Esophageal conduit necrosis.

A cumulative review of the prevalence of esophageal conduit necrosis is summarized in Table 4. The spectrum of conduit ischemia is broad and includes cases in which there is anastomotic leak or stricture as well as cases in which there is frank graft necrosis. Many of the studies that the authors reviewed do not specify the exact nature of postoperative ischemic complications or how they are defined. Therefore, postoperative conduit ischemia is reported globally. Based on the authors' review, average rates of ischemic complications for stomach, colon, and jejunum are 3.2%, 5.1%, and 4.2%, respectively. Results for colon and jejunum include results for both long- and short-segment grafting. Most reports that compare outcomes using different esophageal conduits demonstrate findings similar to the authors'. Davis and colleagues compared results with colon versus gastric conduit esophageal reconstruction. They found that operative mortality, anastomotic leaks, and conduit ischemia rates were all lower for the stomach than for the colon. Specifically, ischemia of the stomach conduit was 0.5%, compared with 2.4% for the colon conduit. Moorehead and Wong, in a large series of 760 esophagectomy patients in whom the stomach, colon, or jejunum was used for reconstruction, demonstrated that the stomach had the lowest incidence of conduit ischemia (1%), followed by jejunum (11.3%), then colon (13.3%). Some of the factors they identified as correlating with the risk of ischemia include length of conduit, technique of stomach graft preparation, whether anastomosis is in the neck or chest, and route of passage of the conduit. Mansour and colleagues compared their results using bowel interposition (either colon or jejunum) to reconstruct the resected esophagus. The authors report an overall mortality of 5.9%, and 3% conduit ischemia. All ischemia was noted in the colon conduits harvested from the left side. No ischemic complications were noted from jejunal segments. Briel and colleagues compared stomach versus colon conduit use after esophagectomy. They note an overall incidence of ischemia of 9.2%. In their series, the incidence of ischemia for stomach and colon was 10.4% and 7.4%, respectively. Anastomotic leak and stricture rates, both thought to be sequelae of ischemia, also were lower for colon conduit use than for stomach conduit. Multivariate analysis identified patient comorbidities as the only independent risk factor for conduit ischemia. The authors use their findings to support the preferential use of colon conduits rather than stomach conduits. The incidence of colon conduit ischemia (7.4%) is directly in line with all other published results, including the cumulative review by the authors of this article, whereas the rate of stomach conduit ischemia (10.4%) is considerable higher than in most other studies. Esophageal conduit necrosis is an uncommon but disastrous complication of esophageal surgery. Careful selection of patients for surgery, preoperative evaluation of the proposed conduit, and meticulous operative technique are the best defenses against conduit ischemia. Postoperatively, surgeons should have a high index of suspicion for this complication. Unexplained tachycardia, respiratory failure, leukocytosis, or any evidence for graft or anastomotic leak should prompt a search for conduit ischemia. The diagnosis is made by contrast esophagography, endoscopy, or direct operative inspection. There is no documented salvage technique once ischemia is identified. Treatment for mild cases may be supportive, with or without management of anastomotic leak. More severe cases of necrosis require débridement and conduit take-down with proximal esophageal diversion and placement of enteral feeding tubes. Reconstruction can be planned for later if possible. The majority of the data demonstrates that risk of ischemia is related to conduit type, length of conduit, comorbidities, and operative technique. The stomach has the lowest reported incidence of conduit ischemia, followed by the jejunum, and colon. In the future, methods to predict conduit ischemia more accurately at the time of surgery may further reduce the incidence of this disastrous complication.