The acute management and surgical reconstruction following failed esophagectomy in malignant disease of the esophagus.

ABSTRACT

The stomach is the favored organ for reconstruction following esophageal resection for malignant disease, but has a 2% failure rate relating to ischemia. This event is associated with a high mortality, although appropriate surgical management with removal of the conduit can be life-saving. Further reconstruction is very challenging. We discuss the management options and surgical techniques for these patients. We reviewed of the surgical management of seven patients referred to a tertiary center over a 2-year period with failure of their primary esophageal reconstruction. Four patients had reconstruction with jejunum (2 free transfers and 2 'supercharged' pedicles with microanastomosis in the neck), and three with left colon. The route of reconstruction was substernal in four patients, subcutaneous in two, and through the left pleural cavity in one. There was 0% mortality, and 57% morbidity. The median intensive care unit stay was 2 days (mean 8, range 1-42). All patients tolerated full enteral nutrition, and had a satisfactory functional outcome. Failure of the conduit post-esophagectomy is a rare but serious complication, and these patients require complex surgical reconstruction. The surgical techniques described require a specialist multidisciplinary approach, but good clinical and functional outcomes are possible, even in patients with an underlying malignancy.