Ann Thorac Surg 1996;62:373-377
© 1996 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Retrosternal Bypass Operation for Unresectable Squamous Cell Cancer of the Esophagus
Bernard Meunier, MD,
Yorgos Spiliopoulos, MD,
Christian Stasik, MD,
Mohamed Lakéhal, MD,
Yannick Malledant, MD,
Bernard Launois, MD
Departments of Digestive Surgery and Intensive Care, Centre Hospitalier, Rennes, France
Accepted for publication April 9, 1996.
 |
Abstract
|
|---|
Background. A palliative bypass operation may be beneficial when severe dysphagia or tracheoesophageal fistula occurs after radiochemotherapy for unresectable tumor of the esophagus.
Methods. Thirty-two patients with an unresectable tumor of the esophagus underwent a palliative retrosternal gastric (29) or colonic (3) bypass operation with ligature of the lower esophagus (3) or drainage (27). Tracheoesophageal fistula was present at operation in 20 (62.5%), including 8 after radiochemotherapy.
Results. The overall operative mortality rate was 34.4%: 45% with tracheoesophageal fistula and 16.6% without (p< 0.01). Median intensive care and hospitalization times were 5 and 19 days, respectively. Median postoperative survival was 6 months (range, 53 to 492 days). Complications in 21 survivors were lung infections (seven), cervical fistulas (eight), and failure of the esophageal suture (two); 19 patients resumed oral nutrition, and quality of life was excellent in 6. All eight cervical fistulas regressed favorably. Postoperative radiotherapy or chemotherapy did not improve survival.
Conclusions. Despite the high operative mortality rate, bypass operation can provide good palliation and allow subsequent radiochemotherapy in selected patients with an unresectable tumor of the esophagus.
|
Introduction
|
|---|
Management of cancer of the esophagus has changed greatly with the advent of effective radiochemotherapy, allowing more precise indications for operation. The beneficial effect of radiochemotherapy, which can alleviate dysphagia and prolong survival time, is especially important in patients with unresectable tumors or those requiring palliation but for whom the risk of operative death outweighs the chances of improvement [1]. Yet despite radiochemotherapy, laser therapy, and dilatations, major dysphagia persists in certain patients, whereas in others, a tracheoesophageal fistula develops, which inevitably leads to death within 1 month [2]. Palliative operations with the aim of improving patient comfort and alleviating dysphagia can be beneficial in such patients. This palliation can be achieved by an esophageal bypass using the stomach, the colon, or the jejunum. The aim of this work was to assess the beneficial effects of esophageal bypass operations in terms of operative and hospital mortality rates, nutritional comfort, and quality of life.
|
Patients and Methods
|
|---|
Between January 1980 and July 1995, 841 patients underwent operations for cancer of the esophagus. Bypass operation was performed in 32 of these patients (3.8%) who had an unresectable tumor. During this same period, 2 other patients also had a retrosternal gastric bypass operation, 1 with lung cancer in whom a fistula developed between an esophageal diverticulum and the pouch created by prior pneumectomy, and 1 with breast cancer in whom neoplastic mediastinitis and undilatable aphagia developed. All 32 patients in the study group were men (mean age, 57.4 ± 10.1 years; range, 26 to 74 years), and 28 of them (87%) had a history of smoking and alcohol consumption. General health status was poor in 70% of the patients, who had a 10% of normal mean weight. In 11 of 32 patients, weight loss during the preceding 6 months was greater than 15% of initial weight loss. The pathologic diagnosis was squamous cell carcinoma involving the upper (n = 7), middle (n = 21), or lower (n = 4) esophagus. The indication for bypass operation was established preoperatively in 26 patients (81.2%). Clinical manifestations were severe dysphagia (n = 16), aphagia (n = 8), uncontrollable cough (n = 11), respiratory failure (n = 7), episodes of false passage (n = 9), and dysphonia (n = 3). Lung abscess (n = 1), hemoptysis (n = 2), and hematemesis (n = 2) also occurred. Tracheoesophageal fistula was suspected clinically in 20 patients (62.5%) and was confirmed by bronchial endoscopy (7 of 16), barium studies (13 of 14) (Fig 1
), or, more rarely, by esophageal endoscopy (5 of 16). The fistula involved the trachea (11 of 20), the primary right bronchus (3 of 20), or the primary left bronchus (6 of 20). Endoscopic studies of the airways in 16 patients revealed generalized inflammatory changes with mucosal redness and edema and copious mucopurulent secretions. In 2 patients, the fistula was initially managed with an esophageal prosthesis followed by radiotherapy with or without chemotherapy. There was no clinical, radiologic, or tomographic evidence of distant metastasis before operation in any of the patients. In 6 patients (18.7%), the bypass was decided on preoperatively because of an unresectable tumor in a young patient (26, 54, and 57 years for 3 of them), with severe dysphagia (n = 3) or aphagia (n = 3). In these 6 patients, operation revealed bronchial adherences (n = 4), aortic adherences (n = 1), or multiple hepatic metastases (n = 1) that had not been diagnosed preoperatively. Among the 32 patients in the study group, 5 had undergone radiochemotherapy at curative doses before operation; a tracheoesophageal fistula developed during treatment in 1 of them. Two others had received radiotherapy alone, with development of a fistula requiring interruption of the treatment in 1; another had received chemotherapy alone. One other patient with prior radiochemotherapy had undergone subsequent esophagectomy without thoracotomy. Six months later in this patient, a fistula developed between the gastric bypass and the primary right bronchus.
View larger version (22K):
[in this window]
[in a new window]
|
Fig 1. . Three months after radiochemotherapy as curative treatment for squamous cell cancer of the esophagus, a tracheoesophageal fistula developed in this 58-year-old patient. At upper gastrointestinal study, the contrast medium flowed from the esophagus directly into the bronchus.
|
|
Preoperative workup included respiratory function tests in all patients who did not have a fistula to exclude any respiratory contraindication (VEMS < 0.7 L). Oral nutrition was discontinued in patients with tracheoesophageal fistula, who were given fluid and electrolyte infusions before operation. These patients were given exclusive parenteral nutrition with antibiotics targeted at potential pulmonary infections and were managed with endoscopic aspirations and respiratory physical therapy (including postural drainage). Retrosternal gastric bypass was performed in most patients (n = 29) following the procedure first described by Kirschner [3]. The colon was used in the other 3 who had undergone prior esophagectomy or partial gastrectomy for gastric ulcer, or who had tumoral extension to the cardia; all 3 of these patients also had a tracheoesophageal fistula. The lower end of the esophagus was drained with a Y-loop in 27 patients and ligated in 3. The lower end of the esophagus was not manipulated in the 3 patients with a colonic bypass. In all patients, a pyloroplasty was performed and a jejunostomy was installed for enteral nutrition. The anastomosis was done manually in 22 patients and with an automatic stapler in 10. A previous transtumoral prosthesis in 2 patients was removed through the lower end of the esophagus before or during the procedure. All patients entered the intensive care unit after operation and were extubated as soon as respiratory status was compatible with spontaneous ventilation. Positive end-expiratory pressure was not used as an extubation criterion. Gastric aspiration was maintained for a long period to avoid distending the retrosternal stomach and to minimize the high risk of a cervical fistula. Oral nutrition was resumed when possible 8 to 10 days after operation, without previous barium study, in combination with adapted enteral nutrition.
|
Results
|
|---|
The mortality rate at 1 month was 34.4% (11 of 32) and median survival was 2.5 months (Fig 2). Mean survival was 4 ± 4 months (range, 3 to 492 days). Death was caused by acute respiratory failure (n = 7) associated with cervical fistula in 1, heart failure (n = 1), massive hemoptysis (n = 1), and multiple organ failure in 1 patient in whom a cervical fistula developed. Extubation was unsuccessful in 1 patient; a portion of the esophageal wall was aspirated through a large tracheoesophageal fistula at each inspiration, interrupting air flow. This patient had had two successive prostheses, first for dysphagia and then for the fistula, and had received radiochemotherapy at curative doses. The operative mortality rate at 1 month was 46% (9 of 20) for patients who had a tracheoesophageal fistula, compared with 16.6% (2 of 12) in those who did not (p < 0.01). The hospital mortality rate was 31.2% (10 of 32); this was less than the operative mortality rate, as 1 patient died at home 29 days after operation because of pulmonary infection after starting chemotherapy. Median length of stay in the intensive care unit was 5 days (range, 1 to 30 days), and median hospital stay was 19 days (range, 3 to 67 days). Excluding patients who died during the 1-month postoperative period, median length of stay in the intensive care unit was 3 days (range, 1 to 30 days) and median hospital stay was 22 days (range, 14 to 67 days); median survival was 6 months (range, 53 to 492 days). The median age of the patients who died within 1 month of operation was 61 years (range, 50 to 74 years), higher than that of patients who survived the postoperative period (57 years; range, 26 to 70 years), although the difference was not significant according to the Mann-Whitney U test.
View larger version (12K):
[in this window]
[in a new window]
|
Fig 2. . Kaplan-Meier plot. Actuarial survival curves for patients who underwent bypass operation for unresectable tumors of the esophagus (triangles), with tracheoesophageal fistula (squares), and without fistula (circles).
|
|
Cervical fistula developed in 10 patients (32%), including 6 who had a tracheoesophageal fistula and 4 without. The cervical fistula regressed favorably in 8 of them and persisted at death in the other 2. None of the fistulas were treated by reoperation. Severe pulmonary complications, none of which was the cause of death, occurred in 7 patients; reintubation was required in 1 of them and drainage of a hemopneumothorax in another. Reoperation was necessary in 2 patients because the ligature of the lower end of the esophagus failed. Oral nutrition was resumed on days 17, 30, 54, and 56 in 4 of the 8 patients who experienced a cervical fistula and who survived more than 1 month; oral nutrition was not possible in the 4 others. Excluding patients who died within the 1-month postoperative period, the median length of hospital stay in patients with a cervical fistula was 47 days (range, 28 to 67 days), which was significantly longer than in those without a fistula (median, 18 days; range, 14 to 24 days). Median stay in the intensive care unit in these patients with a fistula was 2 days (range, 1 to 30 days), compared with 5 days (range, 1 to 17 days) in those without.
Postoperatively, 7 patients received radiotherapy alone, 3 had chemotherapy alone, and 2 had radiochemotherapy. Mean survival in these patients given radiotherapy with or without chemotherapy was 6.6 months, compared with 4.6 months in those not given complementary postoperative treatment (p > 0.05). Among the 21 patients who survived more than 1 month, 19 (90%) were able to resume oral nutrition. Quality of life was assessed as excellent (nearly normal life-style) in 6 patients (28.5%), acceptable (not hospitalized, but bedridden at home) in 12 (57%), and poor (hospitalization) in 3 (14%).
|
Comment
|
|---|
Survival in patients with squamous cell carcinoma of the esophagus with an unresectable tumor or patent metastatic extension is 4 to 6 months [2]. With radiotherapy alone, there is no improvement in survival, and the effect on pain and dysphagia is not always sufficient, requiring dilatations in 50% of the cases and sometimes leading to severe stenosis [4]. When the trachea or bronchi are involved, radiotherapy can be contraindicated [4]. It has been demonstrated [5] that the survival rate at 2 years can be improved greatly by combining radiotherapy and chemotherapy in patients with unresectable tumors, with a significant effect on local recurrence and distant metastasis compared with radiotherapy alone.
As combined radiochemotherapy is often too aggressive for elderly patients in poor general condition, laser therapy for exophytic tumors or endoprostheses for circumferential tumors may be proposed [2]. However, the rate of prosthesis migration is high (38%) and carries the risk of reflux of liquid or semiliquid food [5], causing a high mortality rate (14%). When these techniques fail, the only possibility in certain cases is gastrostomy, with its functional constraints.
In contrast, when the tumor has not invaded the cervical esophagus or when the unresectable nature of the tumor is not recognized preoperatively, a bypass operation can be proposed for young patients or, more generally, for those in relatively good physical condition. Indeed, the operative mortality rate is high for the radical operation proposed by Ong and Kwong [6], and there is little benefit for the patient. Several palliative procedures can be proposed. We prefer the operation initially described by Kirschner [3, 7]. Kirschner's operation consists of a retrosternal gastric bypass with ligature or drainage of the lower esophagus. Palliation is good, though the operative mortality rate is high: 20% to 40% in our experience and in reports in the literature [8–11]. By associating gastric bypass with ligature of the lower esophagus, Kirschner's operation offers the advantage of postoperative radiotherapy while protecting the bypass from tumoral invasion. Wong and associates [12] reported 1 case with a 6-year, 4-month survival after radiotherapy. The operative mortality rate in our series was 34.4%, which may have resulted in part from the large percentage (52.6%) of patients with tracheoesophageal fistula, and also from the fact that we used the Kirschner operation in all cases, including malnourished patients with advanced-stage cancer, instead of using bipolar exclusion for cases with the poorest prognosis. Indeed, with bipolar exclusion, death is very common and the quality of life obtained in survivors is at best mediocre. This procedure does, however, make it possible to control pulmonary infections and renourish the patient, theoretically allowing enough time to reestablish digestive tract continuity if the general status of the patient permits. In the series reported by Ong [13], however, digestive tract continuity could be reestablished in only 1 of 15 patients. These results led certain authors to propose combining bipolar exclusion with gastric [9] or colonic retrosternal bypass. Certain authors [8–10] use the entire stomach, combined with an antireflux technique for some [9]. Others, including us, prefer a tubulized stomach, which can be raised easily into the neck [14]. The mediastinum can accommodate a tubulized stomach better than the entire stomach. Finally, others [15] have obtained similar results with an isoperistaltic gastric tube modeled from the greater curvature. The main drawback with this technique is that gastroesophageal reflux could favor or maintain cervical fistulization.
Not all authors drain the lower esophagus [9, 10]. Like many [7–9], we have found drainage is generally necessary, especially in patients with a tracheoesophageal fistula. Indeed, we had to reoperate in 2 cases because the suture of the lower esophagus failed. The absence of mucosal secretion in the esophagus theoretically justified the lack of drainage, but a true mucocele accumulated in the blind end. Such esophageal secretions or neoplastic suppurations can rupture into the abdomen.
To reduce the risk of anastomotic cervical fistula, which is very high in all reported series (Table 1), and the risk of excessive pressure on the retrosternal stomach, certain authors propose partial exeresis of the clavicle and manubrium sterni [9–11]. We have never used this technique, which does not appear to reduce the number of cervical fistulas [9]. We have observed, as have others [7, 9, 11], that these fistulas are usually temporary, rarely the cause of death, and generally resolve within less than 1 month with medical treatment (nasogastric aspiration and enteral nutrition).
View this table:
[in this window]
[in a new window]
|
Table 1. . Outcome and Cervical Complications After Gastric Bypass Operation for Squamous Cell Carcinoma of the Esophagus
|
|
There are other bypass procedures using the stomach. Side-to-side esogastrostomy through left thoracic access can be used for unresectable tumors of the lower esophagus and can be an interesting alternative in debilitated patients with a high operative risk, but has the inconvenience of allowing massive and highly uncomfortable gastroesophageal reflux. Finally, Gavriliu's operation [16], which often leads to cervical fistula, has been abandoned in favor of the procedures described by Charbit and colleagues [17].
The colon or the jejunum must be used when it is impossible to use the stomach because of prior gastrectomy. Palliative coloplasty is preferred by all authors. Like others, we use the transverse colon, which can be ascended easily into the neck. Others prefer the better congruency obtained with the right ileocolon. The drawback with this technique is the difficulty in ascending a voluminous cecum into the retrosternal space, so that some authors always remove the first rib and the clavicle [11]. Mortality with colonic bypass is high (40% to 50%) [18], and it should be performed only when the stomach cannot be used. Jejunal bypass is rarely used in Europe; the mortality rate has been reported at 27.7% [19] but may be as high as 67%, as reported in another series [20]. A single jejunal loop can be transplanted and revascularized with the inferior thyroid vessels [21], or ascensional jejunoplasty with skeletalized pedicles can be sectioned from the vascular arcades and irrigated through the downstream pedicles [22]. Ong and associates [19] emphasized the requirement to install the transplant subcutaneously to eliminate the risk of prolapse into the pleural cavity, leading to volvulus and strangulation.
In conclusion, patients with unresectable squamous cell carcinoma of the esophagus should be given radiochemotherapy as first-line treatment. In young patients with an unresectable tumor, the Kirschner operation provides good palliation at the cost of a high operative mortality rate and allows subsequent postoperative radiochemotherapy. In the extremely severe situation caused by tracheoesophageal fistula, inevitably leading to death within 1 month, the Kirschner operation can eliminate false passages and the risk of asphyxia while improving the patient's quality of life by allowing normal food intake.
|
Footnotes
|
|---|
Address reprint requests to Dr Launois, Department de Chirurgie Digestive et de Transplantation, Centre Hospitalier de Rennes, Rue Henri le Guilloux, 35033 Rennes Cedex, France.
|
References
|
|---|
- Leprise E, Etienne PL, Meunier B, et al. A randomized study of chemotherapy, radiation therapy and surgery versus surgery for localized squamous cell carcinoma of the esophagus. Cancer 1994;73:1779–84.[Medline]
- Chung SCS, Stuart RC, Li AKC. Surgical therapy for squamous-cell carcinoma of the oesophagus. Lancet 1994;343:521–4.[Medline]
- Kirschner M. Ein neues Verfahren der
sophagus plastik. Arch Klin Chir 1920;114:606–63.
- Earlam R, Cunha-Melo JR. Esophageal squamous cell carcinoma. A critical review of surgery. Br J Surg 1980;67:381–90.[Medline]
- Hersovic A, Martz K, Al-Sarraf M, et al. Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. N Engl J Med 1992;326:1593–8.[Abstract]
- Ong GB, Kwong KH. Management of malignant esophagobronchial fistula. Surgery 1970;67:293–301.[Medline]
- Ong GB. The Kirschner operation. A forgotten procedure. Br J Surg 1973;60:221–7.[Medline]
- Mannell A, Becker PJ, Nissenkorn M. Bypass surgery for unresectable sophageal cancer: early and late results in 124 cases. Br J Surg 1988;75:283–6.[Medline]
- Orringer MB, Sloan H. Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J Thorac Cardiovasc Surg 1975;70:836–51.[Abstract]
- Conlan AA, Nicolaou N, Hammond CA, Pool R, De Nobrega C, Mistry BD. Retrosternal gastric bypass for inoperable esophageal cancer: a report of 71 patients. Ann Thorac Surg 1983;36:396–401.[Abstract]
- Robinson JC, Isa SS, Spees EK, Rogers E, Gadacz TR. Substernal gastric bypass for palliation of esophageal carcinoma: rationale and technique. Surgery 1982;91:305–11.[Medline]
- Wong J, Lam KH, Lei WI, Ong GB. Results of Kirschner operation. World J Surg 1981;5:547–52.[Medline]
- Ong GB. Unresectable carcinoma of the oesophagus. Ann R Coll Surg Engl 1975;56:3–14.[Medline]
- Akiyama H, Hiyama M, Miyazono H. Total esophageal reconstruction after extraction of the esophagus. Ann Surg 1975;182:547–52.[Medline]
- Postlethwait RW. Carcinoma of the esophagus. Curr Probl Cancer 1978;2:3–44.
- Gavriliu D. Transplantation du pylore et du premier duodenum au cou au cours du remplacement de l'sophage. Ann Surg 1968;22:173–81.
- Charbit L, Brun JG, Celerier M. Oesophagoplastie par retournement de l'estomac entier vers le cou. Nouv Press Med 1982;2:669–71.
- Nicks R. Colonic replacement of the esophagus. Br J Surg 1967;54:124–8.[Medline]
- Ong GB, Lam KH, Lim STK, Wong J. Jejunal loop bypass and fundoplication for malignant esophagobronchial fistula. Surgery 1982;154:165–9.
- Ong GB, Lam KH, Wong J, Lim TK. Factors influencing morbidity and mortality in esophageal carcinoma. J Thorac Cardiovasc Surg 1978;76:745–54.[Abstract]
- Germain M, Arsac M. Ressources actuelles de la microchirurgie pour le remplacement de l'sophage cervical et de l'hypopharynx. Ann Otolaryngol Chir Cervicofac 1980;97:189–99.[Medline]
- Foker JE, Ring WS, Varco RL. Technique of jejunal interposition for esophageal replacement. J Thorac Cardiovasc Surg 1982;83:928–33[Medline]
This article has been cited by other articles:
|
|
|
|
 
T. J. Kim, K. H. Lee, Y. H. Kim, S. W. Sung, S. Jheon, S.-k. Cho, and K. W. Lee
Postoperative Imaging of Esophageal Cancer: What Chest Radiologists Need to Know
RadioGraphics,
March 1, 2007;
27(2):
409 - 429.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. P. Whooley, S. Law, S. C. Murthy, A. Alexandrou, K.-M. Chu, and J. Wong
The Kirschner Operation in Unresectable Esophageal Cancer: Current Application
Arch Surg,
November 1, 2002;
137(11):
1228 - 1232.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
