Major modifications to minimize thoracic esophago-gastric leak and eradicate esophageal stricture after Ivor Lewis esophagectomy

BACKGROUND

The Ivor Lewis esophagectomy (ILE) remains the procedure of choice for localized middle or lower esophageal carcinoma. Nevertheless, anastomotic leak remains a common complication with rates from 3% to 25% and a stricture rate as high as 40%. The frequency of these complications suggests that the procedure itself may have inherent limitations including the use of potentially ischemic tissue for the esophagogastric anastomosis. We introduce a modified technique that reduces operative steps, preserves blood supply, and uses a modified esophagogastric anastomosis.

METHODS

All consecutive patients undergoing ILE with the described modified technique were identified. An esophagram was performed on postoperative day six or seven. To ensure that all cases were identified, anastomotic leaks were defined as any radiographic evidence of contrast extravasation.

RESULTS

A total of 110 patients underwent the modified esophagectomy with 2 anastomotic leaks (1.82%) and zero strictures. There was 1 late death but no early deaths (<30 or 90 days) or early re-admissions (<30 days). The average number of risk factors was 2.12, and 98 patients (90%) had at least 1 risk factor in their medical history.

CONCLUSIONS

The modifications proposed simplify procedural steps, limit unnecessary dissection and introduce a technique that ends the practice of connecting ischemic tissue. We believe this technique contributes to surgical durability and reduces the rate of postoperative leak and eliminates stricture.

Age dependence of adenylate cyclase in guinea pig ureter homogenate

Adenylate cyclase activity was measured in ureteral homogenates from guinea pigs of five age groups, ranging from neonates to older adults (retired breeders). Isoproterenol stimulation of adenylate cyclase activity is lost completely in ureters from 90 day and older animals. Forskolin activation also declines rapidly with increasing age; there is a significant (39%) decrease in activation at 30 days when compared to 10-day values with a further decline at 90 days. At 90 days, NaF, GTP and 5'-guanylimido-diphosphate stimulation of adenylate cyclase decreases by only 1, 9 and 23%, respectively, from the 10-day values. Prostaglandin E1 stimulation over 5'-guanylimido-diphosphate control does not decrease with age. 5'-Guanylimido-diphosphate in the presence of ethanol, activates adenylate cyclase to a greater extent in the older animals. These data may suggest that the decreased ability to activate adenylate cyclase with age may be due to a loss of the efficiency of coupling in the more rigid aged membranes. Other explanations include loss of catalytic function with age. The loss of adenylate cyclase activity in aging correlates well with our previously reported study showing that isoproterenol causes a greater decrease in contractility of ureters from younger than from older guinea pigs.