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Original Articles: General Thoracic

Roux-en-Y Diversion for Intractable Reflux After Esophagectomy

^a Department of Surgery, Division of Thoracic Surgery, Université de Montréal, Montréal, Québec, Canada
^b Department of Pathology, Université de Montréal, Montréal, Québec, Canada

Accepted for publication June 18, 2008.

^_* Address correspondence to Dr Duranceau, Department of Surgery, Université de Montréal, Division of Thoracic Surgery, Centre Hospitalier del'Université de Montreal, Pavillon Lachapelle, Bureau D-8051, 1560 rue Sherbrooke Est, Montreal Quebec, H2L 4M1, Canada (Email: andre.duranceau{at}umontreal.ca).

Background: Reflux esophagitis is a significant problem after esophagectomy and gastric reconstruction. When mixed reflux damages the esophageal remnant or results in aspiration problems, appropriate medical management is in order. If medical management fails, a surgical option is available. This study reports results of a Roux-en-Y diversion in postesophagectomy patients affected by debilitating reflux complications.

Methods: Between 1990 and 2006, 4 of 223 esophagectomy patients required surgical correction for mucosal damage to their esophageal remnant or repeat aspirations. Patient, clinical, operative, histopathologic, and postoperative data were collected.

Results: Two of 3 patients with a substernal reconstruction underwent antrectomy with a 60-cm Roux-en-Y diversion. One patient with significant reflux disease and aspiration episodes also had a gastrobronchial fistula. The gastric interposition was defunctionalized, and a staged reconstruction with antrectomy and a Roux-en-Y diversion was completed. One patient with a prevertebral reconstruction had a Roux-en-Y diversion without antrectomy. There was no mortality and minimal morbidity. Two patients are asymptomatic and 2 are improved. Endoscopic assessment documented normal mucosa in the esophageal remnant for 2 of the 4 patients postoperatively; in 2 others, metaplastic columnar mucosa persisted. Active inflammation regressed in all 4 patients.

Conclusions: Complete duodenal diversion with a 60-cm Roux-en-Y gastrojejunostomy is an effective operation to correct debilitating reflux complications after esophagectomy. Reflux symptoms are corrected and the mucosa is allowed to heal. The surgical approach is influenced by the position of the gastric transplant. Protection of the vascular supply to the gastric tube is the challenge of the operation.