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Ann Thorac Surg 1996;62:369-372
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Esophagectomy for Benign Disease: Trends in Surgical Results and Management

Division of General Thoracic Surgery, Department of General Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland

Accepted for publication April 5, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Esophagectomy for benign disease is uncommon.

Methods. From July 1987 to April 1995, 45 consecutive patients (30 men, 15 women; mean age, 50 years) were evaluated in whom the senior author (R.F.H.) performed an esophagectomy, esophageal reconstruction, or both. The study period was divided into two time intervals, July 1987 to January 1992 (time 1) and February 1992 to April 1995 (time 2).

Results. Indications for operation included obstruction (23 patients, 51%), benign neoplasia (17,38%), and perforation (5 patients, 11%). A nonthoracotomy approach was used in 19 (42%) patients: 15 transhiatal and 4 substernal. Thoracotomies were performed in 26 (58%) patients through a left thoracoabdominal or multiincisional techniques. Morbidity occurred in 15 (33%) patients, and there was one operative death (2%).

Conclusions. Despite an operative morbidity of 33%, esophagectomy for benign disease may be performed with acceptably low mortality. We observed the following trends: (1) an increase in patients with benign neoplasia and a decline in patients with obstruction, (2) an increased use of transhiatal esophagectomy, (3) a decreased use of colon, an increased use of stomach for esophageal replacement; and (4) a decreased length of hospital stay.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
At our institution, benign esophageal disease is less common an indication for esophagectomy than malignant disease. Although we have not noted a significant change in the number of esophagectomies performed for benign disease, we have observed changes in specific surgical indications, technique, and results over time. The purpose of this study was to review our overall results with esophagectomy for benign disease, and to evaluate trends in surgical results and management.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The study group consisted of 45 consecutive patients with benign esophageal disease in whom the senior author (R.F.H.) performed esophagectomy, esophageal replacement, or both between July 1987 and April 1995 at the Johns Hopkins Hospital. The diagnosis of benign esophageal disease was confirmed on pathologic examination of the resected esophagus.

The specific surgical esophagectomy technique used was selected on the basis of the underlying esophageal disorder, location and extent of esophageal disease, options for esophageal replacement, and the senior surgeon's evolving experience. The techniques used included transhiatal [1, 2], left thoracoabdominal [3], and multiincisional [4] approaches. One stage esophagectomy and esophageal replacement was used in 39 patients, whereas in 6 patients the resection and esophageal replacement was performed in a staged fashion. Isoperistaltic stomach, jejunum, or colon were used as an interposition graft to replace the esophagus with the graft placed in the posterior mediastinum whenever possible. A pyloromyotomy was performed routinely. A two-layered, hand-sewn, inverting 4-0 silk stitch anastomosis was used. A surgical jejunostomy was placed in all patients using a technique that permits percutaneous replacement if necessary [5].

Postoperatively patients were kept sedated, intubated, and on mechanical ventilation overnight. They were subsequently weaned from the ventilator and extubated as tolerated. The nasogastric tube was removed on postoperative day 5, a cine (or video) esophagogram performed on postoperative day 6, and oral feedings resumed after the completion of the radiographic study if no anastomotic leak, obstruction, or aspiration was identified. A progressive postoperative therapeutic diet was used that increased the consistency of feedings in a graded fashion using a six equal meal daily schedule. Low-dose jejunostomy feedings were initiated on postoperative day 3. The feedings were stopped and the jejunostomy tube removed before discharge if no swallowing problems were encountered.

The hospital medical records were reviewed retrospectively to determine patient age, sex, indications for operation, surgical technique, surgical morbidity and mortality, blood product use, and length of hospital stay.

Indications for operation were divided into three categories: obstruction, benign neoplasia, and perforation (Table 1). Obstruction included peptic, caustic ingestion, and radiation strictures, achalasia, and postsurgical esophageal obstruction from anastomotic stricture, an eroding Angelchik prosthesis, and a tight complete fundoplasty (Nissen). Benign neoplasia included squamous or columnar lined (Barrett) epithelial high-grade dysplasia, which we consider to be an unequivocal neoplastic process [6], and the benign tumors leiomyoma and melanotic schwannoma. Perforation included spontaneous, peptic, and penetrating traumatic causes.

Results are expressed as mean ± the standard error of the mean. Comparisons of continuous data between several groups was made using an analysis of variance. Discrete variables among groups were compared using the ² test. A p value less than 0.05 was considered statistically significant. Statistical analysis was performed using the software package Statview (Brainpower, Inc, Calabasas, CA).

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Patient Characteristics
There were 30 men and 15 women with a mean age of 49.8 ± 13.9 years (range, 17 to 73 years). Twenty-one patients (47%) had undergone previous esophageal operation, and 6 patients (13%) had undergone previous gastrectomy.

Indications
Esophageal obstruction (23 patients, 51%) was the most common indication for operation. The obstructing pathology was peptic (8 patients), caustic ingestion (4 patients), and radiation induced (1 patient) strictures, "end-stage" achalasia with dilated esophagus (6 patients), and postsurgical (4 patients). Postsurgical causes included two nondilatable anastomotic strictures, one eroding Angelchik prosthesis, and a tight complete fundoplasty.

Benign neoplasia was the second most common (17 patients, 38%) indication for operation. There was 1 patient with high-grade squamous epithelial dysplasia, and 14 patients with high-grade epithelial columnar-lined (Barrett) epithelium. There were 2 patients with benign tumors, 1 with a 6-cm leiomyoma involving the distal esophagus, and a 6-cm melanotic schwannoma involving the midesophagus.

Perforation was the least common cause (5 patients, 11%). The cause of the perforation was penetrating peptic ulcer in 1, spontaneous in 2, and penetrating trauma in 2 patients.

Technique
A nonthoracotomy approach was used in 19 (42%) patients: 15 transhiatal resections and four substernal approaches. Thoracotomies were performed in 26 (58%) patients through a thoracoabdominal or multiincisional approach. Staged esophagectomy and esophageal replacement was performed in 6 (13%) patients. The conduit used for esophageal replacement was stomach in 28 (62%), colon in 12 (27%), and jejunum in 5 (11.%) patients.

Surgical Results
There was one operative death (2%) due to right heart failure. Postoperative morbidity occurred in 15 (33%) patients and is detailed in Table 2. There was one contained anastomotic leak that was successfully managed nonoperatively. Respiratory complications occurred in 8 patients including prolonged intubation (more than 48 hours) in 3 patients, pneumonia in 2, pleural effusion in 1, a duodenobronchial fistula [7] in 1, and transhiatal hoarseness with presumed recurrent laryngeal nerve injury in 2 patients. Ischemia of the interposed colon segment occurred in 2 patients. In 1 of these patients, removal of the interposed colon with cervical esophageal diversion was required. Additional morbidity included wound infections (3 patients) and abdominal wound dehiscence (1 patient).

Trends
Figure 1 shows the changes in indications for the time intervals 1987 to 1992 (time 1) and 1992 to 1995 (time 2), respectively. The prevalence of obstructive lesions decreased from 14 to 9, whereas benign neoplastic lesions increased from 5 to 12 (p < 0.05). The prevalence of esophageal perforation remained essentially stable (3 and 2 patients, respectively).

View larger version (21K): [in this window] [in a new window]   Fig 1. . Indication versus time.

View larger version (18K): [in this window] [in a new window]   Fig 2. . Surgical approach versus time.

View larger version (19K): [in this window] [in a new window]   Fig 3. . Conduit use versus time.

View larger version (15K): [in this window] [in a new window]   Fig 4. . Length of stay versus time.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

In our series, the observed postoperative morbidity was 33%. Other series, which vary in terms of benign indications, operative approach, and choice of esophageal conduit, report postesophagectomy morbidity of 16.5% to 50% [8–12]. Preoperative weight loss, comorbidities associated with the specific disease process, and previous operations all are reasons for the observed high complication rates. No specific postoperative complications were identified that were unique to patients with benign disease. Despite the observed morbidity in our review, operative mortality was low (2%), and length of hospital stay were acceptably low as has been demonstrated by others [1, 2].

We have observed the following trends in surgical indication, technique, and results. Esophageal obstruction was the most common surgical indication before January 1992; subsequently, benign neoplasia was most common. The decline in esophageal obstruction from end-stage peptic esophageal strictures most likely reflects improved medical antireflux therapy, and more effective endoscopic management of esophageal strictures. The increased frequency of Barrett mucosa with high-grade epithelial dysplasia reflects an increased number of patients diagnosed with Barrett mucosa, a shift in the frequency of esophageal cancer cell type from squamous cell carcinoma to adenocarcinoma, and, in part, a referral bias as we have advocated prophylactic esophagectomy for select patients with this pathology who are candidates for operation [14]Au: cite ref 13. We observed no change in the incidence of esophageal perforation, as would be expected, as most were the result of unpredictable events such as penetrating trauma or spontaneous perforation.

Two related trends in surgical technique were observed: the increasing use of both the transhiatal approach and the use of the stomach as an esophageal replacement. These trends reflect our favorable experience with the use of transhiatal esophagectomy with gastric pull-up for patients with esophageal carcinoma. Therefore, it is our preference to use this technique for patients with benign and malignant disease. Compared with a colon interposition, use of the stomach is faster, requires one instead of three anastomoses, is equally (or possibly more) durable, and avoids early and subacute [15] ischemic complications associated with colonic grafts. Other investigators have advocated transhiatal esophagectomy as a safe and acceptable approach to the surgical management of patients with benign esophageal disease [2, 4, 15].

Length of stay has declined from 19.7 ± 2.7 days to 11.4 ± 1.2 days from the earlier to the later study time period. We postulate that this change is attributable to improved perioperative management, methods to minimize respiratory infectious complications, the shift in predominant surgical indication to benign neoplasia, and the introduction of a standardized physician and nursing management protocol ("critical pathway") for esophagectomy patients at this institution.

In conclusion, we have found that esophagectomy for benign disease can be done with acceptable mortality and length of stay despite an observed morbidity of 33%.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to* Dr Heitmiller, Johns Hopkins Hospital, Osler 624, 600 N Wolfe St, Baltimore, MD 21287-5674

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Orringer MB. Transhiatal esophagectomy for benign disease. J Thorac Cardiovasc Surg 1985;90:649–55.[Abstract]
2. Orringer MB, Marshall B, Stirling MC. Transhiatal esophagectomy for benign and malignant disease. J Thorac Cardiovasc Surg 1993;105:265–77.[Abstract]
3. Heitmiller RF. The left thoracoabdominal incision. Ann Thorac Surg 1988;46:250–3.
4. McKeown KC. Total three-staged esophagectomy for cancer of the oesophagus. Br J Surg 1976;63:259–62.[Medline]
5. Heitmiller RF, Venbrux AC, Osterman FA. Percutaneous replacement jejunostomy. Ann Thorac Surg 1992;53:711–3.[Abstract]
6. Hamilton SR, Smith RRL. The relationship between columnar epithelial dysplasia and invasive adenocarcinoma arising in Barrett's esophagus. Am J Clin Pathol 1987;87:301–12.[Medline]
7. Heitmiller RF, Yeo CJ. Duodenobronchial fistula. Surgery 1991;110:546–8.[Medline]
8. Orringer MB, Stirling MC. Cervical esophagogastric anastomosis for benign disease. J Thorac Cardiovasc Surg 1988;96:887–93.
9. Rice TW, Falk GW, Achar E, Petras RE. Surgical management of high-grade dysplasia in Barrett's esophagus. Am J Gastroenterol 1993;88:1832–6.[Medline]
10. Jankins JR, Cole FN, McLaughlin JS. Colon interposition for benign esophageal disease. Experience with 23 patients. Ann Thorac Surg 1984;37:192–6.[Abstract]
11. Mansour KA, Hansen HA, Hersh T, Miller JI, Hatcher CR. Colon interposition for advanced nonmalignant esophageal stricture: experience with 40 patients. Ann Thorac Surg 1981;32:584–91.[Abstract]
12. Pera M, Trastek VF, Carpenter HA, Allen MS, Deschamps C, Pairolero PC. Barrett's esophagus with high grade dysplasia: an indication for esophagectomy? Ann Thorac Surg 1992;54:199–204.[Abstract]
13. Daniel TM, Fleischer KJ, Flanagan TL, Tribble CG, Kron IL. Transhiatal esophagectomy: a safe alternative for selected patients. Ann Thorac Surg 1992;54:686–90.[Abstract]
14. Wright C, Cuschieri A. Jejunal interposition for benign esophageal disease. Ann Surg 1987;205;54–60.[Medline]
15. Heitmiller RF, Redmond M, Hamilton SR. Barrett esophagus with high grade dysplasia: an indication for prophylactic esophagectomy. Ann Surg (in press)Au: update?.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Davis, E. A. Articles by Heitmiller, R. F. Search for Related Content PubMed PubMed Citation Articles by Davis, E. A. Articles by Heitmiller, R. F.