ESOPHAGEAL RESECTION AND BYPASS - A 6 YEAR EXPERIENCE WITH A LOW POSTOPERATIVE MORTALITY

From 1984 to 1989, 175 esophageal cancer patients, 10 patients admitted for severe caustic esophagitis, and 1 patient with pyothorax due to iatrogenic perforation of the esophagus underwent an esophageal resection or bypass operation. One hundred sixty-eight esophageal resections were performed on 167 patients; 13 were total, 106 subtotal and 49 distal. Nineteen digestive transplants were pulled up to the neck to bypass the esophagus or re-establish continuity after an esophagectomy made elsewhere. Digestive continuity was restored by a long gastric transplant in 120 patients, a colon segment in 17, a jejunal loop in 35, and a short gastric transplant after limited esophago-gastrectomy in 14 patients. Thirty day mortality was 0 in the whole group. Hospital mortality was 1.2% in the resection group and 10.5% in the bypass group (p = 0.048). Nonfatal postoperative complications consisted of respiratory distress in 33 patients, recurrent nerve palsy in 10, anastomotic fistula in 10 (cervical in 8 and intrathoracic in 2) and anastomotic stenosis in 18 patients. Respiratory complications were more frequent in patients with a cancer of the thoracic esophagus (29/111) than in those operated on for a cancer located in the esophago-gastric junction (4/50) (p < 0.01). Anastomotic stenosis occurred more frequently in the neck (17/137) than in the chest (1/49) (p < 0.05). Nine patients were reoperated on for a technical complication; intraabdominal hemorrhage (1), thoracic duct injury (2), acute cholecystitis (1), tight stricture of the esophageal anastomosis (2), jejuno-duodenal anastomotic fistual (2), or stridor related to recurrent nerve palsy (1). Low postoperative mortality may be achieved after esophageal surgery, even in a nonselected Caucasian population. However, nonfatal complications indicate that an esophageal resection or bypass operation remains a major surgical procedure. The surgical principles which we have applied to minimize postoperative mortality and severe complications are presented.