WHEN IS ESOPHAGECTOMY THE BEST FOR BENIGN ESOPHAGEAL DISEASES? David … · 2017-12-29 · Baylor St. Luke’s Medical Center, Houston, TX . Baylor St. Luke’s Medical Center. WHEN

Baylor St. Luke’s Medical Center, Houston, TX

Baylor St. Luke’s Medical Center

WHEN IS ESOPHAGECTOMY THE BEST FOR

BENIGN ESOPHAGEAL DISEASES?

David J. Sugarbaker, M.D.Director, The Lung Institute

Chief, Division of Thoracic SurgeryThe Olga Keith Weiss Chair of Surgery

Baylor College of Medicine



Indications• Primary motility disorder (Dysfunctional esophagus) End Stage Achalasia Refractory esophageal motility disorder

• GERD Failed anti-reflux surgery

• Refractory stricture



Indications• Watson et al, 1998• 104 patients from 1975-1996 requiring

esophagectomy for benign disease• 98% felt cured or improved symptoms• 2% mortality rate

Watson TJ, DeMeester TR, Kauer WK, Peters JH, Hagen JA. Esophageal replacement for end-stage benign esophageal disease. J Thorac Cardiovasc Surg. 1998;115(6):1241-7; discussion 7-9.



Indications

Watson TJ, DeMeester TR, Kauer WK, Peters JH, Hagen JA. Esophageal replacement for end-stage benign esophageal disease. J Thorac Cardiovasc Surg. 1998;115(6):1241-7; discussion 7-9.


Indications• Madenci et al 2013• 661 underwent esophagectomy

for benign disease• 111 had prior intervention

Madenci AL, Reames BN, Chang AC, Lin J, Orringer MB, Reddy RM. Factors associated with rapid progression to esophagectomy for benign disease. J Am Coll Surg. 2013;217(5):889-95. Baylor St. Luke’s Medical Center, Houston, TX



Madenci AL, Reames BN, Chang AC, Lin J, Orringer MB, Reddy RM. Factors associated with rapid progression to esophagectomy for benign disease. J Am Coll Surg. 2013;217(5):889-95.

Indications for esophagectomy

•May consider esophagectomyafter 2nd/3rd intervention


Achalasia• Refractory dysphagia from

atonic esophagus

• Megaesophagus, sigmoid esophagus

Watson TJ. Esophagectomy for end-stage achalasia. World J Surg. 2015;39(7):1634-41.

D.J. Sugarbaker; R. Bueno, Y.L. Colson, M.T. Jaklitsch, M.J. Krasna, S.J. Mentzer, M.Williams, A. Adams: Adult Chest Surgery, 2nd Edition: www.accesssurgery.com



https://radiologykey.com/esophageal-achalasia-2




Achalasia• Esophagectomy may be required in up to 5% of

patients with achalasia

• Molena et al showed lower postoperative mortality (2.9 vs. 7.8 %, p = 0.08) in patients with achalasia undergoing esophagectomy when compared for cancer

Duranceau A, Liberman M, Martin J et al (2012) End-stage achalasia. Dis Esophagus 25:319–330Molena D, Mungo B, Stem M, Feinberg RL, Lidor AO (2014) Outcomes of esophagectomy for esophageal achalasia in the United States. J Gastrointest Surg 18:310–317



Achalasia Outcomes after EsophagectomyAuthor N Year Conduit Mortality Follow-up

(years)Outcomes

Peters et al. 19 1995 Colon 0 6 93 % cured/improved/satisfied

Miller et al. 37 1995 Stomach = 26colon = 6small bowel = 5

5.4 % 6.3 91 % excellent/good

Banbury et al. 32 1999 Stomach 0 3.6 87 % “felt better”

Devaney et al. 93 2001 Stomach = 91colon = 2

2 % 3.2 93 % “felt better”

Hsu et al. 9 2003 Colon (short) 0 6 75 % good




Other Motility Disorders• Diffuse esophageal spasm• Scleroderma

Waters PF, Pearson FG, Todd TR, et al. Esophagectomy for complex benign esophageal disease. J Thorac Cardiovasc Surg. 1988;95(3):378–381.Orringer MB, Orringer JS. Esophagectomy: definitive treatment for esophageal neuromotor dysfunction. Ann Thorac Surg. 1982;34(3):237–248.



GERD

D.J. Sugarbaker; R. Bueno, Y.L. Colson, M.T. Jaklitsch, M.J. Krasna, S.J. Mentzer, M.Williams, A. Adams: Adult Chest Surgery, 2nd Edition: www.accesssurgery.com



GERD• Up to 6% of all anti-reflux procedures

will require re-operative intervention• Options after failed anti-reflux surgery

include: Redo fundoplication Roux-en-Y diversion Esophagectomy

Pennathur A, Awais O, Luketich JD. Minimally invasive redo antireflux surgery: lessons learned. Ann Thorac Surg. 2010;89(6):S2174-9.



GERD• Awais et al, 2011• Retrospective review of 275

patients underwent redo antireflux surgery

Awais O, Luketich JD, Schuchert MJ, Morse CR, Wilson J, Gooding WE, et al. Reoperative antireflux surgery for failed fundoplication: an analysis of outcomes in 275 patients. Ann Thorac Surg. 2011;92(3):1083-9; discussion 9-90.



GERD• 31 patients (11.3%) had failure of redo 4 patients required esophagectomy

Trend for multiple redo operations to be associated with failure Conversion to esophagectomy individualized, not specific to # of

redo surgeries

Awais O, Luketich JD, Schuchert MJ, Morse CR, Wilson J, Gooding WE, et al. Reoperative antireflux surgery for failed fundoplication: an analysis of outcomes in 275 patients. Ann Thorac Surg. 2011;92(3):1083-9; discussion 9-90.



GERD Review experience of patients

undergoing esophagectomy after fundoplication, 1988-2008• 80 patients underwent esophagectomy after

at least 1 prior anti-reflux surgery• Compared to matched controls undergoing

esophagectomy for esophageal cancer

Shen KR, Harrison-Phipps KM, Cassivi SD, Wigle D, Nichols FC, 3rd, Allen MS, et al. Esophagectomy after anti-reflux surgery. J Thorac Cardiovasc Surg. 2010;139(4):969-75.



GERD• Mortality 3.7%

• Patients with previous anti-reflux surgery when undergoing esophagectomy had higher rates of anastomotic leak when compared to control group

Shen KR, Harrison-Phipps KM, Cassivi SD, Wigle D, Nichols FC, 3rd, Allen MS, et al. Esophagectomy after anti-reflux surgery. J Thorac Cardiovasc Surg. 2010;139(4):969-75.



GERD• Chang et al, 2010• Retrospective review, 258 patients Evaluate the impact of prior

gastroesophageal operations on outcomes after esophagectomy for recurrent GERD or hiatal hernia.

• 2% mortality

Chang AC, Lee JS, Sawicki KT, Pickens A, Orringer MB. Outcomes after esophagectomy in patients with prior antireflux or hiatal hernia surgery. Ann Thorac Surg. 2010;89(4):1015-21; discussion 22-3.



GERD• In setting of previous GERD/hiatal hernia

surgery:• Transhiatal resection accomplished in

fewer patients undergoing reoperation• Gastric conduit was used as the

esophageal replacement in fewer patients• Fewer patients reported good to excellent

swallowing functionChang AC, Lee JS, Sawicki KT, Pickens A, Orringer MB. Outcomes after esophagectomy in patients with prior antireflux or hiatal hernia surgery. Ann Thorac Surg. 2010;89(4):1015-21; discussion 22-3.



Stricture• Majority of experience for esophagectomy for

caustic injury is in pediatric population• Typically performed after serial dilations for

stricture have failed• No consensus on type of esophageal

replacement in pediatric population

Hamza AF, Abdelhay S, Sherif H, Hasan T, Soliman H, Kabesh A, et al. Caustic esophageal strictures in children: 30 years' experience. J Pediatr Surg. 2003;38(6):828-33.



Choice of conduit• Conduit: stomach, colon, jejunum• Location: posterior mediastinum,

retrosternal• Operative technique: transhiatal,

transthoracic, minimally invasive, vagal-sparing

• No randomized controlled trials, Level 1 data supporting one method over other

Colon Interposition Brian E. Louie, Steven R. DeMeesterPearson's Thoracic and Esophageal Surgery, chapter 59, 630-642

Blackmon SH, Correa AM, Skoracki R, Chevray PM, Kim MP, Mehran RJ, et al. Supercharged pedicledjejunal interposition for esophageal replacement: a 10-year experience. Ann Thorac Surg. 2012;94(4):1104-11; discussion 11-3.



Conclusion• Esophagectomy can be an effective treatment in patients with end

stage esophageal disease• Reconstruction can be done with low mortality and acceptable

morbidity• Operative approach and choice of conduit is up to surgeon experience

and needs to be individualized • Assessment and surgery should be done by experienced surgeons at

high volume centers



Thank you

Documents

WHEN IS ESOPHAGECTOMY THE BEST FOR BENIGN ESOPHAGEAL DISEASES? David … · 2017-12-29 · Baylor St. Luke’s Medical Center, Houston, TX . Baylor St. Luke’s Medical Center. WHEN