Jessica Yu Rove1, A Sasha Krupnick1, Frank A Baciewicz2, Bryan F Meyers3. 1. Division of Cardiothoracic Surgery, Washington University, St. Louis, Mo. 2. Division of Cardiothoracic Surgery, Wayne State University, Detroit Medical Center, Karmanos Cancer Center, Detroit, Mich. 3. Division of Cardiothoracic Surgery, Washington University, St. Louis, Mo. Electronic address: meyersb@wudosis.wustl.edu.
Abstract
OBJECTIVE: Severe postesophagectomy gastric conduit dysfunction refractory to standard endoscopic intervention is rare, with few published reports discussing timing, technique, or results of reoperation. This case series examines assessment and management of severe conduit dysfunction and details techniques for conduit revision. METHODS: We retrospectively reviewed patients who underwent esophagectomy between September 2008 and October 2015 and studied patients who underwent conduit revision. RESULTS: More than 400 patients underwent Ivor Lewis or transhiatal esophagectomies during this 7-year period. Eight patients underwent reoperation for conduit revision. The strategy for initial anastomosis and management of the pylorus were variable. Symptoms included dysphagia, delayed emptying, aspiration, and weight loss. Evaluation and management included esophagram, computed tomography, repeated esophagoscopy with pyloric intervention, and selective anastomotic dilation. Two patients also had associated paraconduit hiatal hernias. Average time to reoperation was 3.8 years (range 2 weeks to 6.5 years). All revisions were performed through a thoracotomy with either laparoscopy or laparotomy. Revisions were completed in 7 patients. Average length of stay was 9.9 days (range 4-21). Average follow up was 10.1 months (range 1-36). The completed revisions led to restoration of a regular diet with improved patient satisfaction. CONCLUSIONS: Severe gastric conduit dysfunction after esophagectomy is rare. Symptoms, esophagram findings, and response to interventional esophagoscopy guide the decision to revise the conduit. Principles of conduit revision include reducing paraconduit hernias, reducing redundant conduit, tubularizing a dilated conduit, and ensuring adequate gastric drainage. Selective revision was performed with minimal morbidity and durable improvement in subjective symptoms of dysphagia and reflux.
OBJECTIVE: Severe postesophagectomy gastric conduit dysfunction refractory to standard endoscopic intervention is rare, with few published reports discussing timing, technique, or results of reoperation. This case series examines assessment and management of severe conduit dysfunction and details techniques for conduit revision. METHODS: We retrospectively reviewed patients who underwent esophagectomy between September 2008 and October 2015 and studied patients who underwent conduit revision. RESULTS: More than 400 patients underwent Ivor Lewis or transhiatal esophagectomies during this 7-year period. Eight patients underwent reoperation for conduit revision. The strategy for initial anastomosis and management of the pylorus were variable. Symptoms included dysphagia, delayed emptying, aspiration, and weight loss. Evaluation and management included esophagram, computed tomography, repeated esophagoscopy with pyloric intervention, and selective anastomotic dilation. Two patients also had associated paraconduit hiatal hernias. Average time to reoperation was 3.8 years (range 2 weeks to 6.5 years). All revisions were performed through a thoracotomy with either laparoscopy or laparotomy. Revisions were completed in 7 patients. Average length of stay was 9.9 days (range 4-21). Average follow up was 10.1 months (range 1-36). The completed revisions led to restoration of a regular diet with improved patient satisfaction. CONCLUSIONS: Severe gastric conduit dysfunction after esophagectomy is rare. Symptoms, esophagram findings, and response to interventional esophagoscopy guide the decision to revise the conduit. Principles of conduit revision include reducing paraconduit hernias, reducing redundant conduit, tubularizing a dilated conduit, and ensuring adequate gastric drainage. Selective revision was performed with minimal morbidity and durable improvement in subjective symptoms of dysphagia and reflux.