|
|
Esophagectomy Following Previous Antireflux Surgery
K. Robert Shen, Karen Harrison-Phipps, Stephen D. Cassivi, Dennis A. Wigle, Francis C. Nichols, III, Mark S. Allen, Claude Deschamps
Mayo Clinic, Rochester, MN
Background
Due to an increased utilization of antireflux surgery, many more patients that undergo esophageal resection have a history of prior fundoplication. There is little data on whether prior surgery on the esophagogastric junction has an impact on subsequent esophageal resection and reconstruction. The aim of this study is to review our experience with patients that undergo esophagectomy after an antireflux operation to determine short and long term results.
Methods
The medical records were reviewed of all patients who underwent esophageal resection from 1988 through 2008 at our institution.
Results
Of the 2313 esophageal resections, 80 patients (46 men and 34 women) had undergone previous antireflux surgery. Median age was 63 years (range, 19-92). Median interval between anti-reflux operation and esophagectomy was 43.4 months (range, 1 day-398 months). Indications for anti-reflux surgery were paraesophageal hernia in 22 and gastroesophageal reflux disease in 58. Esophageal lengthening by gastroplasty had been performed in 13 patients. Complications of antireflux surgery were leak in 19, severe dysphagia in 11, and chronic gastropleural fistula in 2. Two antireflux operations had been performed in 24 patients, three in 3 patients, and 4 in one patient. Indications for esophagectomy were benign stricture/perforation in 41, adenocarcinoma in 28 and high grade dysplasia (HGD) in 11. The approach for the esophagectomy was an Ivor Lewis in 38 patients, thoracoabdominal in 29, transhiatal in 10 and McKeown in 3. The conduit used was stomach in 70, jejunum in 6, and colon in 3 (due to inadequacy of the gastric conduit) and one patient had a cervical esophagostomy after resection and was not reconstructed. Jejunostomy feeding tubes were placed in 35 patients. The anastamosis was hand-sewn in 63 patients, and stapled in 16. Five patients received neoadjuvant chemoradiotherapy. The pathologic stage was I in 8 patients, IIA in 7, IIB in 5, III in 3 and IVb in 2. Operative mortality occurred in 3 (3.7%) secondary to respiratory failure in two patients and pulmonary artery rupture in one patient. Postoperative complications occurred in 50 patients (62.5%) and included atrial fibrillation in 19 (23.7%), anastomotic leak in 17 (21.5%), pneumonia in 16 (20%), wound infection in 16 (20%), and prolonged need for mechanical ventilation in 11 (13.7%). Sixteen patients (20%) required reoperation for complications. The leak rate for an anastomosis in the neck was 38.5% compared to 21.4% in the left chest and 15.8% in the right chest. Median length of stay was 11.5 days (range, 7-165). Median follow-up was 43.4 months and was complete in 95%. Overall five-year survival was 42.8%; 87.5% and 83.3% in the adenocarcinoma, HGD and benign diagnoses groups respectively.
Conclusions
Esophagectomy after prior antireflux surgery is challenging. The stomach is usually a suitable conduit for esophageal replacement in these circumstances. An anastomosis in the neck has a significantly higher leak rate than in the chest and should be avoided. The incidence of postoperative complications is high in this group of patients, but operative mortality and long-term survival are comparable to historical controls.
Back to 2009 Annual Meeting
Back to Main Program
|
