3 anastomoses to establish alimentary continuity (detailed later).[6,12,23,32,49,56]

Jejunum or duodenum are preferred for restoring alimentary continuity in gastric strictures [Table 2].[42-49]

Technical aspects

Posterior mediastinum is preferred when the oesophagus is resected and retrosternum when oesophagectomy is neither considered nor possible.[8-17,19-25,27-51] Only two studies document the use of retrosternal route despite oesophageal resection, for unclear reasons.[18,26]

Laparoscopy

French position (30° reverse-Trendelenberg, with legs split apart) is preferred in adults for unhindered access to the abdomen and beyond [Table 1]. A pad beneath the chest in children facilitates hiatal dissection by aligning thorax to the plane of laparoscopic instruments.[19] Team positioning, monitor placement and ports siting are as for fundoplication, with extra working ports for gastric mobilisation and laparoscopic trans-hiatal oesophagectomy (LTHE).[13-16,20-22,24,27,29,31,35,40,51] Twelve or 15 mm port may replace a working port for endoscopic stapler, as needed.[15,22,41] Access through single peri-umbilical incision too is possible with multiaccess ports and articulating instruments.[37] Existing gastrostomies can be taken down using endostapler or intra/extra-corporeal sutures and the defect utilised for siting larger port or miniceliotomy.[13,14,16,19,20,30] Alteration in the port positions avoiding the feeding access is feasible and often prudent [Table 2].[19,23,24,32,35] Ports for laparoscopic gastro-jejunostomy and antroduodenostomy remain as above or may be reduced, if extra-corporeal anastomosis is planned.[42-49] For laparoscopic Billroth I procedure, both the surgeon and stapling port are sited to patients’ left for ergonomics.[41,47]

Colon is conventionally mobilised using 5-6 ports configuration.[23,41] However, it may be mobilised using 3 ports by placing them diagonally across the axis of mesentery and changing the position of patient/surgeon corresponding to the portion of colon being dissected.[19,32] It helps to elevate the operative site, allowing gut to fall away and to stand opposite for operative ease.[32]

Previous incisions may be reutilised for creating miniceliotomies (3–8 cm) or to place hand port for constructing, transposing conduits and ligating vessels.[12,19,29,32,35] Number of ports and endoscopic consumables are reduced whilst operative ergonomics gets enhanced (detailed later).[12,32,35] Use of Alexis self-retaining retractor enhances exposure, without trauma, and reduces infection.[12,32]

Thoracoscopy

Thoracoscopic oesophagectomy (TE) is conventionally performed in the left lateral decubitus position, using 3-5 ports.[11,13,14,21,29,36,51,58] Surgeon and assistant (s) stand to the patients’ right and left, respectively, while the monitor is placed cranially on the left. Ports (10/5 mm) for camera and lung retractor are placed anterior to mid-axillary line, in the 7/8th intercostal space (ICS) and 5th ICS, respectively. Working ports (5/3 mm) are sited posteriorly in the 9th ICS, below the tip of scapula.[13,14,21,29] Some site the camera port inferiorly and working ports cranially, on either side.[11,36]

TE may also be performed in prone/semi-prone position.[25,28,34,37-40] Both the surgeon and assistant(s) stand to the patients’ right while monitor is placed opposite. Patients’ right arm is elevated above the head, in both positions, to move the scapula away for placing working ports.[11,58] Usually, a 10/12 mm camera port is placed anterior to mid-axillary line in 5-7th ICS and two to three working ports are placed posteriorly, under vision, triangulated towards the oesophagus.[25,28,37,40,58] Cuffed ports prevent subcutaneous emphysema and repeated slippage during manipulation. Correct placement of rolls and paddings is mandatory to prevent respiratory embarrassment, abdominal compartment and skeletal/nerve injuries, as oesophagectomy takes time.[37,58,59]

While laparoscopy requires 10–15 mm Hg of air pressure, 5–8 mm Hg suffices for thoracoscopy as collapsible lung under a rigid ribcage provides ample space.[12,15,20,25,28,31,58] A 30° telescope proves ideal both for thoracoscopy and laparoscopy.[31,32,58] Ligasure and Enseal are favored vessel sealers whereas harmonic scalpel is preferred for dissection.[11-13,15,16,18-25,27,31,32,35,37,40,41,46,47] Cautery is chosen for sealing small blood vessels, scoring the serosa, making enterotomy/gastrotomy and dissecting areolar tissue.[8-10,19,24,27,31,49]

All patients need general anaesthesia with epidural catheterisation, preferably, to reduce pain and enhance recovery [Table 1].[32,54,58] Double lumen tube or bronchial blocker is chosen for conventional TE, to deflate the right lung.[11,13,14,25,36] Single lumen tube may also be negotiated into the left main bronchus for the purpose.[29] Though TE in prone position obviates such needs, it is wiser to keep the provision available, should a need arise.[25,28,40,58] A low tidal volume 5–6 ml/kg, optimised PEEP of 5 cm H2O, plateau and peak inspiratory pressure of 25 and 35 cm H2O, respectively, are desirable.[58]

Minimal access procedures

Thoracoscopic procedures

Although TE in lateral position entails right lung deflation and retraction, viewing “down on” the oesophagus as accustomed in open procedure proves advantageous.[11,13,14,51,52,58] The disadvantage of viewing oesophagus “up on the roof” i.e., inverted in prone TE is offset by gravity and pneumothorax which render the above manoeuvres redundant.[25,58] Furthermore, gravity drains blood away from the operative field clarifying vision and rendering suctioning unnecessary, unlike lateral position where oesophagus is most dependent. Hence, TE in prone position proves more ergonomic than in lateral decubitus.[2,28,58]

Surgery commences by scoring the mediastinal pleura along the oesophagus.[21,25] Fibrotic adhesions and ongoing inflammation render dissection and identification of planes exigent [Table 2].[11,13,14,18,25,40] Hence, unlike in malignancy, dissection here is performed close to the oesophagus.[15,29,40] It is prudent to choose an unstrictured portion of oesophagus for initial dissection and looping, using tape/Penrose drain, for manipulation.[13,14,16,19,21,29,37,40,51] Adherent vital structures viz. membranous left main bronchus, left brachiocephalic vein and left pleura need meticulous separation and, if necessary, a layer of oesophageal wall may be left behind.[11,13,18,19,24,25] Magnification, CO2 separation and energy devices enable precise dissection and absolute haemostasis.[11,13,14,16-18,40] Magnification also facilitates vagal preservation, although, its function remains ambivalent as fibrosis causes functional autovagotomy.[2,17,25,26,36] Care is taken not to breach the phreno-oesophageal membrane till the last lest air escapes into the abdomen.[13,40]

On completion of TE, the oesophagus is extracted either through the neck, with the conduit in tow, or through a (mini) celiotomy.[13-15,19,21,25,29,37,39,40,51] It may also be anastomosed to the conduit intra-thoracically using intra-corporeal sutures/staples.[34,51] Short segmental strictures may be thoracoscopically resected and primarily anastomosed relying on the longitudinal oesophageal vasculature for adequate perfusion.[17] Endoscopic confirmation of anastomotic integrity and calibre is desirable to prevent mediastinal leak and re-stricture.[17]

Laparoscopic procedures

Laparoscopic trans-hiatal oesophagectomy

Stomach is first mobilised, as outlined earlier, on right gastric and right gastro-epiploic vessels, specifically staying 1–2 cm away from the arcade.[13-16,20-22,29,39] Hiatal dissection is commenced after taping the GEJ.[13,14,16] Nathanson, fan or finger retractors are useful for retracting liver, crurae and anterior chest structures. In children, transparietal sutures accomplish the same.[19-21,24,27,40] Once posterior mediastinum is entered, direct oesophageal branches from aorta are easily dissected and coagulated, as CO2 opens up the tissue planes.[15,20]

Hiatal retraction and oesophageal manipulation enable safe lower oesophageal dissection and damage, if any, is restricted to the pleurae or diaphragm.[15,19,20,24] Dissection further cranially through the hiatus brings the working instruments and camera together, almost parallel, which impedes progress in the confined space.[19] Crossing of major vessels/airway further renders dissection of mid third strictures difficult and hazardous, but with experience and care, one can dissect up to the sternal angle.[19] In children, root of the neck may be reached from below owing to their short thorax/oesophagus and shallow thoracic curvature.[15,19,24,27] Left gastric vessels are then divided and gastric tube is constructed using endostaplers and tacked to the specimen for cervical extrication.[14,21,22,35,40] These are done prior to commencing neck dissection, lest air escapes.[15] If oesophagectomy is abandoned and/or a bypass/hybrid procedure is planned using the gastric conduit through substernal route, no further oesophageal mobilisation is done and GEJ is stapled off after gastric mobilisation.[22,27]

Colon

Laparoscopy, aided by energy devices, simplifies mobilising colon off the periphery, dissecting off omentum, isolating colonic pedicles and harvesting colonic/ileocolonic conduits.[12,19,23,34,41] Conduits may then be transposed into the neck either orthotopically, following oesophagectomy, or through a substernal tunnel. Harmonic scalpel aids in creating substernal tunnel for which the working port is sited infra-umbilically, close to midline, for correct angulation to avoid breaching the pleurae.[22,23,32,41] Tendency to cut too cranially or posteriorly should be curbed to prevent peri-cardial damage.[22,23,32] Needle/finger indentation helps identify the xiphisternum/lower end of sternum for entering the correct plane, after dissecting the falciform ligament off the abdominal wall.[22,23,32,41] The conduit is pulled into the neck using Ryle’s tube/tape passed down the tunnel while avoiding slack and twist.[22,23,41] In hybrid procedures, the same is ensured by using plastic camera sleeve.[32,53,60]

Gastric strictures

Laparoscopic Billroth I is performed for type I and II gastric strictures, provided the rest of the stomach and duodenum are unaffected [Figure 2].[41,47] Alternative for type I gastric strictures is hand sewn diamond configuration antroduodenostomy between longitudinally incised duodenum and transversely incised antrum.[49] Laparoscopic loop/Roux-en-Y gastro-jejunostomy, with or without truncal vagotomy, however, remains an easier/safer option when the stomach is fixed [Figure 2].[42-46] If free, stomach is easily exteriorised along with jejunum, through miniceliotomy, for extra-corporeal anastomosis [Figure 2].[45]

Combinations, their pros and cons

A classification of the various MAS procedures and a schematic approach to the options are outlined in Table 3 and Figure 2, respectively.

Completely minimal access surgery

Thoracoscopic oesophagectomy + laparoscopic gastric transposition

Either thoracic or abdominal part of the procedure may be performed first [Table 1].[11,13,14,16,21,51] The former may be wiser as it caters for unanticipated abandonment of oesophageal resection owing to unfeasibility. Such situations would necessitate repositioning to reroute the conduit or convert into a temporary feeding procedure, in the abdomen first approach. Dense adhesions due to previous surgeries may necessitate conversion into open thoracotomy (detailed later) [Table 2]. This arises seldom due to stricture-related issues, as part of oesophagus may be left behind without adverse consequences.[14] This combination suits extensively strictured/adherent oesophagi needing precise dissection under vision.[13,14,16,21] Any mishap can also be dealt with. However, the need for repositioning, painful thoracic ports, consumables, chest drainage and tedium of dissection render it uneconomical in terms of cost, effort, operative time and patient comfort.

Thoracoscopic oesophagectomy + laparoscopic colonic transposition

This 3 stage procedure has been employed in an isolated case:[34] In stage 1, laparoscopic ileo-colic mobilisation based on middle colic vessels, stapling off the GEJ, LTHE till inferior pulmonary vein, right pleural incision and positioning of conduit into the right thorax are done; Stage 2 involves TE in semi-prone position, difficult end-to-end oesophago-ileal anastomosis at thoracic inlet; In stage 3, patient is turned back to supine position for restoring alimentary continuity. This cumbersome exercise merely prevents a cervical incision and has several issues against it, namely, a. need for recurrent repositioning; b. unergonomic and precarious intra-thoracic anastomosis known for high leak rate; c. escape of air into the abdomen during thoracoscopy, if insufflated instead of deflating the lung; and d. too cumbersome to be temporally efficacious.

Laparoscopic trans-hiatal oesophagectomy + laparoscopic gastric transposition

This option doesn’t entail lung deflation or change in the patients’ position.[15,20,21] It is less invasive, consequently less painful, as thoracoscopy and chest tubes are avoided.[15,20,21] Placement of conduit is also under vision. However, mid thoracic strictures pose serious challenges to the feasibility and safety of this procedure, as outlined earlier. Use of operating endoscope/mediastinoscope, introduced through the neck, may overcome these challenges.[61]

Laparoscopic gastric transposition and laparoscopic colonic transposition

These are essentially bypass procedures which have all the benefits alluded above, while difficult stricture resections are avoided.[22,23] However, Laparoscopic Gastric Transposition (LGT) can only be performed if stomach is unstrictured, which is uncommon in acid induced injuries. laparoscopic colonic transposition (LCT) is suitable if either stomach is unavailable or longer conduit is needed, as in pharyngeal/cervical oesophageal strictures.[23] But, it is more time consuming and technically demanding.[23] It demands dissection/ligation of multiple pedicles, precise measurement of conduit length and multiple intra-corporeal anastomoses.

Hybrid procedures

Most cases are effectively addressed by hybrid combinations, wherein the arduous steps requiring magnification and precision viz. oesophagectomy and conduit mobilisation are performed by MAS, whilst steps requiring tactical feedback of hand for careful, secure and gentle handling viz. pedicle ligation, conduit construction, measurement and transposition are performed through laparotomy/mini-celiotomy.[11,18,19,24,25,28,29,32,35,38,40] Abdominal anastomoses, obliteration of mesenteric windows and construction of feeding access, too, prove easier, faster, secure and cheaper.[19,29,32,35,38,40] Formal laparotomies are best avoided in favor of equally efficacious miniceliotomy/hand port, as upper abdominal incisions are morbidly painful, cause respiratory problems and incisional hernia in the short and long term, respectively.[12,19,28,32,35,41] A concern against miniceliotomy is the risk of unnoticed conduit twist and consequent vascular embarrassment.[19] Use of camera sleeve may overcome these problems, as mentioned earlier.[32,60]

Use of hand for blind mediastinal dissection of the mid-third oesophagus, following laparoscopic dissection of the lower third, has been propounded by a study.[35] This combination is inadvisable as the crucial step requiring meticulous dissection under vision is performed blindly and bluntly jeopardising vital mediastinal structures. Recognition of damage, if any, would be late and access to visualise, limit and control it, would be restricted.

Creation of additional feeding access is judicious, though time/effort consuming, in all the above procedures.[13,16,21,22,27] CS patients are nutritionally compromised and any mishap will hurl them irretrievably towards catabolism. If necessary, oesophagectomy may be performed subsequent to a bypass, when patients assume oral diet, gain weight and complete growth (personal experience). By then, inflammation subsides and adhesions mature, simplifying resection. Mishap, if any, would also be withstood better.

Neck and abdominal anastomoses

Neck

Apart from cosmetic skin crease incisions, MAS is impracticable in the neck.[22,51] Wide exposure is mandatory both for dissection and anastomosis, to avoid damaging adjacent adherent nerves, vessels and airway.[32] Left pre-sternomastoid ‘hockeystick’ incision adequately exposes the hypopharynx, pyriform fossa and oesophagus in adults, while right cervical incision suffices in children [Table 2].[31,32,41] Higher/complex strictures requiring pharyngo-laryngectomy necessitate U-shaped neck incision.[32] Widening the thoracic inlet is largely unnecessary, but possible by dividing the medial ends of manubrium, left clavicle and ribs.[32,41,55] Strictured cervical oesophagi are dilated using Hegar’s dilator to facilitate anastomosis or by rendezvous technique under endoscopic guidance as shown by us.[32] Tight strictures just below cricopharyngeal sphincter need lateral pharyngeal incision for anastomosis.[32] Pharyngo-oesophageal strictures with pristine pyriform fossa and functional larynx benefit form partial laryngectomy for exposing pyriform fossa for anastomosis. Higher/unsalvageable laryngo-pharyngeal injuries need pharyngo-laryngectomy with tracheostomy.[32]

Following oesophagectomy, anastomoses between the cervical oesophagus and conduits can be end-to-end, end-to-side or side-to-side [Table 2]. In bypass procedures, the continuity of oesophagus may either be retained or divided. Retaining continuity warrants a wide side-to-side anastomosis between the oesophagus/pharynx and the conduit.[6,23,32,41] This specifically suits extensive oesophago-gastric strictures with narrowing of both cervical inflow and gastric outflow.[6,32] This manoeuvre widens the narrow cervical oesophageal lumen, promoting transit of food bolus, and prevents oesophagocele/gastrocele formation by facilitating retrograde drainage of secretions.[6,32] By avoiding circumferential oesophageal dissection, the side-to-side anastomosis minimises perils of nerve damage and anastomotic leak.[6,32] The wide anastomosis does not stricture even when it leaks.[32] When proximal oesophagus is divided, the anastomoses are akin to resectional surgeries, but, a remote possibility of retention of secretions persists.[22]

Anastomosis to the lumen of pyriform fossa is inevitably sideways, which the end of ileum matches perfectly.[32] Pharyngo-laryngectomy exposes the wide pharyngeal inlet for an end-to-end anastomosis with the colon.[22,32] However, the oesophagus needs closure at the thoracic inlet.[22,32] Reconstruction with stomach proves impracticable for want of length.[12,32]

Abdominal anastomoses

Gastric conduits require no distal anastomosis, but may need pyloric drainage, if vagotomised.[13-15,20,51] Gastric tubularisation obviates this need.[16,22,39,51] Antropyloric strictures in gastric conduits, however, necessitate additional proximal gastro-jejunostomy or pedicled patch antropyloroplasty.[12,41,62,63] Colonic conduits, as outlined earlier, need anastomosis to the stomach (usually distal and posterior wall) or jejunum (loop/Roux-en-Y) followed by colo-colic/ileo-colic anastomoses for alimentary continuity [Table 2].[12,19,23,32,34,36,41,64] Following colo-antral anastomosis, denerved proximal stomach may be resected for preventing delayed gastric emptying, regurgitation and stomal ulceration.[55] It is important to divide and/or anastomose colon without damaging the marginal arcade for good vascularity.[32] If the proximal colon is found too short to comfortably reach the descending colon following conduit harvest, then it may be brought to the left side through a mesenteric defect for tension free anastomosis.[32] All of the above are efficaciously achieved by MAS [Table 2].

Outcome

Blood loss, operative time and recovery

Negligible access damage, lesser insensible fluid loss and bloodless field maintained for endoscopic vision render transfusions infrequent [Table 2], unlike open surgeries (average blood loss <200 ml vs. >500 ml).[3,6,7,11,12,15,22-24,32,41] Completely MAS resectional procedures take 6-7 h [Tables 2 and 3], a third consumed by oesophagectomy alone.[11,36] Hybrid resectional procedures take 25% lesser time [Table 2].[19] Due to simplicity, LGT and hybrid colonic transposition take 4 h, proving swifter (25%) than LCT.[12,22,23,32] These espouse a few facts: The abdominal part is performed as fast laparoscopically as by open technique, if aided by miniceliotomy; bypasses are faster than resections by a third; conventional surgery and MAS consume similar operative time, despite limited experience with the latter.[3-51] Recovery is uniformly rapid owing to lesser invasion and pain.[11,12,22,23,32,41] Post-operative ventilation is scarcely required, excepting peri-operative period and more in children than adults.[11,12,15,19-21,27,30,37,41]

Surgery-related complications

Unlike conventional surgery, mortality is seldom encountered as MAS generates fewer infections and cardio-pulmonary complications, latter being less in bypass than in resectional procedures [Table 2].[2,3,5-51] The magnification aided precision completely averts major vascular/airway injuries while minimising pneumothorax (<4% vs. 24%) and chylothorax [Table 2].[3,5,15,19,24] It also enables early detection and repair of such injuries without the need to convert.[19,65] Laryngeal nerve paresis (<2% vs 7.8%) are predominantly transient and observed more in cervical/thoracic inlet strictures where the dissection is conventional and often blunt [Table 2].[3] Bypass procedure, unilateral dissection and side-to-side anastomosis may prevent nerve injuries, as explained earlier.[6,32,41] Owing to reduced adhesions, hiatus hernia may trail LTHE [Table 2].[20,27,31,61,66] Hiatal narrowing and anchoring conduits to the crurae may prevent this. Extensive adhesions compromise vision, safe dissection and conduit transposition, predisposing to inadvertent iatrogenic injuries, which may necessitate conversion into open procedure.[14,20,27,41] However, the required incision to complete the procedure is small as majority of the procedure is already completed by MAS.[14] Anastomosis at pharynx/pyriform fossa necessitate re-education for a few months for an effective swallow and speech.[11,32]

Conduit-related complications

Anastomotic/staple line leaks and strictures are prime complications [Table 2] observed frequently in gastric conduits, particularly if reversed or short, but uncommonly in colon (reasons highlighted earlier).[3,6,25,31,32,41] Strictures are preferably dilated/stented, but stubborn ones need resection achievable often using MAS [Table 2].[31,33,67] Dumping, delayed gastric emptying, gastro-oesophageal and bile reflux are other distressing complications in gastric conduits, which may occasionally transform into Barrett’s or adenocarcinoma. Hence, stomach may not be the most suitable conduit for CS.[15,32,33] Isolated case of gastro-bronchial fistula owing to a penetrating peptic ulcer, necessitating thoracotomy and repair, is reported.[14]

Though expected, bile reflux in colo-jenunostomies (loop) is seldom observed owing to conduits’ length and isoperistaltic nature.[1,23,32] Use of Roux loop would both prevent and treat this complication.[32] Colonic redundancy, resulting from interposition of excessive length or obstruction beyond colo-gastric anastomosis, remains unobserved in MAS studies owing to endoscopic scrutiny during transposition and, probably, due to novelty/short follow up [Table 2].[6,19] It may be avoided by trimming the excessive length, facilitating outflow and two point fixation of the conduit.[6,19,23,41,60,68] Isolated case of conduit necrosis is reported following MAS substernal bypass, reasons unspecified.[41] However, it is more common in conventional surgery.[6] Shear during transposition could damage conduit/vessels, which the use of camera sleeve prevents.[32] Vitamin B12 deficiency and cholerectic diarrhea are known in ileo-colonic conduits, which need methylcobalamine and cholestryramine therapy, respectively.[26,32]

Conduit-related complications are mostly unrelated to the approach. Lesser handling and visual inspection under magnification may lessen/detect subtle injuries early, thereby reducing complications in MAS.[27,32] It is underscored that the MAS procedures have been undertaken by surgeons with considerable expertise which may explain their efficacy and lower complication rates.

Remote complications

Fear of mucocele formation and malignant transformation have propelled stricture resections.[11,13,22] Both are over estimated, if not unfounded.[6,32,41] Corroded mucosa produces negligible mucus, expelled easily through the residual lumen, rendering mucocele formation unlikely. Besides, interventional drainage/sclerosants or enteric drainage promptly obliterate it.[6,22,23,32,69,70] Strictures restrict food inflow, thereby, averting putrefaction and consequent malignancy.[6] Lympho-vascular obliteration confines tumour spread, even if formed, rendering cure achievable.[28] Malignant transformation takes decades and is reported in single digits despite continued consumption of corrosives.[6,28] It remains uncertain whether corrosive insult or other factors, such as, environment or smoking trigger malignancy.[2]

CONCLUSIONS

Corrosive/thermal strictures are immensely treatable by MAS utilising its numerous techniques and combinations. Enhanced vision, absolute haemostasis, precise dissection, lesser tissue handling and limited access trauma translate into low rate of complications, early recovery, lesser post-operative pain and blood loss, thereby, proving efficacious in the treatment of caustic/thermal strictures. Choice of procedure, combination, conduit and route need to be based on the degree, location of strictures; status, availability, suitability of conduits/routes; feasibility, philosophy and experience of the treating team.

Financial support and sponsorship

The authors, V Baskaran, JK Banerjee, SR Ghosh, SS Kumar, SK Dey, SV Kulkarni and R Saranga Bharathi have no sources of funding and financial relations to declare.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

Corrosive/caustic strictures; oesophageal strictures; gastric strictures; laparoscopy; thermal strictures; thoracoscopy

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