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Ann Thorac Surg 1996;62:369-372
© 1996 The Society of Thoracic Surgeons
Division of General Thoracic Surgery, Department of General Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
Accepted for publication April 5, 1996.
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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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.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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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.
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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).
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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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).
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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).
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); however, transhiatal was the more common technique for the interval 1992 to 1995 (p < 0.05).
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shows the changes in conduit use between the two time intervals. Colon was the most commonly used conduit for esophageal replacement during time 1, however, stomach was most commonly used during time 2 (p < 0.05). The frequency of use of jejunal conduits remained relatively constant during the study period.
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). The frequency of perioperative blood transfusion decreased from 0.7 ± 0.4 units to 0.3 ± 0.2 units for time 1 and time 2, respectively. This change was not statistically significant. Although there was no significant change in morbidity overall noted with time, there was a trend toward decreasing respiratory complications from four (18.1%) to one (4.3%).
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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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%.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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References |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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