P1.018. Complex Esophageal Replacements for Benign Pathologies: An Institutional Review

Abstract

Abstract Topic Benign Disease: Esophageal Surgery Background Resistant benign esophageal pathologies require complex esophageal replacements. Ideal scenario permitting native esophageal resection and subsequent gastric pull-up is unsuitable in many cases. This warrants alternatives like substernal/subcutaneous gastric pull-ups, or colonic interpositions. We present our institutional experience of complex esophageal reconstructions supplemented by relevant literature. Methods This retrospective report analyzes 13 patients who underwent complex esophageal replacement for benign pathologies over a 20-year period. Indications were corrosive strictures (n=6), tracheoesophageal fistulas (n=4), long-segment strictures (n=2), and gastric conduit necrosis following transhiatal esophagectomy (n=1). We highlight upon the preoperative preparation, choice of conduit, reconstructive techniques and challenges, complications owing to the native esophagus, and functional outcomes. Results Gastric pull-up with excision of native esophagus was feasible in one patient. The native esophagus was left-in-situ in eleven patients due to dense mediastinal fibrosis or operative complexity. Eight underwent retrosternal esophagogastric anastomosis and five patients required retrosternal colonic interposition using right colon grafts. Early complications included aspiration pneumonia, posterior mediastinitis, and acute coronary syndrome. Cervical anastomotic complications were managed conservatively or with dilatation. No graft necrosis was encountered. Two deaths noted in the same admission because of immediate complications. Three patients developed mucocele of the native esophagus, from which two succumed to it's consequences. Some patients necessitated serial dilatations and nutritional rehabilitation, but satisfactory relief of dysphagia was noted in most patients. Conclusion Esophagus with it's complexity presents as a challange. Benign pathologies are often very debilitating and not tackled surgically by inexperienced surgeons. Complex reconstructions require careful patient selection, meticulous assessment of available anatomy, conduit and route selection, and individualized surgical approach. In experienced hands, colonic interposition provides an acceptable functional outcome with proportionate morbidity and mortality. Larger cohort studies and dedicated esophageal treatment centers are imperative.