An experience of 108 cases of Esophagectomy using left Thoracolaparotomy and cervical anastomosis with feeding Jejunostomy, without gastric drainage procedure

摘要

Objective: To study efficacy and safety of esophagectomy using left thoracolaparotomy and left neck anastomosis with feeding jejunostomy, but no gastric drainage procedure. Design: An observational descriptive study. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from June 2002 to September 2004. Subjects and Methods: Computerized clinical data of 108 surgically treated patients during twenty eight months was retrospectively analyzed. Detailed scrutiny of record was carried out to determine the suitability and safety of the surgical procedure and surgical outcome. Results: A total of 108 patients underwent esophagectomy through left thoracolaparotomy and left neck incision. Male: Female was 72: 36, age range was 18 - 72 years with a mean age of 42.3 years. The predominant clinical presentation was dysphagia. Tumor level was upper third of thoracic esophagus in 3 (2.7%), middle third in 48 (44.4%) and lower third in 57 (52.7%) patients. Tumor histology was squamous cell carcinoma in 72 (66.6%) and adenocarcinoma in 36 (33.3%) patients. The mean operative time was 155 (25+/-) minutes. Postoperative morbidity was 19.4% (21/108). The complications were anastomotic leak in 7(6.5%), Hoarseness in 6(5.5%), aspiration in 3(2.7%); reopening in 1(0.9%) and stricture in 4(3.7%) patients. The overall mortality was 8.3% (9/108). Deaths were due to anastomotic leak in 3(2.7%) tracheal injury in 2(1.85%), respiratory failure in 2(1.85%) and pulmonary embolism in 2(1.85%) patients. 28 patients were lost to follow-up while incisional hernia was seen in 1, hoarseness in 3 and stricture in 3 patients over a last one month to 2 years follow-up. Recurrence occurred in 3/108 (2.77%); one developed malignant ascities, after 4 months, one developed nodule in hypopharynx after 18 months, and one developed a subcutaneous nodule on the back after 14 months. Conclusion: Left thoracolaparotomy and cervical anastomosis is a safe approach for carcinoma of the esophagus. A 30 day mortality of 8.3% in a large series of 108 oesophagectomies with 2.7% recurrence and 19.4% morbidity speak volumes for the technique. Omitting a gastric drainage procedure does not adversely effect the outcome, while routine placement of a jejunostomy feeding catheter is a safe and cost effective mode of nutrition. Neck anastomosis gives a generous tumor free margin, a s a 11 except one resection margin was free o f tumor. T his i s further consolidated by only 3 cases of recurrence out of 80, with 28 being lost to follow up.