A Novel Use of Human Acellular Dermis for Conduit Salvage After Esophagectomy Mathew Thomas, MD, Mark S. Allen, MD, K. Robert Shen, MD, and Dennis A. Wigle, MD, PhD Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
Postesophagectomy anastomotic leaks cause significant morbidity and mortality. Esophageal diversion is often required when extensive tissue loss precludes primary repair. We describe a technique in which human acellular dermis (AlloDerm) is used to repair the conduit, and report
a series of 3 patients with significant anastomotic dehiscence whose conduits were salvaged using this technique.
C
included peripheral vascular disease, coronary artery disease, and a significant smoking history. Three weeks after his surgery, he experienced an anastomotic leak. Endoscopy revealed circumferential ulceration of the anastomosis (Fig 3). After a few days of conservative management with nasogastric and chest tube drainage, he exhibited hemoptysis. A small tear in the right mainstem bronchus was seen on bronchoscopy, and was suspected of being a tracheal-conduit fistula. He failed to progress with esophageal stenting, and an exploratory right thoracotomy was performed. The small (2 to 3 mm) tracheal-conduit fistula was primarily closed and covered with a pericardial fat pad. A larger anastomotic defect identified in the lateral wall could not be primarily reapproximated. After removing the stent, a thick AlloDerm patch was circumferentially wrapped around the anastomosis as described above (Fig 4A). The bronchial repair was intact when tested under saline solution immersion. A nasogastric tube and multiple chest drains were placed. Two days later, the esophageal stent was reinserted to support healing of the trachealconduit fistula. During the next 5 months, the fistula was evaluated with interval endoscopies. The stent was removed after the fistula had healed, which was confirmed by an esophagram (Fig 4B). He tolerated an oral diet but required intermittent dilatation for an anastomotic stricture that developed 4 months after stent removal. PATIENT 2. A 69-year-old man with stage 1 (T2 N0 M0) distal esophageal adenocarcinoma underwent Ivor Lewis esophagectomy after neoadjuvant chemoradiation. He had a strong smoking history and previous endovascular repair of an abdominal aortic aneurysm. Esophagram after 1 week was negative for leak. Two days later, he experienced severe sepsis secondary to a large anastomotic leak and required intubation. Multiple chest tubes were placed. Bronchoscopy showed a large amount of pus in the right lower lobe, but no obvious fistula. Upper endoscopy revealed near-circumferential necrosis and a large anastomotic defect. Given his surgical history, an
Technique Our approach is through a right thoracotomy, which provides adequate exposure to evaluate and repair the conduit. After debriding all nonviable tissue, the conduit is assessed to determine whether primary closure is feasible. An existing esophageal stent can be left in place (Fig 1A) or removed as required to facilitate repair. If feasible, primary closure is first performed and then reinforced with a patch of thick AlloDerm. The patch is anchored to the surrounding healthy tissues with 3-0 silk (Ethicon, Somerville, NJ) horizontal mattress sutures (Fig 1B). When extensive loss of tissue precludes primary closure, a thick piece of AlloDerm is placed as an onlay patch (Fig 2A) or wrapped around the conduit (Fig 2B), depending on how much the conduit can be mobilized. If wrapped around the graft, the longitudinal edges of the AlloDerm are also sewn to each other with interrupted 3-0 silk sutures (Fig 2B). Multiple chest drains as well as a nasogastric tube are placed.
Patients and Methods A 75-year-old man with stage I (T1b N0 M0) distal esophageal adenocarcinoma underwent a right transthoracic (Ivor Lewis) esophagectomy after unsuccessful endoscopic mucosal resection. His comorbidities
PATIENT 1.
Accepted for publication Aug 21, 2013. Address correspondence to Dr Wigle, Division of General Thoracic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: wigle. [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.08.051
FEATURE ARTICLES
onduit necrosis or ischemia after esophagectomy can have severe consequences. In such instances, few options remain other than esophageal diversion, with or without delayed reconstruction using an alternative conduit. We report a series of 3 patients in whom human acellular dermis, AlloDerm (LifeCell Corporation, Branchburg, NJ), was successfully used to salvage dehisced conduits after esophagectomy.
(Ann Thorac Surg 2014;97:1459–63) Ó 2014 by The Society of Thoracic Surgeons
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Fig 1. (A) The esophageal stent may be left in place, and (B) the AlloDerm patch is sutured to the healthy tissues surrounding the dehiscence with 3-0 silk horizontal mattress sutures.
Fig 2. (A) AlloDerm may be placed as an onlay patch or (B) a cylindrical wrap with the free edges sewn to each other.
FEATURE ARTICLES Fig 3. Endoscopic view of the anastomotic dehiscence (arrow) in patient 1.
attempt was made to salvage the conduit using an esophageal stent. Owing to a persistent right lung collapse and failure to extubate, an exploratory right thoracotomy was performed. Intraoperative findings included extensive gastric conduit necrosis with a 5-cm anastomotic defect through which the stent was easily visualized (Fig 5A).
Extensive debridement was performed without removing the stent. A thick AlloDerm patch was used to completely cover the defect and anchored with 3-0 silk horizontal mattress sutures (Fig 5B) to healthy areas of the esophagus and stomach. Severe mediastinal inflammation prevented inspection of the medial wall. Intraoperative bronchoscopy showed a small tracheal defect just above the carina. A tracheal stent was not placed because of concerns of pressure necrosis between two stents. A tracheostomy was performed. After a prolonged recovery, the chest drains were eventually removed. Endoscopy (Fig 6A) and esophagram (Fig 6B) showed complete healing of the fistula after 4 months, and the stent was removed. He tolerated an oral diet but required serial endoscopic dilations of a benign anastomotic stricture. PATIENT 3. A 59-year-old man with stage 1 (T2 N0 M0) distal esophageal adenocarcinoma underwent Ivor Lewis esophagectomy after neoadjuvant chemoradiation. A week later, he experienced severe chest pain and sepsis owing to anastomotic breakdown. A right thoracotomy revealed necrosis of the proximal gastric conduit. Debridement resulted in a 1-cm defect surrounded by a 3-cm-wide area of partial-thickness ischemia but healthy mucosa. As a result of tension, only a single full-thickness layer closure could be performed. A thick AlloDerm patch was wrapped circumferentially around the anastomosis and sutured to the healthy conduit and esophagus using 3-0 silk horizontal mattress sutures. A nasogastric tube and
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Fig 4. (A) Intraoperative view of the AlloDerm wrapped around the anastomosis and (B) esophagram showing healed tracheoesophageal fistula and restored esophageal continuity in patient 1.
FEATURE ARTICLES
Fig 5. Intraoperative views showing (A) anastomotic dehiscence with exposed stent and (B) AlloDerm patch in patient 2.
Fig 6. (A) Endoscopic view and (B) esophagram at 4 months showing intact anastomosis with AlloDerm patch in patient 2.
multiple chest drains were placed. An esophageal stent was placed 2 days later and removed after 6 weeks. Endoscopy and esophagram showed no leak, but a
small pseudodiverticulum where the patch had been placed was observed (Fig 7). An oral diet was started, which he has tolerated well.
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Fig 7. Endoscopic views showing (A) healed esophagogastric anastomosis with AlloDerm patch forming a small pseudodiverticulum in patient 3; (B) focused endoscopic view within diverticulum.
Comment FEATURE ARTICLES
Anastomotic leaks occur in 6% to 14% of esophagectomies [1, 2], leading to mortality rates as high as 35% [3]. Up to 40% of patients with an intrathoracic anastomotic leak may require reoperation, including diversion in more than 4% [4]. Once diverted, restoring esophageal continuity can be difficult [5], with few patients healthy enough to undergo reconstruction. Our case series suggests that AlloDerm can be effectively used to salvage neoesophageal conduits, even with extensive tissue loss. In 2 of our patients, the extent of necrosis and poor clinical conditions gave us few alternatives to diversion or patching with a viable tissue flap. In the third patient, we performed a single-layer primary closure in the setting of partial-thickness ischemia of the conduit and reinforced it with AlloDerm. The use of AlloDerm to restore continuity in a gastric conduit has been reported only once before. In that report, an onlay patch of AlloDerm was used to close a 2-mm anastomotic breakdown after laparoscopic-assisted Ivor Lewis esophagectomy, with the patient resuming a full liquid oral diet by the second postoperative week [6]. In 2 other patients, tracheal membrane defects attributable to acquired tracheoesophageal fistulas were repaired using AlloDerm with muscle flap coverage and primary repair of the esophagus [7, 8]. Sinha and associates [9] described pharyngeal reconstruction with AlloDerm and sternocleidomastoid muscle flap after partial pharyngectomy in 14 patients, all of whom eventually resumed an oral diet. AlloDerm is resistant to infection and serves as a natural scaffold for cellular regeneration by extension from adjacent normal tissue. Unlike native tissue flaps, AlloDerm can be tailored to fit any size of defect. It has been used successfully to patch esophageal leaks in canine laboratory models [10]. Becksted and colleagues [11] demonstrated that rat esophageal epithelial cells seeded on AlloDerm showed superior morphology, resembling native esophagus, when compared with those seeded on synthetic scaffolds. A caveat is that even though epithelialization occurs, esophageal muscle is not restored, which may affect swallowing.
Vascular flaps such as muscle, pericardium, or omentum can theoretically be used to patch a conduit defect, but may not be readily available. Intercostal muscle flaps and pericardial patches can be difficult to harvest when significant inflammation is present. Most patients with significant intrathoracic leaks present in extremis, and prolonging the operative time to harvest native biologic flaps may be undesirable. The available length of these flaps may also be limited. Esophageal stenting has been shown to reduce the reoperation rates in smaller thoracic anastomotic dehiscences, but extensive tissue loss may limit the success of stenting. In such cases, buttressing of the defect with native tissue flaps may be a useful adjunct to stenting. Although the conduit was successfully salvaged with AlloDerm in all the patients described, many questions remain. These include the role of concomitant stenting, timing of oral intake, and the risk of stricture formation. The long-term results are unknown. Despite this, we suggest that reconstruction with AlloDerm can be considered for repair of the dehisced conduit as an alternative option to diversion.
References 1. Sarela AI, Tolan DJ, Harris K, Dexter SP, Sue-Ling HM. Anastomotic leakage after esophagectomy for cancer: a mortality-free experience. J Am Coll Surg 2008;206:516–23. 2. Escofet X, Manjunath A, Twine C, Havard TJ, Clark GW, Lewis WG. Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network. Dis Esophagus 2010;23:112–6. 3. Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2004;10:71–5. 4. Crestanello JA, Deschamps C, Cassivi SD, et al. Selective management of intrathoracic anastomotic leak after esophagectomy. J Thorac Cardiovasc Surg 2005;129:254–60. 5. Barkley C, Orringer MB, Iannettoni MD, Yee J. Challenges in reversing esophageal discontinuity operations. Ann Thorac Surg 2003;76:989–95. 6. Bozuk MI, Fearing NM, Leggett PL. Use of decellularized human skin to repair esophageal anastomotic leak in humans. JSLS 2006;10:83–5. 7. Morse CR. Repair of bronchial esophageal fistula using AlloDerm. Ann Thorac Surg 2009;88:1018–9.
8. Su JW, Mason DP, Murthy SC, Rice TW. Closure of a large tracheoesophageal fistula using AlloDerm. J Thorac Cardiovasc Surg 2008;135:706–7. 9. Sinha UK, Chang KE, Shih CW. Reconstruction of pharyngeal defects using AlloDerm and sternocleidomastoid muscle flap. Laryngoscope 2001;111(11 Pt 1): 1910–6.
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10. Isch JA, Engum SA, Ruble CA, Davis MM, Grosfeld JL. Patch esophagoplasty using AlloDerm as a tissue scaffold. J Pediatr Surg 2001;36:266–8. 11. Beckstead BL, Pan S, Bhrany AD, Bratt-Leal AM, Ratner BD, Giachelli CM. Esophageal epithelial cell interaction with synthetic and natural scaffolds for tissue engineering. Biomaterials 2005;26:6217–28.
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1459–63
Postesophagectomy anastomotic leaks cause significant morbidity and mortality. Esophageal diversion is often required when extensive tissue loss precludes primary repair. We describe a technique in which human acellular dermis (AlloDerm) is used to repair the conduit, and report
a series of 3 patients with significant anastomotic dehiscence whose conduits were salvaged using this technique.
C
included peripheral vascular disease, coronary artery disease, and a significant smoking history. Three weeks after his surgery, he experienced an anastomotic leak. Endoscopy revealed circumferential ulceration of the anastomosis (Fig 3). After a few days of conservative management with nasogastric and chest tube drainage, he exhibited hemoptysis. A small tear in the right mainstem bronchus was seen on bronchoscopy, and was suspected of being a tracheal-conduit fistula. He failed to progress with esophageal stenting, and an exploratory right thoracotomy was performed. The small (2 to 3 mm) tracheal-conduit fistula was primarily closed and covered with a pericardial fat pad. A larger anastomotic defect identified in the lateral wall could not be primarily reapproximated. After removing the stent, a thick AlloDerm patch was circumferentially wrapped around the anastomosis as described above (Fig 4A). The bronchial repair was intact when tested under saline solution immersion. A nasogastric tube and multiple chest drains were placed. Two days later, the esophageal stent was reinserted to support healing of the trachealconduit fistula. During the next 5 months, the fistula was evaluated with interval endoscopies. The stent was removed after the fistula had healed, which was confirmed by an esophagram (Fig 4B). He tolerated an oral diet but required intermittent dilatation for an anastomotic stricture that developed 4 months after stent removal. PATIENT 2. A 69-year-old man with stage 1 (T2 N0 M0) distal esophageal adenocarcinoma underwent Ivor Lewis esophagectomy after neoadjuvant chemoradiation. He had a strong smoking history and previous endovascular repair of an abdominal aortic aneurysm. Esophagram after 1 week was negative for leak. Two days later, he experienced severe sepsis secondary to a large anastomotic leak and required intubation. Multiple chest tubes were placed. Bronchoscopy showed a large amount of pus in the right lower lobe, but no obvious fistula. Upper endoscopy revealed near-circumferential necrosis and a large anastomotic defect. Given his surgical history, an
Technique Our approach is through a right thoracotomy, which provides adequate exposure to evaluate and repair the conduit. After debriding all nonviable tissue, the conduit is assessed to determine whether primary closure is feasible. An existing esophageal stent can be left in place (Fig 1A) or removed as required to facilitate repair. If feasible, primary closure is first performed and then reinforced with a patch of thick AlloDerm. The patch is anchored to the surrounding healthy tissues with 3-0 silk (Ethicon, Somerville, NJ) horizontal mattress sutures (Fig 1B). When extensive loss of tissue precludes primary closure, a thick piece of AlloDerm is placed as an onlay patch (Fig 2A) or wrapped around the conduit (Fig 2B), depending on how much the conduit can be mobilized. If wrapped around the graft, the longitudinal edges of the AlloDerm are also sewn to each other with interrupted 3-0 silk sutures (Fig 2B). Multiple chest drains as well as a nasogastric tube are placed.
Patients and Methods A 75-year-old man with stage I (T1b N0 M0) distal esophageal adenocarcinoma underwent a right transthoracic (Ivor Lewis) esophagectomy after unsuccessful endoscopic mucosal resection. His comorbidities
PATIENT 1.
Accepted for publication Aug 21, 2013. Address correspondence to Dr Wigle, Division of General Thoracic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: wigle. [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.08.051
FEATURE ARTICLES
onduit necrosis or ischemia after esophagectomy can have severe consequences. In such instances, few options remain other than esophageal diversion, with or without delayed reconstruction using an alternative conduit. We report a series of 3 patients in whom human acellular dermis, AlloDerm (LifeCell Corporation, Branchburg, NJ), was successfully used to salvage dehisced conduits after esophagectomy.
(Ann Thorac Surg 2014;97:1459–63) Ó 2014 by The Society of Thoracic Surgeons
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Fig 1. (A) The esophageal stent may be left in place, and (B) the AlloDerm patch is sutured to the healthy tissues surrounding the dehiscence with 3-0 silk horizontal mattress sutures.
Fig 2. (A) AlloDerm may be placed as an onlay patch or (B) a cylindrical wrap with the free edges sewn to each other.
FEATURE ARTICLES Fig 3. Endoscopic view of the anastomotic dehiscence (arrow) in patient 1.
attempt was made to salvage the conduit using an esophageal stent. Owing to a persistent right lung collapse and failure to extubate, an exploratory right thoracotomy was performed. Intraoperative findings included extensive gastric conduit necrosis with a 5-cm anastomotic defect through which the stent was easily visualized (Fig 5A).
Extensive debridement was performed without removing the stent. A thick AlloDerm patch was used to completely cover the defect and anchored with 3-0 silk horizontal mattress sutures (Fig 5B) to healthy areas of the esophagus and stomach. Severe mediastinal inflammation prevented inspection of the medial wall. Intraoperative bronchoscopy showed a small tracheal defect just above the carina. A tracheal stent was not placed because of concerns of pressure necrosis between two stents. A tracheostomy was performed. After a prolonged recovery, the chest drains were eventually removed. Endoscopy (Fig 6A) and esophagram (Fig 6B) showed complete healing of the fistula after 4 months, and the stent was removed. He tolerated an oral diet but required serial endoscopic dilations of a benign anastomotic stricture. PATIENT 3. A 59-year-old man with stage 1 (T2 N0 M0) distal esophageal adenocarcinoma underwent Ivor Lewis esophagectomy after neoadjuvant chemoradiation. A week later, he experienced severe chest pain and sepsis owing to anastomotic breakdown. A right thoracotomy revealed necrosis of the proximal gastric conduit. Debridement resulted in a 1-cm defect surrounded by a 3-cm-wide area of partial-thickness ischemia but healthy mucosa. As a result of tension, only a single full-thickness layer closure could be performed. A thick AlloDerm patch was wrapped circumferentially around the anastomosis and sutured to the healthy conduit and esophagus using 3-0 silk horizontal mattress sutures. A nasogastric tube and
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Fig 4. (A) Intraoperative view of the AlloDerm wrapped around the anastomosis and (B) esophagram showing healed tracheoesophageal fistula and restored esophageal continuity in patient 1.
FEATURE ARTICLES
Fig 5. Intraoperative views showing (A) anastomotic dehiscence with exposed stent and (B) AlloDerm patch in patient 2.
Fig 6. (A) Endoscopic view and (B) esophagram at 4 months showing intact anastomosis with AlloDerm patch in patient 2.
multiple chest drains were placed. An esophageal stent was placed 2 days later and removed after 6 weeks. Endoscopy and esophagram showed no leak, but a
small pseudodiverticulum where the patch had been placed was observed (Fig 7). An oral diet was started, which he has tolerated well.
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Fig 7. Endoscopic views showing (A) healed esophagogastric anastomosis with AlloDerm patch forming a small pseudodiverticulum in patient 3; (B) focused endoscopic view within diverticulum.
Comment FEATURE ARTICLES
Anastomotic leaks occur in 6% to 14% of esophagectomies [1, 2], leading to mortality rates as high as 35% [3]. Up to 40% of patients with an intrathoracic anastomotic leak may require reoperation, including diversion in more than 4% [4]. Once diverted, restoring esophageal continuity can be difficult [5], with few patients healthy enough to undergo reconstruction. Our case series suggests that AlloDerm can be effectively used to salvage neoesophageal conduits, even with extensive tissue loss. In 2 of our patients, the extent of necrosis and poor clinical conditions gave us few alternatives to diversion or patching with a viable tissue flap. In the third patient, we performed a single-layer primary closure in the setting of partial-thickness ischemia of the conduit and reinforced it with AlloDerm. The use of AlloDerm to restore continuity in a gastric conduit has been reported only once before. In that report, an onlay patch of AlloDerm was used to close a 2-mm anastomotic breakdown after laparoscopic-assisted Ivor Lewis esophagectomy, with the patient resuming a full liquid oral diet by the second postoperative week [6]. In 2 other patients, tracheal membrane defects attributable to acquired tracheoesophageal fistulas were repaired using AlloDerm with muscle flap coverage and primary repair of the esophagus [7, 8]. Sinha and associates [9] described pharyngeal reconstruction with AlloDerm and sternocleidomastoid muscle flap after partial pharyngectomy in 14 patients, all of whom eventually resumed an oral diet. AlloDerm is resistant to infection and serves as a natural scaffold for cellular regeneration by extension from adjacent normal tissue. Unlike native tissue flaps, AlloDerm can be tailored to fit any size of defect. It has been used successfully to patch esophageal leaks in canine laboratory models [10]. Becksted and colleagues [11] demonstrated that rat esophageal epithelial cells seeded on AlloDerm showed superior morphology, resembling native esophagus, when compared with those seeded on synthetic scaffolds. A caveat is that even though epithelialization occurs, esophageal muscle is not restored, which may affect swallowing.
Vascular flaps such as muscle, pericardium, or omentum can theoretically be used to patch a conduit defect, but may not be readily available. Intercostal muscle flaps and pericardial patches can be difficult to harvest when significant inflammation is present. Most patients with significant intrathoracic leaks present in extremis, and prolonging the operative time to harvest native biologic flaps may be undesirable. The available length of these flaps may also be limited. Esophageal stenting has been shown to reduce the reoperation rates in smaller thoracic anastomotic dehiscences, but extensive tissue loss may limit the success of stenting. In such cases, buttressing of the defect with native tissue flaps may be a useful adjunct to stenting. Although the conduit was successfully salvaged with AlloDerm in all the patients described, many questions remain. These include the role of concomitant stenting, timing of oral intake, and the risk of stricture formation. The long-term results are unknown. Despite this, we suggest that reconstruction with AlloDerm can be considered for repair of the dehisced conduit as an alternative option to diversion.
References 1. Sarela AI, Tolan DJ, Harris K, Dexter SP, Sue-Ling HM. Anastomotic leakage after esophagectomy for cancer: a mortality-free experience. J Am Coll Surg 2008;206:516–23. 2. Escofet X, Manjunath A, Twine C, Havard TJ, Clark GW, Lewis WG. Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network. Dis Esophagus 2010;23:112–6. 3. Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2004;10:71–5. 4. Crestanello JA, Deschamps C, Cassivi SD, et al. Selective management of intrathoracic anastomotic leak after esophagectomy. J Thorac Cardiovasc Surg 2005;129:254–60. 5. Barkley C, Orringer MB, Iannettoni MD, Yee J. Challenges in reversing esophageal discontinuity operations. Ann Thorac Surg 2003;76:989–95. 6. Bozuk MI, Fearing NM, Leggett PL. Use of decellularized human skin to repair esophageal anastomotic leak in humans. JSLS 2006;10:83–5. 7. Morse CR. Repair of bronchial esophageal fistula using AlloDerm. Ann Thorac Surg 2009;88:1018–9.
8. Su JW, Mason DP, Murthy SC, Rice TW. Closure of a large tracheoesophageal fistula using AlloDerm. J Thorac Cardiovasc Surg 2008;135:706–7. 9. Sinha UK, Chang KE, Shih CW. Reconstruction of pharyngeal defects using AlloDerm and sternocleidomastoid muscle flap. Laryngoscope 2001;111(11 Pt 1): 1910–6.
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10. Isch JA, Engum SA, Ruble CA, Davis MM, Grosfeld JL. Patch esophagoplasty using AlloDerm as a tissue scaffold. J Pediatr Surg 2001;36:266–8. 11. Beckstead BL, Pan S, Bhrany AD, Bratt-Leal AM, Ratner BD, Giachelli CM. Esophageal epithelial cell interaction with synthetic and natural scaffolds for tissue engineering. Biomaterials 2005;26:6217–28.
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1459–63
