Motility across esophageal anastomoses after esophagectomy or gastrectomy

Utility of routine oral contrast study for detecting postesophagectomy anastomotic leak - a systematic review and meta-analysis

Oral contrast studies are used to detect anastomotic leak (AL) postesophagectomy. However, recent evidence suggests oral contrast studies have low sensitivity in detecting ALs, and their false positive results can lead to unnecessary prolonged hospital stay. The objective of this study was to determine if oral contrast studies should be used routinely post-esophagectomy for cancer. A systematic literature search was conducted for studies published between January 1990 and June 2018. Data extracted for analyses included type of esophagectomy, operative morbidity (such as AL and pneumonia), mortality rates, timing of contrast study, and type of oral contrast used. The sensitivity, specificity, and positive and negative predictive values of routine oral contrast studies to detect AL were calculated using the aforementioned variables. Two hundred and forty-seven studies were reviewed with 16 studies included in the meta-analysis. Postoperative oral contrast study was performed in 94.0% of cases between day 5 and 7. The rates of early and delayed leaks were 2.4% (1.8%-3.3%) and 2.8% (1.8%-4.4%), respectively. Routine contrast studies have a sensitivity and specificity of 0.44 (0.32-0.57) and 0.98 (0.95-0.99), respectively. Analysis of covariates revealed that sensitivity is reduced in centers with a higher volume of cases (greater than 15 per year: 0.50 [0.34-0.75; p = 0.0008]) and specificity was higher in centers with a lower leak rate. Given its poor sensitivity and inability to detect early/delayed AL, oral contrast study should be used selectively with endoscopy and/or computerized tomography scan to assess surgical anastomoses following esophagectomy.

The esophageal remnant after gastric interposition

Gastric interposition is usually considered the reconstruction of choice following esophageal resection. However, a number of reports show that esophagectomy followed by a gastric transplant is associated with poor quality of life and significant reflux esophagitis in the esophageal remnant. The aim of this work is to review the factors affecting the mucosa of the esophageal remnant when using the stomach. A Medline was conducted. Additional references and search pathways were sourced from the references of reviewed articles. Reflux disease is considered an unavoidable consequence of esophageal resection followed by gastric interposition. Mucosal damage from acid and bile exposure in the esophageal remnant affects approximatively 50% of these patients. There is usually no correlation between symptoms and the presence of mucosal damage in the remaining esophagus. Endoscopy and endoscopic biopsies are the only reliable methods to document the status of the mucosa. When present, reflux esophagitis shows a progression from inflammation to erosions and to the development of columnar lined metaplasia. Esophageal and gastric function, gastric drainage operation, level of the anastomosis, route of reconstruction, and patients' position after the operation have all been shown to influence the severity and extent of damage in the esophageal remnant. Prevention and treatment of esophagitis in the remaining esophagus are discussed. When the stomach is used as a substitute to reconstruct the esophagus whether for malignant or benign conditions, an in vivo model of reflux diseases is created. Studies using this model may help clarify molecular and cellular events that lead to irreversible insult on the esophageal mucosa. Improvement to the reconstruction itself must be sought to favor better results with the gastric transplant.

Esophageal ileus following laparoscopic fundoplication

Early postoperative dysphagia occurs in most patients following laparoscopic fundoplication. Whether dysphagia is associated with a change in esophageal motor function and/or a change in gastroesophageal junction characteristics is unknown. Esophageal motility in the early postoperative period has not been evaluated previously. Esophageal motility was studied on the first postoperative day in 10 patients who underwent laparoscopic Nissen fundoplication and 10 patients who underwent laparoscopic cholecystectomy (control group), using standard perfusion manometry. Primary peristalsis on water swallows following fundoplication elicted a median response of 5% successful peristalsis compared with median response of 100% successful peristalsis following cholecystectomy (P = 0.05). The fundoplication was associated with failure of primary esophageal peristalsis in 7/10 patients, compared to 2/10 patients who underwent cholecystectomy (P = 0.068 Fisher's exact test). Three months after fundoplication, in nine patients studied, primary peristalsis was similar to peristalsis observed preoperatively in seven patients and two patients still had an aperistaltic esophagus. In this study, esophageal manometry 1 day after surgery demonstrated grossly disturbed esophageal motility in most patents following laparoscopic fundoplication, compared to normal motility following laparoscopic cholecystectomy. Peristalsis improved at 3 months or more following surgery. This suggests that an 'esophageal ileus' occurs during the early period after laparoscopic fundoplication.

Imaging following surgery for oesophageal cancer

The incidence of oesophageal malignancy is increasing in the UK. Surgical management with oesophagectomy is determined by tumour location, stage and extent of lymphadenectomy,and is also dependent on patient age and co-morbidity. Surgery is associated with considerable postoperative morbidity and mortalities of up to 7%. The indications for imaging and findings in both the immediate and delayed postoperative periods are discussed.

Functional Conduit Disorders After Esophagectomy

Unfortunately normal gastrointestinal function after an esophagectomy is rare. Most patients will never eat the way they did before their illness. Most patients require smaller more frequent meals. It is common for patients to loose up to 15% of their body weight from the time of diagnosis through the first 6 months postoperatively, but fortunately this trend levels off after 6 months. Dumping syndrome, delayed gastric emptying, reflux, and dysphagia can all contribute to nutritional deficiency and poor quality of life. There is no one surgical modification to eliminate any one of these complications, but several guidelines can help reduce conduit dysfunction. Most patients seem to benefit from a 5-cm-wide greater-curvature gastric tube brought up through the posterior mediastinum. The gastric-esophageal anastomosis should be placed higher than the level of the azygous vein. Drainage procedures seem to be helpful, especially when using the whole stomach as a conduit. Early erythromycin therapy significantly aids in the function of the gastric conduit. Proton-pump inhibitors are important for improvement of postoperative reflux symptoms and to help prevent Barrett's metaplasia in the esophageal remnant. Single-layer hand-sewn or semi-mechanical anastomoses provide greater cross-sectional area and fewer problems with stricture. When benign strictures occur, early endoscopy and dilation with proton-pump inhibition greatly reduces the morbidity. Patients should be instructed to eat six small meals a day and to remain upright for as long as possible after eating. Simple sugars and fluid at mealtime should be avoided until the function of the conduit is established.

Reflux after oesophagectomy

Background

Reflux of gastric and duodenal content after oesophagectomy with gastric conduit reconstruction is a common problem and largely considered an inevitable consequence of surgery. Cervical burning and regurgitation, often more pronounced when supine, can be troublesome and even disabling, interfering substantially with quality of life. The aim of this study was to identify the factors contributing to reflux after oesophagectomy and evaluate measures to prevent or control it.

Methods

A Medline search using the terms ‘gastro-oesophageal reflux’, ‘oesophagectomy’ and ‘antireflux surgery’ was conducted. Additional references and search pathways were sourced from the bibliographies of articles located.

Results and conclusion

Reflux after oesophagectomy is a significant problem, with both clinical and pathological consequences. Simple measures to facilitate gastric emptying, such as creating a gastric tube, performing a pyloric drainage procedure and using gastric motility agents, may produce a reduction in symptoms but do not alone control reflux itself. A variety of surgical reconstructions have been used, many of which are either difficult to fashion or not suitable when a radical resection has been performed. A modified fundoplication at the anastomosis seems to be the simplest technique and may be relatively effective in controlling symptoms. The impact of strategies to reduce reflux on quality of life and on pathological sequelae of reflux in the oesophageal remnant remains to be evaluated.