Esophageal resection and by-pass: a 6 year experience with a low postoperative mortality

Incidence and management of chyle leakage after esophagectomy

BACKGROUND

Postoperative chyle leakage is a rare but well-recognized complication after esophageal surgery. The aim of this study was to identify its incidence and potentially predisposing factors and to assess the consequences and management.

METHODS

A consecutive series of 536 patients who underwent esophagectomy for malignant disease of the esophagus or gastroesophageal junction was reviewed.

RESULTS

There were 20 patients (3.7%) with chyle leakage. After transthoracic esophagectomy the risk for the development of chyle leakage was higher than after transhiatal resection (p = 0.006). Chyle leakage was associated with more positive nodes (p = 0.041). Patients with chyle leakage had significantly more pulmonary complications (p < 0.001) and longer intensive care unit (p = 0.015) and hospital stays (p = 0.001). No patient with chyle leakage died. Conservative management, consisting of no enteral feeding and total parenteral nutrition, was instituted in all patients, but was abandoned in 4 patients (20%) because of persistence of high chyle output through the chest tube. In contrast to patients who were successfully treated with conservative measures, patients who eventually needed a reoperation had a drain output of more than 2 L on the day conservative therapy was started and 1 and 2 days later.

CONCLUSIONS

Chyle leakage is seen more often in patients who undergo transthoracic esophagectomy and in patients who have more positive nodes. Patients with chyle leakage have more pulmonary complications. Conservative therapy is often successful, but operative therapy should be seriously considered in patients with a persistently high daily output of more than 2 L after 2 days of optimal conservative therapy.

Outcomes of dysplasia arising in Barrett's esophagus: a dynamic view

BACKGROUND

The management of dysplasia arising in Barrett's esophagus is controversial.

STUDY DESIGN

Twenty patients (group 1, prompt attitude) underwent operation as soon as high-grade dysplasia (HGD) was discovered (n = 8) or just after either the presence of HGD was confirmed (n = 9) or invasive carcinoma (IC) was found (n = 3) in a second set of biopsy samples taken soon after HGD had been discovered. In contrast, esophagectomy in 13 patients (group 2, expectant attitude) was performed only because HGD persisted (n = 4) or turned into IC (n = 4) at endoscopic followup (7 to 23 months) (subgroup 2a, n = 8) or because HGD (n = 2) or low-grade dysplasia (LGD) (n = 3) was disregarded until dysphagia and IC developed (12 to 70 months) (subgroup 2b, n = 5). Skeletonizing en-bloc esophagectomy was performed in 29 patients and four patients (three with HGD and one with mucosal IC in the resected specimen) underwent vagus-sparing esophagectomy.

RESULTS

Invasive carcinoma was found in 11 of 24 patients (45.8%) supposed to have only HGD (in repeat biopsies in 3 patients from group 1 and in the resected specimen in eight of 21 patients (38%) operated on for HGD. Metastatic lymph nodes were found in the resected specimen of seven patients (group 1: one of 20 or 5%, versus subgroup 2a: two of eight or 25%, versus subgroup 2b: four of five or 80%; p = 0.001). Unlike none of the 26 patients (0%) with an intramural process, five of the seven patients (71.4%) with an extramural process (one had had disregarded LGD) developed neoplastic recurrence at followup (p < 0.0001). Cancer-related survival in the long term was 100% in group 1 versus 52.5% in group 2 (p = 0.0094).

CONCLUSIONS

Invasive carcinoma is present in almost one half of patients with HGD within a Barrett's area. Promptness in the decision regarding an esophageal resection as soon as HGD is found is much safer than expectant observation. Not enrolling a patient with LGD in an endoscopic surveillance program can lead to the development of extramural IC with poor outcomes.

Pulmonary complications after esophagectomy

BACKGROUND

Pulmonary complications are common in patients who have undergone esophagectomy. There are no good predictive variables for these complications. In addition, the role that preoperative treatment with chemotherapy and radiation may play in postoperative complications remains unclear.

METHODS

We performed a retrospective review of all patients who underwent esophagectomy by a single surgeon at our institution over a 6-year period. Data were analyzed for a correlation between patient risk factors and pulmonary complications, including mortality, prolonged mechanical ventilation, and hospital length of stay.

RESULTS

Complete data were available on 61 patients. Nearly all patients had some pulmonary abnormality (eg, pleural effusion), although most of these were clinically insignificant. Pneumonia was the most common clinically important complication, and 19.7% of patients required prolonged ventilatory support. Significant risk factors identified included impaired pulmonary function, especially for patients with forced expiratory volume in 1 second (FEV1) less than 65% of predicted, preoperative chemoradiotherapy, and age.

CONCLUSIONS

Impaired lung function is a significant risk factor for pulmonary complications after esophagectomy. Patients with FEV1 less than 65% of predicted appear to be at greatest risk. There also seems to be an associated risk of preoperative chemoradiotherapy for pulmonary complications after esophagectomy.

Management of thoracic duct injuries after oesophagectomy

BACKGROUND

Thoracic duct laceration is a rare but potentially life-threatening complication of oesophagectomy. The management of such an injury is uncertain in respect of the relative merits of conservative and surgical treatment.

METHODS

The literature was reviewed by searching Medline databases from 1966 to the present time. The majority of the evidence presented is level 3, as no randomized or controlled data are available.

RESULTS

Prolonged conservative treatment of thoracic duct injury is associated with a mortality rate of 50-82 per cent. The results of early surgical ligation of the duct are more encouraging, with a mortality rate of 10-16 per cent. Elective ligation of the duct reduces the incidence of postoperative chylothorax.

CONCLUSION

The thoracic duct should be ligated during oesophagectomy. A high index of suspicion for duct injury must be maintained in all patients after operation. A policy of very early thoracic duct ligation at 48 h from diagnosis is proposed for duct injury if aggressive conservative management fails.

Radical esophageal resection for adenocarcinoma arising in Barrett's esophagus

BACKGROUND

Esophagectomy with extensive lymph node dissection is the best way to give Barrett's patients with locally advanced adenocarcinoma a good chance of cure.

MATERIAL AND METHODS

Fifty-five patients underwent subtotal (n = 47) or distal (n = 8) esophagectomy for Barrett's adenocarcinoma (n = 43) or high-grade dysplasia (HGD) (n = 12). Thirteen patients (23.6%) never had had any reflux symptom before disclosure of the neoplastic lesion, and 20 patients (36.4%) had esophageal shortening. Ro resections (n = 50) included removal of the esophageal tube en bloc with the locoregional lymph nodes.

RESULTS

An invasive carcinoma was found in the resected specimen of 4 of the 12 patients operated on for HGD. Two of the 5 patients whose metaplasia was surveyed endoscopically were operated on for an advanced lesion (T2N1, T3N1) because they had not strictly complied with the proposed schedule. One of the 4 patients whose HGD was followed up endoscopically until disclosure of deeper mucosal invasion had positive lymph nodes at operation. The prevalence of early lesions (Tis, T1, T2, No) was 7.4% in patients with tumor-related symptoms versus 85.7% in those having unrelated symptoms (P = 0.0000), which resulted in a 5-year survival rate of 33.8% and 82.4%, respectively (P = 0.0012). Five-year survival rate after Ro resection made for invasive carcinoma was 59.3% (all cases), 73.1% (No), 61.5% (< or =5 positive lymph nodes), and 0% (>5 positive lymph nodes).

CONCLUSIONS

High-grade dysplasia is an indication for esophageal resection. Early detection of the neoplastic transformation of Barrett's metaplasia prior to the onset of obstructive symptoms gives the best chance of cure. Esophagectomy with radical lymph node clearance is capable of curing a large proportion of the patients having no or a limited number of metastatic lymph nodes.

Oesophagogastrectomy with an anastomosis using linear staplers

BACKGROUND

Fibrous stricture formation causing dysphagia after oesophagogastrectomy with a circular stapled or sutured anastomosis remains a significant complication, occurring in up to one-third of cases. An anastomosis that avoids this complication would be desirable, given that resection is often performed to palliate dysphagia. We describe a technique of oesophagogastric anastomosis using linear staplers which eliminates the postoperative complication of fibrous stricture formation.

METHOD

A retrospective analysis of 111 consecutive patients who underwent oesophagogastrectomy for neoplasm or benign oesophageal stricture between March 1980 and April 1991 was carried out. Cadaveric models of the anastomosis were constructed and compared to models of circular stapled anastomoses.

RESULTS

An anastomosis using linear staplers was used in 111 patients with a leak rate of 2.7%, 30-day and hospital mortality rates of 5.4% and 8.1%, respectively, and no benign stricture formation. In the cadaveric models, the cross-sectional areas of the linear stapled anastomoses were greater than those of the circular stapled anastomoses, suggesting that this is an important factor in preventing fibrous stricture formation.

CONCLUSIONS

An anastomosis using linear staplers can be performed with a low leak rate, an acceptable operative mortality and no benign stricture formation. We suggest that an anastomosis using linear staplers should be the preferred type of anastomosis in oesophagogastrectomy.

Oesophageal cancer: outcome of modern surgical management

Many clinicians still associate oesophagectomy for oesophageal carcinoma with low cure rates, poor palliation and prohibitive peri-operative mortality. Surgical advances have rendered such perceptions inaccurate. A prospective study of all patients undergoing surgery for oesophageal cancer in an Australian teaching hospital between 1979 and 1993 has been undertaken. Selection, staging, pre-operative preparation, surgical technique and postoperative care were all carefully controlled. One hundred and thirty-seven patients were explored. Twenty-one were inoperable. One hundred and sixteen underwent resection with intent to cure. Hospital mortality for oesophagectomy was 1.7%. There were no cases of clinical anastomotic leakage. Eighty-nine per cent achieved excellent to good swallowing. The median survival for all cases was 14 months and the 5 year survival was 18%. Median survival for resected cases was 18 months and the 5 year survival was 26%. The long-term survival was related to postoperative stage of the disease but not to tumour type. Oesophagectomy for oesophageal cancer will restore good swallowing in 90% of cases. Operative mortality should be less than 5% and the overall 5 year survival 20-30%. Early tumours can often be cured (ca in situ 100%, stages I and II 50-60%), indicating the benefits of early detection. Poor survival in advanced disease (stage III 15%, stage IV 0%) on a background of low surgical mortality indicate the need for better staging and more effective adjuvant therapies.

Risk analysis in resection of squamous cell carcinoma of the esophagus

A study of risk factors that affect morbidity and mortality in 523 patients with squamous cell cancer of the esophagus who had one-stage resection was undertaken. The 30-day and hospital mortality rates were 5.0% and 15.5%, respectively. Pulmonary complications, malignant cachexia, and surgical complications accounted for 42%, 25%, and 21% of hospital deaths, respectively. Major pulmonary complications occurred in 23% of patients. Multivariate analysis identified six factors that predicted major pulmonary complications: age, mid-arm circumference, percent of predicted FEV1, abnormal chest radiograph, amount of blood loss, and palliative resection. Three risk groups of pulmonary complications were identified: low, median, and high risk group with complications in 3%, 17%, and 43% of patients, respectively. Significantly, patients with curative resection had a lower hospital mortality rate (9%) than those with palliative resection (20%), p = 0.001. Patients with stage I, IIa, or IIb disease had a lower hospital mortality rate (9%) than those with stage III or IV disease (18%), p = 0.026. Multivariate analysis identified six factors that predicted hospital death: age, mid-arm circumference, history of smoking, incentive spirometry, number of stairs climbed, and amount of blood loss. Three risk groups of hospital death were identified: low, median, and high risk groups with death in 7%, 30%, and 38%, respectively. Anastomotic leakage rate was 4%. Technical faults were identified in 53% of patients with leakage. Together with other surgical complications, a presumed or apparent technical error was noted in 63% of patients. The identification of high-risk patients and prevention of technical faults can help improve surgical outcome.

Prediction of outcome in "resectable" esophageal carcinoma

A retrospective review was performed of 51 patients with esophageal carcinoma, deemed "resectable" by preoperative workup (e.g., CT scan, barium swallow), who presented to Hahnemann University Hospital between 1980 and 1991. This represented 21.8% of the total number of patients (234) with esophageal cancer who presented during that time period. At exploration, only 21 of the 51 patients (41%, or 9% overall) were truly resectable; 59% had more extensive disease than was appreciated preoperatively and that precluded resection for cure. Of the 21 patients resected for cure, 24% were alive at two years and only 5% were alive at 3 years. Neither age, gender, tumor type nor location in the esophagus significantly affected overall survival. Furthermore, none of these parameters, taken as independent variables, were able to predict true resectability at the time of operation. We conclude that preoperative assessment of resectability, even in those patients who appear to be good candidates for cure, remains imprecise at best. Given an operative mortality rate of 6-8% (in most series) and an overall 3- to 5-year survival rate of less than 10% (even in patients thought to have had curative resections), we reinforce the fact that meticulous patient selection and multimodality management strategies remain the keys to making any impact on this disease.

Long-term results of transhiatal esophagectomy for esophageal carcinoma. A multivariate analysis of prognostic factors

BACKGROUND

Perioperative mortality and survival after esophagectomy have improved over the past 10 years. Although stage is the most powerful predictor of long-term survival, it remains unclear whether other factors influence prognosis.

METHODS

Between 1981-1991, 100 patients with esophageal carcinoma were uniformly treated by transhiatal esophagectomy without adjuvant therapy. Results and prognostic factors of long-term survival were analyzed by univariate and multivariate analyses (log-rank test and Cox regression model).

RESULTS

Forty-eight patients had severe associated medical conditions, and 26 patients were older than 69 years of age. Mortality was 3%, and morbidity was 68%. With a median follow-up of 52 months, median survival was 18 months. The overall 5-year survival was 23%, but it was 63% for early stages (pT1 + pT2). In the multivariate analysis, the risk of dying was increased by 4.9 (risk ratio) for patients with carcinomas invading beyond the muscularis propria (pT3 + pT4), compared to lower stages (pT1 + pT2) (P < 0.0001). To a lesser extent, longterm survival was also adversely affected by transfusions (packed erythrocytes) after controlling for stage (risk ratio 1.7; P = 0.047). Age (> 69 years), preoperative weight loss, tumor location, histology (adenocarcinoma versus squamous cell carcinoma), fresh frozen plasma, and splenectomy did not influence survival.

CONCLUSION

In this study, transhiatal esophagectomy provided palliation for esophageal cancer with a low-perioperative mortality. Prolonged survival or cure was obtained for the majority of patients operated on in the early stages. Blood transfusions had a slight adverse effect on long-term survival.

Incidence and management of benign anastomotic stricture after cervical oesophagogastrostomy

Benign anastomotic stricture after transhiatal oesophagectomy and gastric tube reconstruction constitutes a major problem. From August 1988 to April 1991, 81 patients were followed after cervical oesophagogastrostomy. Twenty-four patients (30 per cent) developed a benign anastomotic stricture 3-23 (median 8) weeks after operation. Poor vascularization of the gastric tube, determined during operation, and postoperative anastomotic leakage were statistically significant risk factors for stricture formation. Symptoms related to stricture were often typical and were confirmed by endoscopy and/or radiography. Radiography did not yield information additional to that obtained from endoscopy. Strictures were treated in the outpatient clinic by dilatation with Savary dilators. Repeated dilatation completely alleviated dysphagia in 20 of the 24 patients (83 per cent). In ten patients dilatations could be discontinued after a median of 8 (range 1-17) sessions. Dilatation was continued until the end of follow-up in nine patients or until death from recurrent disease in five. No complications of dilatation were seen.