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Aanastomotic leakage after excision of esophageal and high gastric carcinoma
Aanastomotic Leakage after Excision of Esophageal and High Gastric Catzinoma M. V. INBERG, MD, Turku, Finland M. 1. LINNA, MD, Turku, Finland T. M. SCHEININ, MD, Turku, Finland E. VANTTINEN, MD, Turku, Finland
Despite advances in anesthetic methods, surgical technics, and postoperative care, early postoperative mortality after radical surgery for esophageal or high gastric carcinoma continues to be high, usually within the range of 10 to 30 per cent, in most series recently published [I-9]. The lowest hospital mortality ever reported, 6 per cent, belongs to Nakayama [IO]. This high mortality is partly due to the fact that the patients in whom these procedures are carried out tend to be elderly. The main cause of failure has been insufficiency of the suture of the esophageal anastomosis [I$, 7,9,1.2-151. Management of this complication is difficult and the results have often been disappointing [I-18]. The purpose of this study was to analyze the incidence, causes, and results of management of this serious complication. Material
Results
and Methods
In the period from September 1956 to September 1970 excisions of esophageal or high gastric carcinoma were performed in 207 patients at the Department of Surgery, University of Turku. Fifty-nine patients had esophageal carcinoma and 148 had neoplasms involving the esophagogastric junction. There were 120 male and 87 female patients, varying in age from twenty-three to eighty-three years, with a mean age of 60.9 years. (Figure 1.) In the 148 patients with high gastric carcinoma sixty-five proximal and eighty-three total gastrectomies were carried out. (Table I.) Reconstruction Procedures (Table II). The following types of reconstruction were used in esophageal cancer:
esophagogastrostomy
in fifty-one
From the Department of Surgery, University Finland. Reprint requests should be addressed to Dr Surgery, University of Turku, Turku, Finland.
540
transposition in five, esophagojejunostomy in two, and an indwelling Berman tube in one patient. High gastric carcinoma was treated by excision and esophagogastric anastomosis in sixty-five cases, end to side esophagojejunostomy in fifty-seven, reconstruction by the Roux method in seventeen, esophagoduodenostomy in eight, and colon interposition in one case. (Figure 2.) Management of Anastomotic Leak. Since 1967 all patients have been subjected to radiologic examination of the anastomotic area, using water-soluble contrast medium, to exclude the possibility of anastomotic leakage. This examination was performed on the sixth or seventh postoperative day. If an anastomotic rupture was revealed, immediate exploration was undertaken to close or cover the leaking area and to ensure adequate drainage. A feeding jejunostomy by the method of Witzel or Marwedel was performed in eight cases. in three cases. Double jejunostomy was accomplished (Figure 3.)
of
cases, Turku,
Inberg.
colon
Turku
52,
Department
of
Early Mortality (Table 111). All deaths during the first postoperative month were included. The highest mortality (22 per cent) was recorded after esophagectomy and the lowest (13 per cent) after total gastrectomy. Mortality was 15 per cent after proximal gastrectomy and 16 per cent in the whole series. Anastowtotic Leaks (Tables IV and V). Anastomotic ruptures were most often found after proximal gastrectomy (eight cases of sixty-five or 12 per cent). The figure was 8 per cent after esophagectomy and ‘7 per cent after total gastrectomy. Leaks resulting in death were most frequent in connection with proximal gastrectomy and esophagoantrostomy. Nine patients in whom anastomotic leaks were diagnosed recovered. Repeated radiologic studies showed gradual shrinkage and
The American
Journal
of Surgery
Excision
TABLE
I
of
Esophageal
and
High
Gastric
Carcinoma
Esophageal Anastomosis after Excisional Surgery for Carcinoma Number of Patients
Location of Tumor
59 148
Esophageal carcinoma (esophagectomy) High gastric carcinoma (65 proximal plus 83 total gastrectomies) Total
TABLE
II
Reconstruction Procedures after Tumor Excision High Gastric Carcinoma
EsophagealCarcinoma Figure 1.
Number of Patients
Age distribution. Procedure Esophagogastrostomy Colon interposition Esophagojejunostomy Berman tube
TABLE III
207
51 5 2 1
Number of Patients
Procedure
65 57
Esophagoantrostomy Esophagojejunostomy end to side Esophagojejunostomy Roux-en-Y Esophagoduodenostomy Colon interposition
17 8 1
Operative Mortality in Relation to Surgical Procedure Operative Deaths
Surgical Procedure Diagram showing technic of esophagoantrostomy Figure 2. (left) and esophagojejunostomy end to side (right) as performed in ‘our series.
Number of Patients
Number of Patients
Per cent
59 65 83 207
13 10 11 34
22 15 13 16
Esophagectomy Proximal gastrectomy Total gastrectomy Total
TABLE IV
Mortality and Anastomotic Leakage
Surgical mortality Anastomotic leaks Deaths caused by anastomotic
TABLE V
leaks
Number of Patients
Percentage
34/207 19/207 lo/207
16 9 5
Anastomotic Leaks and Type of Excision Anastomotic Leaks
Surgical Procedure
Figure 3.
Anastomotic
leakage
after
proximal
and esophagoantrostomy managed by drainage compressive and feeding jejunostomy.
Volume 122, October 1971
gastrectomy and by de-
Esophagectomy Proximal gastrectomy Total gastrectomy Total
Number of Patients
Number of Patients
Per cent
Died
Per cent
59 65 83 207
5 8 6 19
(8) (12) (7) ( 9)
2 5 3 10
(3) (8) (4) (5)
541
lnberg et al
TABLE
Anastomotic Leaks in Relation to Reconstruction Procedure in High Gastric Carcinoma
VI
Anastomotic Leaks
Reconstruction Esophagojejunostomy Esophagoantrostomy Esophagoduodenostomy
Number of Patients
Number of Patients
74 65 8
3 8 3
Per Per cent Died cent ( 4) (12) (38)
1 5 2
( 1) ( 8) (25)
disappearance of the cavity associated with the anastomotic leak. In high gastric carcinoma after esophagojejunostomy, anastomotic leaks occurred in 4 per cent, and only one patient died from this complication. (Table VI.) After proximal gastrectomy and esophagoantrostomy, on the other hand, anastomotic leaks occurred in 12 per cent, and five of the eight patients died. The highest incidence of leakage was observed after esophagoduodenostomy (three cases of eight). The relationship between leaks and the age of the patient was clearly demonstrable. (Table VII.) The mortality from this complication was five times as high in patients over seventy, as in patients between sixty and seventy. Comments
When different series of esophagectomy and total gastrectomy are compared with respect to primary mortality and incidence of anastomotic leaks, knowledge of resectability rates as well as of the age distribution is essential. It is clear that a high degree of selectivity in the choice of surgical candidates ensures the best postoperative results. However, since prognosis is very poor in patients with. esophageal and high gastric carcinoma not subjected to surgery, radical surgery is Over-all Operative Mortality Leaks In Relation to Age
TABLE VII
Total Series Age W
Number of Patients
20-29 30-39 40-49 50-59 60-69 >70
1 8 19 52 89 38
542
--
Died ... ‘;’ 4 15 14
and Anastomotic
Anastomotic Leaks Per cent
Number of Patients
Per cent
Died
Per cent
... . *. 5 8 17 37
... ... 1 3 7 8
... ... 5 6 8 21
... ... ... 1 3 6
... ... ... 2 3 16
to be recommended even if it is associated with a certain mortality. The over-all results in the treatment of these malignant lesions have improved with higher resectability rates and acceptance of older patients for surgery. In our series 61 per cent of the patients were more than sixty years of age and 18 per cent were more than seventy years. According to previous reports anastomotic leakage has been observed in 8 to 21 per cent of patients after excision of malignant tumors and formation of esophageal anastomoses [2,21,19, 15-191. Nineteen of our patients (9 per cent) had this complication and ten died. Thus, a third of the 16 per cent total primary mortality was caused by anastomotic leaks. In a large series of 472 patients disruptions were observed in eighty-eight (19 per cent), eighty-two of whom died (93 per cent) [15]. In another series there were sixteen patients with leakage and all died [1S]. Published reports differ widely as to the way in which the leaks were diagnosed and sought for. Unless routine radiologic check-up is performed in the early postoperative period, some almost subclinical leaks may entirely escape notice, others may be labelled as purulent empyemas at autopsy, and the rupture may be overlooked. Finally some instances may not come to autopsy at all. In our series, autopsy was performed in twenty-eight of thirty-six cases. During the last four years routine radiologic checking of the anastomosis with watersoluble contrast medium has been carried out six or seven days after surgery. Our results showed anastomotic leaks to increase with advancing age and to be five times more frequent in patients over seventy years than in those between sixty and sixty-nine. Of the various reconstructive technics used in surgery for high gastric carcinoma, end to side esophagojejunostomy appeared to us to be the most reliable. This method was also supported by Sanchez and Gordon [11] and Hegemann and Gall [14]. On the other hand, the incidence of anastomotic leaks and the ensuing mortality were particularly alarming after proximal gastrectomy with esophagoantrostomy and after total gastrectomy with esophagoduodenostomy. Reconstructive methods such as esophagoantrostomy and duodenostomy or various interposition procedures preserve duodenal passage and may give an impression of being more physiologic than esophagojejunostomy. Some investigators [20,21] have stated that absorption conditions have been improved by interposition procedures [20,21]. Others have noticed no differences when
The American
Journal
of Surgery
Excision of Esophageal and High Gastric Carcinoma
comparing the results of end to side and Roux-en-Y esophagojejunostomy and esophagoduodenostomy [221 or of Roux-en-Y a#nd interposition procedures [23]. Our absorption studies have revealed the same incidence and severity of malabsorption after both proximal and total gastrectomy [24]. Esophagojejunostomy end to side is, however, the most frequent cause of reflux esophagitis, a complication which is less frequent after interposition and Roux-en-Y procedures [7]. According to Fischermann and associates [25] the disadvantages of proximal gastrectomy have been so great that it is worth considering total gastrectomy in high gastric carcinoma. Kock, Lewin, and Pettersson [6] have also abandoned the use of proximal gastrectomy because of poor five year survival and high incidence of anastomotic leaks. In our series differences in five year survival were not observed [S] but at present we have avoided proximal gastrectomy partly because of frequent anastomotic failures and partly because absorption is not improved by this procedure. We have also considered esophagoduodenostomy unsuitable. The simplicity and rapidity of this procedure may be tempting particularly when treating aged and feeble patients. However, the subsequent incidence of anastomotic leaks is then particularly high. Since extensive surgery of this kind still carries grave risks, efforts should be directed to lowering the primary mortality, especially by reducing the danger of anastomotic leaks. The various reconstructive procedures aiming at pouch replacement and preservation of duodenal passage must be weighed against the increased postoperative mortality. We agree with Herrington’s statement that in these reconstructions complicated surgical procedures have only a limited place in the surgeon’s repertoire [26]. In our opinion interposition procedures should be reserved for young, good risk patients with a long life expectancy. In esophagectomy for esophageal carcinoma a simple esophagogastrostomy seems preferable to more complicated interposition procedures except when only a colon transplant can bridge the defect between the esophagus, stomach, and duodenum. Most observers have reported extremely high mortality figures, 50 to 100 per cent, in anastomotic leakage [1,25-181. In our series this figure was 53 per cent. An aggressive approach with early diagnosis of the rupture, use of routine radiologic check-up, and usually immediate reoperation with adequate drainage and feeding jejunostomy are indicated and may prove life-saving in a high proportion of these patients.
Volume 122, October 1971
Summary
Excision of esophageal or high gastric carcinoma was performed in 207 patients with a primary mortality of 16 per cent. Anastomotic leakage occurred in 9 per cent and was fatal in every other patient. A third of the primary mortality was due to this complication. Leaks were five times more frequent in patients more than seventy years of age than in those between the ages of sixty and sixty-nine. Ruptures leading to death were most often found in connection with proximal gastrectomy with esophagoantrostomy. After total gastrectomy with esophagojejunostomy leaks occurred in 4 per cent and only one patient (1 per cent) died because of this complication. At present, we have avoided proximal gastrectomy for high gastric carcinoma because of frequent anastomotic failures with high mortality, and we prefer to perform total gastrectomy with simple end to side esophagojejunostomy. References L, Silander T, Soderhmd S: Surgery for car1. Johansson cinoma of the esophagus and the cardia. Ann Chir Gynaec Fenn 52: 429, 19863. B,, Helsingen N Jr: Late re2. Efskind L, Bugge-Asperheim suits in the treatment of high gastric carcinoma requiring total gastrectomy. Acta Chir Stand suppl 356: 80, 1965. N Jr: Carcinoma of the lower por3. Efskind L, Helsingen tion of the esophagus. Acta Chir Stand suppl 366: 110, 1965. K: Surgical treatment of malig4. Zacho A, Fischermann nancies of the oesophago-gastric junction. Acta Chir Stand supp1356: 121, 1965. and 5. lnberg MV, Scheinin TM: The surgery of oesophageal high gastric carcinoma. Ann Chir Gynaec Fenn 58: 197, 1969. Kock NG, Lewin E, Pettersson S: Partial or total gastrectomy for adenocarcinoma of the cardia. Acta Chir Stand 135: 340, 1969. Maki T: Ergebnisse d’er totalen Gastrektomie beim Magencarcinom. Langenbecks Arch Klin Chir 325: 450, 1%9. Gunnlaugsson GH, Wychulis AR, Roland C, Ellis FH Jr: Analysis of the records of 1,657 patients with carcinoma of the esophagus and cardia of the stomach. Surg Gynec Obstet 130: 997, 1970. 9. Ohman U, Wetterfors J: Carcinoma of the stomach. Acta Chir Stand 136: 219, 1970. 10. Nakayama K: Carcinoma of the esophagus and the cardia. J Int Coil Surg 35: 143, 1961. 11. Sanchez RE, Gordon HE: Complications of total gastrectomy. Arch Surg 100: 136. 1970. 12. Logan A: Honored guest’s address: The surgical treatment of carcinoma of the esophagus and cardia. J Thorac Cardiovasc Surg 46: 150, 1963. 13. Kyllonen KEJ, Virkkula L: On operative treatment of carcinoma of the esophagus. Acta Chir Stand suppl356: 117, 1965. 14. Hegemann G, Gall F: Die Behandlung des Magenkarzinoms durch totale Magenentfernung. Deutsch Med Wschr 93: 329, 1968.
543
lnberg
et al
15. Maillard JN, Launois B, Lagausie Ph, Lellouch J, LortatJacob JL: Cause of leakage at the site of anastomosis after esophagogastric resection for carcinoma. Surg Gynec Obstet 127: 1014, 1969. 16. Miller C: Carcinoma of thoracic oesophagus and cardia. Brit J Surg 49: 507, 1961. 17. Franklin RH, Burn JI, Lynch G: Carcinoma of the oesophagus. Brit J Surg 51: 178,1964. 18. Magill TG, Simmons RL: Resection of cardioesophageal carcinoma. Arch Sorg 94: 865, 1967. 19. Cole WR, Petit R, Bernard HR: Factors affecting incidence of anastomotic leak following esophagogastrectomy. Ann Thorac Surg 6: 396, 1968. 20. Hays RP, Clark DA: Nutrition in patients with total gastrectomy and a jejunal food pouch. Ann Surg 152: 864, 1960. 21. Bugge-Asperheim 8, Helsingen N Jr: The state of nutrition of patients who have undergone total gastrectomy. Acta Chir Stand suppl332: 86, 1965.
544
22. Lawrence W, Vanamee P, Peterson AS, McNeer G, Lewin S, Randall HT: Alterations in fat and nitrogen metabolism after total and subtotal gastrectomy. Surg Gynec Obstet 110: 601, 1960. 23. Fischermann K. Harlv S. Wornine H. Zacho A: Pancreatic function and the-absorptionif fat, iron, vitamin BIz, and calcium after total gastrectomy for gastric cancer. Gut 8: 260, 1967. 24. lnberg MV, Markkanen T, Scheinin TM, Harri J: Absorption studies after excisional surgery of esophageal and high gastric carcinoma. Acta Chir Stand 136: 509, 1970. 25. Fischermann K, Mouridsen H, Neesgaard I, Worning H, Zacho A: Gastric and pancreatic function and the absorption of iron, vitamin BIz, and calcium after proximal gastric resection for cancer in the upper part of the stomach. Stand J Gastroent 4: 697, 1969. 26. Herrington JL: Various types of pouch replacement following total gastrectomy. Amer Surg 34: 879, 1968.
The American
Journal
of Surgery
Despite advances in anesthetic methods, surgical technics, and postoperative care, early postoperative mortality after radical surgery for esophageal or high gastric carcinoma continues to be high, usually within the range of 10 to 30 per cent, in most series recently published [I-9]. The lowest hospital mortality ever reported, 6 per cent, belongs to Nakayama [IO]. This high mortality is partly due to the fact that the patients in whom these procedures are carried out tend to be elderly. The main cause of failure has been insufficiency of the suture of the esophageal anastomosis [I$, 7,9,1.2-151. Management of this complication is difficult and the results have often been disappointing [I-18]. The purpose of this study was to analyze the incidence, causes, and results of management of this serious complication. Material
Results
and Methods
In the period from September 1956 to September 1970 excisions of esophageal or high gastric carcinoma were performed in 207 patients at the Department of Surgery, University of Turku. Fifty-nine patients had esophageal carcinoma and 148 had neoplasms involving the esophagogastric junction. There were 120 male and 87 female patients, varying in age from twenty-three to eighty-three years, with a mean age of 60.9 years. (Figure 1.) In the 148 patients with high gastric carcinoma sixty-five proximal and eighty-three total gastrectomies were carried out. (Table I.) Reconstruction Procedures (Table II). The following types of reconstruction were used in esophageal cancer:
esophagogastrostomy
in fifty-one
From the Department of Surgery, University Finland. Reprint requests should be addressed to Dr Surgery, University of Turku, Turku, Finland.
540
transposition in five, esophagojejunostomy in two, and an indwelling Berman tube in one patient. High gastric carcinoma was treated by excision and esophagogastric anastomosis in sixty-five cases, end to side esophagojejunostomy in fifty-seven, reconstruction by the Roux method in seventeen, esophagoduodenostomy in eight, and colon interposition in one case. (Figure 2.) Management of Anastomotic Leak. Since 1967 all patients have been subjected to radiologic examination of the anastomotic area, using water-soluble contrast medium, to exclude the possibility of anastomotic leakage. This examination was performed on the sixth or seventh postoperative day. If an anastomotic rupture was revealed, immediate exploration was undertaken to close or cover the leaking area and to ensure adequate drainage. A feeding jejunostomy by the method of Witzel or Marwedel was performed in eight cases. in three cases. Double jejunostomy was accomplished (Figure 3.)
of
cases, Turku,
Inberg.
colon
Turku
52,
Department
of
Early Mortality (Table 111). All deaths during the first postoperative month were included. The highest mortality (22 per cent) was recorded after esophagectomy and the lowest (13 per cent) after total gastrectomy. Mortality was 15 per cent after proximal gastrectomy and 16 per cent in the whole series. Anastowtotic Leaks (Tables IV and V). Anastomotic ruptures were most often found after proximal gastrectomy (eight cases of sixty-five or 12 per cent). The figure was 8 per cent after esophagectomy and ‘7 per cent after total gastrectomy. Leaks resulting in death were most frequent in connection with proximal gastrectomy and esophagoantrostomy. Nine patients in whom anastomotic leaks were diagnosed recovered. Repeated radiologic studies showed gradual shrinkage and
The American
Journal
of Surgery
Excision
TABLE
I
of
Esophageal
and
High
Gastric
Carcinoma
Esophageal Anastomosis after Excisional Surgery for Carcinoma Number of Patients
Location of Tumor
59 148
Esophageal carcinoma (esophagectomy) High gastric carcinoma (65 proximal plus 83 total gastrectomies) Total
TABLE
II
Reconstruction Procedures after Tumor Excision High Gastric Carcinoma
EsophagealCarcinoma Figure 1.
Number of Patients
Age distribution. Procedure Esophagogastrostomy Colon interposition Esophagojejunostomy Berman tube
TABLE III
207
51 5 2 1
Number of Patients
Procedure
65 57
Esophagoantrostomy Esophagojejunostomy end to side Esophagojejunostomy Roux-en-Y Esophagoduodenostomy Colon interposition
17 8 1
Operative Mortality in Relation to Surgical Procedure Operative Deaths
Surgical Procedure Diagram showing technic of esophagoantrostomy Figure 2. (left) and esophagojejunostomy end to side (right) as performed in ‘our series.
Number of Patients
Number of Patients
Per cent
59 65 83 207
13 10 11 34
22 15 13 16
Esophagectomy Proximal gastrectomy Total gastrectomy Total
TABLE IV
Mortality and Anastomotic Leakage
Surgical mortality Anastomotic leaks Deaths caused by anastomotic
TABLE V
leaks
Number of Patients
Percentage
34/207 19/207 lo/207
16 9 5
Anastomotic Leaks and Type of Excision Anastomotic Leaks
Surgical Procedure
Figure 3.
Anastomotic
leakage
after
proximal
and esophagoantrostomy managed by drainage compressive and feeding jejunostomy.
Volume 122, October 1971
gastrectomy and by de-
Esophagectomy Proximal gastrectomy Total gastrectomy Total
Number of Patients
Number of Patients
Per cent
Died
Per cent
59 65 83 207
5 8 6 19
(8) (12) (7) ( 9)
2 5 3 10
(3) (8) (4) (5)
541
lnberg et al
TABLE
Anastomotic Leaks in Relation to Reconstruction Procedure in High Gastric Carcinoma
VI
Anastomotic Leaks
Reconstruction Esophagojejunostomy Esophagoantrostomy Esophagoduodenostomy
Number of Patients
Number of Patients
74 65 8
3 8 3
Per Per cent Died cent ( 4) (12) (38)
1 5 2
( 1) ( 8) (25)
disappearance of the cavity associated with the anastomotic leak. In high gastric carcinoma after esophagojejunostomy, anastomotic leaks occurred in 4 per cent, and only one patient died from this complication. (Table VI.) After proximal gastrectomy and esophagoantrostomy, on the other hand, anastomotic leaks occurred in 12 per cent, and five of the eight patients died. The highest incidence of leakage was observed after esophagoduodenostomy (three cases of eight). The relationship between leaks and the age of the patient was clearly demonstrable. (Table VII.) The mortality from this complication was five times as high in patients over seventy, as in patients between sixty and seventy. Comments
When different series of esophagectomy and total gastrectomy are compared with respect to primary mortality and incidence of anastomotic leaks, knowledge of resectability rates as well as of the age distribution is essential. It is clear that a high degree of selectivity in the choice of surgical candidates ensures the best postoperative results. However, since prognosis is very poor in patients with. esophageal and high gastric carcinoma not subjected to surgery, radical surgery is Over-all Operative Mortality Leaks In Relation to Age
TABLE VII
Total Series Age W
Number of Patients
20-29 30-39 40-49 50-59 60-69 >70
1 8 19 52 89 38
542
--
Died ... ‘;’ 4 15 14
and Anastomotic
Anastomotic Leaks Per cent
Number of Patients
Per cent
Died
Per cent
... . *. 5 8 17 37
... ... 1 3 7 8
... ... 5 6 8 21
... ... ... 1 3 6
... ... ... 2 3 16
to be recommended even if it is associated with a certain mortality. The over-all results in the treatment of these malignant lesions have improved with higher resectability rates and acceptance of older patients for surgery. In our series 61 per cent of the patients were more than sixty years of age and 18 per cent were more than seventy years. According to previous reports anastomotic leakage has been observed in 8 to 21 per cent of patients after excision of malignant tumors and formation of esophageal anastomoses [2,21,19, 15-191. Nineteen of our patients (9 per cent) had this complication and ten died. Thus, a third of the 16 per cent total primary mortality was caused by anastomotic leaks. In a large series of 472 patients disruptions were observed in eighty-eight (19 per cent), eighty-two of whom died (93 per cent) [15]. In another series there were sixteen patients with leakage and all died [1S]. Published reports differ widely as to the way in which the leaks were diagnosed and sought for. Unless routine radiologic check-up is performed in the early postoperative period, some almost subclinical leaks may entirely escape notice, others may be labelled as purulent empyemas at autopsy, and the rupture may be overlooked. Finally some instances may not come to autopsy at all. In our series, autopsy was performed in twenty-eight of thirty-six cases. During the last four years routine radiologic checking of the anastomosis with watersoluble contrast medium has been carried out six or seven days after surgery. Our results showed anastomotic leaks to increase with advancing age and to be five times more frequent in patients over seventy years than in those between sixty and sixty-nine. Of the various reconstructive technics used in surgery for high gastric carcinoma, end to side esophagojejunostomy appeared to us to be the most reliable. This method was also supported by Sanchez and Gordon [11] and Hegemann and Gall [14]. On the other hand, the incidence of anastomotic leaks and the ensuing mortality were particularly alarming after proximal gastrectomy with esophagoantrostomy and after total gastrectomy with esophagoduodenostomy. Reconstructive methods such as esophagoantrostomy and duodenostomy or various interposition procedures preserve duodenal passage and may give an impression of being more physiologic than esophagojejunostomy. Some investigators [20,21] have stated that absorption conditions have been improved by interposition procedures [20,21]. Others have noticed no differences when
The American
Journal
of Surgery
Excision of Esophageal and High Gastric Carcinoma
comparing the results of end to side and Roux-en-Y esophagojejunostomy and esophagoduodenostomy [221 or of Roux-en-Y a#nd interposition procedures [23]. Our absorption studies have revealed the same incidence and severity of malabsorption after both proximal and total gastrectomy [24]. Esophagojejunostomy end to side is, however, the most frequent cause of reflux esophagitis, a complication which is less frequent after interposition and Roux-en-Y procedures [7]. According to Fischermann and associates [25] the disadvantages of proximal gastrectomy have been so great that it is worth considering total gastrectomy in high gastric carcinoma. Kock, Lewin, and Pettersson [6] have also abandoned the use of proximal gastrectomy because of poor five year survival and high incidence of anastomotic leaks. In our series differences in five year survival were not observed [S] but at present we have avoided proximal gastrectomy partly because of frequent anastomotic failures and partly because absorption is not improved by this procedure. We have also considered esophagoduodenostomy unsuitable. The simplicity and rapidity of this procedure may be tempting particularly when treating aged and feeble patients. However, the subsequent incidence of anastomotic leaks is then particularly high. Since extensive surgery of this kind still carries grave risks, efforts should be directed to lowering the primary mortality, especially by reducing the danger of anastomotic leaks. The various reconstructive procedures aiming at pouch replacement and preservation of duodenal passage must be weighed against the increased postoperative mortality. We agree with Herrington’s statement that in these reconstructions complicated surgical procedures have only a limited place in the surgeon’s repertoire [26]. In our opinion interposition procedures should be reserved for young, good risk patients with a long life expectancy. In esophagectomy for esophageal carcinoma a simple esophagogastrostomy seems preferable to more complicated interposition procedures except when only a colon transplant can bridge the defect between the esophagus, stomach, and duodenum. Most observers have reported extremely high mortality figures, 50 to 100 per cent, in anastomotic leakage [1,25-181. In our series this figure was 53 per cent. An aggressive approach with early diagnosis of the rupture, use of routine radiologic check-up, and usually immediate reoperation with adequate drainage and feeding jejunostomy are indicated and may prove life-saving in a high proportion of these patients.
Volume 122, October 1971
Summary
Excision of esophageal or high gastric carcinoma was performed in 207 patients with a primary mortality of 16 per cent. Anastomotic leakage occurred in 9 per cent and was fatal in every other patient. A third of the primary mortality was due to this complication. Leaks were five times more frequent in patients more than seventy years of age than in those between the ages of sixty and sixty-nine. Ruptures leading to death were most often found in connection with proximal gastrectomy with esophagoantrostomy. After total gastrectomy with esophagojejunostomy leaks occurred in 4 per cent and only one patient (1 per cent) died because of this complication. At present, we have avoided proximal gastrectomy for high gastric carcinoma because of frequent anastomotic failures with high mortality, and we prefer to perform total gastrectomy with simple end to side esophagojejunostomy. References L, Silander T, Soderhmd S: Surgery for car1. Johansson cinoma of the esophagus and the cardia. Ann Chir Gynaec Fenn 52: 429, 19863. B,, Helsingen N Jr: Late re2. Efskind L, Bugge-Asperheim suits in the treatment of high gastric carcinoma requiring total gastrectomy. Acta Chir Stand suppl 356: 80, 1965. N Jr: Carcinoma of the lower por3. Efskind L, Helsingen tion of the esophagus. Acta Chir Stand suppl 366: 110, 1965. K: Surgical treatment of malig4. Zacho A, Fischermann nancies of the oesophago-gastric junction. Acta Chir Stand supp1356: 121, 1965. and 5. lnberg MV, Scheinin TM: The surgery of oesophageal high gastric carcinoma. Ann Chir Gynaec Fenn 58: 197, 1969. Kock NG, Lewin E, Pettersson S: Partial or total gastrectomy for adenocarcinoma of the cardia. Acta Chir Stand 135: 340, 1969. Maki T: Ergebnisse d’er totalen Gastrektomie beim Magencarcinom. Langenbecks Arch Klin Chir 325: 450, 1%9. Gunnlaugsson GH, Wychulis AR, Roland C, Ellis FH Jr: Analysis of the records of 1,657 patients with carcinoma of the esophagus and cardia of the stomach. Surg Gynec Obstet 130: 997, 1970. 9. Ohman U, Wetterfors J: Carcinoma of the stomach. Acta Chir Stand 136: 219, 1970. 10. Nakayama K: Carcinoma of the esophagus and the cardia. J Int Coil Surg 35: 143, 1961. 11. Sanchez RE, Gordon HE: Complications of total gastrectomy. Arch Surg 100: 136. 1970. 12. Logan A: Honored guest’s address: The surgical treatment of carcinoma of the esophagus and cardia. J Thorac Cardiovasc Surg 46: 150, 1963. 13. Kyllonen KEJ, Virkkula L: On operative treatment of carcinoma of the esophagus. Acta Chir Stand suppl356: 117, 1965. 14. Hegemann G, Gall F: Die Behandlung des Magenkarzinoms durch totale Magenentfernung. Deutsch Med Wschr 93: 329, 1968.
543
lnberg
et al
15. Maillard JN, Launois B, Lagausie Ph, Lellouch J, LortatJacob JL: Cause of leakage at the site of anastomosis after esophagogastric resection for carcinoma. Surg Gynec Obstet 127: 1014, 1969. 16. Miller C: Carcinoma of thoracic oesophagus and cardia. Brit J Surg 49: 507, 1961. 17. Franklin RH, Burn JI, Lynch G: Carcinoma of the oesophagus. Brit J Surg 51: 178,1964. 18. Magill TG, Simmons RL: Resection of cardioesophageal carcinoma. Arch Sorg 94: 865, 1967. 19. Cole WR, Petit R, Bernard HR: Factors affecting incidence of anastomotic leak following esophagogastrectomy. Ann Thorac Surg 6: 396, 1968. 20. Hays RP, Clark DA: Nutrition in patients with total gastrectomy and a jejunal food pouch. Ann Surg 152: 864, 1960. 21. Bugge-Asperheim 8, Helsingen N Jr: The state of nutrition of patients who have undergone total gastrectomy. Acta Chir Stand suppl332: 86, 1965.
544
22. Lawrence W, Vanamee P, Peterson AS, McNeer G, Lewin S, Randall HT: Alterations in fat and nitrogen metabolism after total and subtotal gastrectomy. Surg Gynec Obstet 110: 601, 1960. 23. Fischermann K. Harlv S. Wornine H. Zacho A: Pancreatic function and the-absorptionif fat, iron, vitamin BIz, and calcium after total gastrectomy for gastric cancer. Gut 8: 260, 1967. 24. lnberg MV, Markkanen T, Scheinin TM, Harri J: Absorption studies after excisional surgery of esophageal and high gastric carcinoma. Acta Chir Stand 136: 509, 1970. 25. Fischermann K, Mouridsen H, Neesgaard I, Worning H, Zacho A: Gastric and pancreatic function and the absorption of iron, vitamin BIz, and calcium after proximal gastric resection for cancer in the upper part of the stomach. Stand J Gastroent 4: 697, 1969. 26. Herrington JL: Various types of pouch replacement following total gastrectomy. Amer Surg 34: 879, 1968.
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