Abstract

Objective: The optimal method for bypassing or reconstructing the esophagus is unknown. In the past decade attention has shifted away from the use of intestinal conduits for reconstruction due to the perceived increase in morbidity and mortality and due to the lack of perceived long-term advantage associated with their use. A review was performed of our institutional experience to determine the short-term outcomes of intestinal conduit use and to see whether a change in the indications for or frequency of such use has occurred.

Methods: A retrospective analysis of patients who underwent esophageal bypass or reconstruction using intestinal conduits was performed for patients operated on between 1978 and 1997. Data were analyzed using Student's t-test and chi;² analysis.

Results: There were 106 operations performed on 105 patients, 64 men and 41 women, with a mean age of 51.2 ± 1.4 yrs (range 13 to 78 yrs). Prior esophageal surgery had been performed on 29 patients. The Kamovsky performance status was from 8 to 10 in 52 patients (67%) and 96 patients were in New York Heart Association (NYHA) class 1 or 2. The mean preoperative weight loss was 6.8 ± 1.0 kg. The indications for operation were cancer in 48, benign stricture in 27, achalasia in 5, perforation in 7, and other disease in 19 patients. The operation was transthoracic in 73, transhiatal in 31, and was unspecified in 2 patients. Reconstruction or bypass was accomplished with an isoperistaltic segment of left colon in 91 patients (of whom 47 had a short segment interposition), with jejunum in 8 (free graft in 3), and using combined organs in 7. The mean blood loss was 1,650 ± 139 ml and the mean perioperative blood transfusion was 4.1 ± 0.4 units. Pulmonary complications developed in 36 patients, cardiovascular complications in 37, other surgical complications in 42, and the mortality rate was 9/106 (8.5%). More intestinal reconstructions were performed during the first decade (86 vs 20) and the patients in the earlier period were older (52.6 ± 1.5 vs 44.9 ± 3.1 yrs; p = 0.035). The indications for operation were not significantly different between the two decades. The routes chosen for resection and reconstruction and the grafts used for esophageal replacement were similar between the two decades. The blood loss was slightly less during the latter decade (1273 ± 374 vs 1716 ± 150 ml) and the amount transfused was significantly lower (2.0 ± 0.8 vs 4.5 ± 0.5 units; p = 0.012). Complication rates were similar, and the mortality rate dropped from 9.3% (8/86) to 5% (1/20; p = NS).

Conclusions: The use of intestinal interposition for esophageal reconstruction has declined during the past decade. The indications for its use remain unchanged, and the frequency of nonfatal complications has not decreased. There has been a moderate decrease in the associated mortality. The use of intestinal conduits for esophageal replacement or bypass should be limited to carefully selected patients who are likely to survive long-term to enable them to experience the theoretical benefits of such conduits.