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Ann Thorac Surg 2000;70:1651-1655
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results

^a Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
^b Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Address reprint requests to Dr Deschamps, Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, 200 First St, SW, Rochester, MN 55905
e-mail: deschamps.claude{at}mayo.edu

Presented at the 46th Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Esophagectomy for benign disease is performed infrequently. We reviewed the Mayo Clinic’s experience with patients who required esophageal reconstruction for benign esophageal disease.

Methods. From March 1956 to October 1997, all patients who required resection and reconstruction for a benign condition of the esophagus were reviewed.

Results. There were 255 patients (141 male, 114 female). Median age was 55 years (range, 2 to 100). The original diagnosis was an esophageal stricture in 108 patients (42%), primary motility disorder in 84 (33%), perforation in 36 (14%), hiatal hernia in 18 (7%), and other in 9 (4.0%). Reconstruction was with stomach in 168 patients (66%), colon in 70 (27%), and small bowel in 17 (7%). The anastomosis was intrathoracic in 144 patients (57%) and cervical in 111 (43%). There were 13 postoperative deaths (mortality 5%); 142 patients (56%) had at least one complication. Median hospitalization was 14 days (range, 6–95 days). Follow-up was complete in 226 patients (88.6%) for a median of 52 months (range, 1 month to 29 years). A total of 175 patients (77.4%) were improved. Functional results were classified as excellent in 72 patients (31.8%), good in 23 (10.2%), fair in 80 (35.4%), and poor in 51 (22.6%).

Conclusions. Esophageal reconstruction for benign disease resulted in functional improvement in a majority of patients. It can be done with low mortality and acceptable morbidity. Early morbidity is adversely affected by the diagnosis of perforation and the route through which the conduit is placed. Late functional outcome is adversely affected by the diagnosis of paraesophageal hernia and a cervical anastomosis.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Successful reconstruction of the esophagus can be a challenge, particularly for patients with benign disease [1]. These patients often have had repeated endoscopic procedures and frequently have undergone prior esophageal operations. The goal of esophageal reconstruction is to restore both swallowing and a barrier to gastroesophageal reflux with minimal mortality and morbidity. This report reviews our experience in patients who underwent esophageal reconstruction for benign disease.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
From March 1956 to October 1997, 255 patients underwent esophageal reconstruction for benign esophageal disease at the Mayo Clinic in Rochester, Minnesota. The records of these patients were analyzed for age, gender, symptoms, operative morbidity and mortality, and factors affecting late functional outcome. Patients with Barrett’s high-grade dysplasia or those with esophageal varices secondary to portal hypertension were excluded. Follow-up data were acquired from questionnaires sent to patients and referring physicians and from visits to the outpatient clinic. Operative deaths included patients who died within the first 30 days after surgery or during the same hospitalization. Functional results were considered excellent if the patient had no symptoms and was not receiving medication; good if the patient had only mild symptoms, was not taking medication, or needed only one postoperative dilatation; fair if symptoms were controlled with medication or periodical dilatations; and poor if the patient was not improved or required reoperation for a complication.

Two-way contingency tables were used to determine which clinical factors were associated with the functional outcome. Tests for independence were carried out using an exact Wilcoxon test for ordered categorical variables [2]. The relationship between the functional result and the clinical factors was analyzed further by fitting a logistic regression model [3]. In this case, the outcome variable was treated as binary, using the categories excellent/good and fair/poor. The risk of reoperation was estimated by computing Kaplan-Meier survival curves [4]. Estimates were computed for the overall patient sample as well as for subgroups, based on clinical risk factors. Patient groups exhibiting different levels of a particular risk factor were compared using the log rank test [5]. The threshold for statistical significance for all tests was set at p = 0.05.

Clinical findings
There were 141 men (55.3%) and 114 women (44.7%). The median age at the time of esophageal reconstruction was 55 years (range 2 to 100 years). Initial diagnosis was a stricture in 108 patients (36.7%), primary motility disorder in 84 (32.9%), esophageal perforation in 36 (14.1%), hiatal hernia in 18 (7.1%) and other in 9 (3.5%) (Table 1). A total of 162 patients (63.5%) had prior esophageal surgery (Table 2); 94 patients (37.0%) had one previous esophageal surgical procedure, 45 (17.6%) had two, 18 (7.1%) had three, 4 (1.6%) had four, and 1 (0.5%) had six. A total of 244 patients (94.9%) were symptomatic. Dysphagia was present in 156 patients (61.2%), regurgitation in 58 (22.7%), pain in 41 (16.1%), pyrosis in 30 (22.8%), and episodic aspiration in 10 (3.9%). Sixteen patients (6.3%) had been previously diverted with a cervical esophagostomy. Weight loss was observed in 55 patients (21.6%). Indications for surgery were esophageal obstruction in 198 patients (78.0%), perforation in 33 (12.9%), upper gastrointestinal discontinuity in 16 (6.3%), bleeding in 5 (2.0%), and other in 3 (1.2%).

	Results

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Complications occurred in 142 patients (55.7%) (Table 3). There were 13 postoperative deaths (operative mortality, 5.1%). Causes of death included respiratory failure in 4 patients, sepsis in 4, cardiac in 2, intraoperative hemorrhage in 2, and ruptured abdominal aortic aneurysm in 1. Median postoperative hospitalization was 14 days (range, 6 to 95 days).

Gender, type or number of previous operations, and presence or type of symptoms did not significantly affect early morbidity or hospital mortality. Increasing age was associated with a higher incidence of cardiovascular complications (p < 0.0001) and preoperative esophageal perforation with an increased incidence of anastomotic leak (p = 0.006). The surgical approach, type of conduit, and location of anastomosis did not affect early morbidity or hospital mortality. However, placing the conduit through the longest route (substernal or subcutaneous) was associated with an increased incidence of anastomotic leak as compared with placement in the esophageal bed (p = 0.001).

Preoperative factors including gender, age, symptoms, type or number of previous operations, surgical approach, type of conduit, and method of reconstruction did not affect late functional results. The presence of paraesophageal hiatal hernia, however, was associated with a poor functional outcome as compared with that for all other patients (p = 0.02). Similarly, a high anastomosis (cervical vs high thoracic vs low thoracic) was associated with a poor functional result (p = 0.02).

Overall, the estimated 5-, 10-, and 20-year cumulative probability of reoperation for related complications was 23.7% (95% confidence interval [CI], 17.9% to 29.5%), 26.3% (95% CI, 19.6% to 33.0%), and 30.4% (95% CI, 18.1% to 42.7%), respectively (Fig 1).

View larger version (13K): [in this window] [in a new window]   Fig 1. Actuarial cumulative probability of reoperation after esophageal reconstruction.

	Comment

Top Abstract Introduction Material and methods Results Comment References

In our series, more than two thirds of patients had prior esophageal surgery. For this reason, we prefer to visualize the esophagus directly at the time of reconstruction, usually through a right thoracotomy [9]. The decision of which conduit to use is based on multiple factors including the required length, the blood supply of the intended conduit, the local anatomy, and which conduits are available. Orringer and Stirling [19, 20] and others [6, 16] concluded that gastric interposition was the procedure of choice for most patients with benign disease. Other authors have suggested that the colon is the best conduit [21–23] to restore swallowing function, mainly because of an increased incidence of aspiration and reflux with gastric conduit. Although our report suggests that the type of conduit did not influence functional outcome, we favor the stomach as the conduit of choice in adults for most situations because the blood supply is dependable, the reservoir capacity is maintained and only one anastomosis is required [24].

If the stomach is inadequate or absent, our preference is the left colon based on the ascending branch of the left colic artery [25–27]. Our preference is also to use the colon when only a short segmental reconstruction of the distal esophagus is required, as the colon serves the dual purpose of preserving gastric function while at the same time acting as an effective barrier to reflux. Alternatively, colon conduits can be based on different vascular pedicles and placed in the antiperistaltic position [28]. Jejunum is best used in a Roux-en-Y fashion to divert biliary and pancreatic secretions away from the esophagus after a proximal gastrectomy and distal esophagectomy [29]. Although jejunum rarely reaches above the arch of the aorta, it can be used as a free graft in selected patients to replace the upper thoracic and cervical esophagus [30].

Patients in our series who had a cervical anastomosis were associated with a worse functional outcome than those with a thoracic anastomosis. This might be a reflection of the high revision rate of the cervical anastomosis noted in our series. Although a cervical anastomosis is clearly associated with less postoperative reflux [20, 23, 31, 32], reduction in late reflux has to be balanced against an increased rate of fistula and recurrent nerve injury associated with the cervical anastomosis [33]. Others have also shown that complications associated with cervical anastomosis can have long-lasting consequences [34].

It is difficult to explain the poor functional result associated with the diagnosis of paraesophageal hernia other than by the fact that most of these patients had been operated on in the past.

Placing the conduit through the longest route was associated with a higher incidence of postoperative leaks at the proximal anastomosis in our series. For this reason, we prefer placement of the conduit in the esophageal bed because of a more direct route and reduced chance of tension, kinking, or twisting on the vascular pedicle [25, 27].

As noted by us and by others [35], only a minority of patients are asymptomatic after esophageal reconstruction for benign disease. However, the cumulative risk of reoperation becomes minimal after 5 years and the majority of our patients were improved on long-term follow-up.

Comparison with other similar series reveals that our operative mortality is similar to results reported by others [6, 16, 19, 20, 22, 23, 28, 32, 35, 36]. In contrast, functional results are difficult to compare because of the heterogeneity of the different scales used to grade the functional outcome.

We recognize that the extended period of time covered by this review introduces the possibility of uncontrolled factors such as different surgeons, evolving surgical techniques, and perioperative care.

In conclusion, esophageal reconstruction for benign disease results in functional benefit to the majority of patients. Reconstruction can be done with low mortality and acceptable morbidity. Early morbidity is adversely affected by the diagnosis of perforation and the route through which the conduit is placed. Functional outcome after surgery is adversely affected by the diagnosis of paraesophageal hernia and a cervical anastomosis. The choice of conduit should be tailored to the individual patient. In all cases, the ultimate goal is to restore the function of swallowing as close to normal as possible, with minimal morbidity and mortality.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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