Novel Use of Spy Elite in Esophagectomy With Colonic Interposition Graft

Jeffrey R Watkins, MD, Houssam G Osman, MD, Rohan Jeyarajah, MD. Methodist Dallas Medical Center

Introduction – We present a series of three patients who underwent colonic interposition grafts with vascular evaluation using the Spy Elite imaging system. Gastric pull-up is the preferred method for reconstruction following esophagectomy, but when the stomach is not a suitable conduit colonic interposition is can be performed. Colonic interposition procedures are more complex than gastric pull-up and carry higher morbidity. The anastomotic leak after colonic interposition in the literature ranges from 0-47%. SPY Elite is an intraoperative perfusion assessment system that enables surgeons to visualize and evaluate tissue perfusion in real-time with a great degree of accuracy. While its use is well-documented in the evaluation of other gastrointestinal anastamoses, there are currently no reports of its application in colonic interpostition grafts.

Cases Presentation – Trans-hiatal esophagectomy with colonic interposition was performed in three patients: a 58 year-old female (patient 1) with gastroesophageal junction tumor extending into the proximal stomach and the thoracic esophagus, a 61 year-old male (patient 2) with a gastroesophageal junction tumor, and a 50 year-old male (patient 3) with chronic esophageal stricture secondary to gastroesophageal caustic injury.

Gastroesophagectomy was performed in standard trans-hiatal fashion in all cases. The right colon was prepared for interposition along with the middle colic pedicle and the ileocolic vessels were ligated. While the colonic conduit perfusion appeared to be adequate on visual inspection in all three patients, this was further evaluated using the SPY Elite system. The conduit and the cecum appeared well vascularized in patient 1 and 2 during SPY visualization, but the conduit in patient 3 appeared less vascularized. Colo-esophageal anastomosis was performed using a linear stapler and oversewn.

A contrast study was performed postoperatively to evaluate the anastomosis. No clinical or radiological leak was noted in the patients with appropriate perfusion as determined by Spy Elite visualization. A radiological leak was noted however, in the patient with abnormal Spy Elite visualization. This was treated conservatively and required no further intervention.

Conclusion – Anastomotic leak is a major complication after esophagectomy and colonic interposition. Conduit ischemia is an important risk factor for anastomotic leak. The use of SPY Elite may accurately assess the conduit perfusion and provide information to aid with intraoperative decision to avoid this complication.

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