Classification and early recognition of gastric conduit failure after minimally invasive esophagectomy.
BACKGROUND
Esophagectomy is a high-risk procedure, with significant morbidity resulting from gastric conduit failure. Early recognition and management of these complications is essential. This study aimed to investigate the clinical value of routine investigations after minimally invasive esophagectomy (MIO) and to propose a classification system for gastric conduit failure.


METHODS
For esophagogastric resection, MIO is the procedure of choice in the authors' unit. Standard postoperative care similar to that for open esophagectomy is undertaken on a specialist ward. Routine investigations include daily assessment of C-reactive protein (CRP), white cell count (WCC), and a contrast swallow on postoperative day (POD) 5. The authors performed a retrospective analysis to assess the utility of these tests.


RESULTS
Of a prospective cohort of 50 patients from April 2004 to July 2006, 26 (52%) had an uneventful recovery (U), 24 (48%) experienced complications (C) of varying nature and severity, and 1 died (2%). All the patients demonstrated a transient abnormal rise in CRP until POD 3. In group U, the levels then fell, but in group C, they remained elevated (POD 5: U = 96, C = 180; p < 0.01). This discrepancy trend was further exaggerated in the nine patients with gastric conduit failure (POD 5: GC = 254; p < 0.01), whereas contrast swallow failed to identify this complication in six patients. Simple anastomotic leaks (type 1, n = 4) were managed conservatively. Patients with conduit tip necrosis (type 2, n = 3) and complete conduit ischemia (type 2, n = 2) were managed by repeat thoracotomy and either refashioning of the conduit or take-down and cervical esophagostomy. None of the patients with conduit failure died.


CONCLUSIONS
Postoperative CRP monitoring is a highly effective, simple method for the early recognition of gastric conduit failure. This new system of classification provides a successful guide to conservative management or revisional surgery.
Veeramootoo
Darmarajah
D
Department of Thoracic and Upper GI Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, EX2 5DW, UK.
Parameswaran
Rajeev
R
Krishnadas
Rakesh
R
Froeschle
Peter
P
Cooper
Martin
M
Berrisford
Richard G
RG
Wajed
Shahjehan A
SA
D000230:Adenocarcinoma / Q000601:surgery; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects; D002097:C-Reactive Protein / Q000032:analysis; D002294:Carcinoma, Squamous Cell / Q000601:surgery; D042241:Early Diagnosis; D004938:Esophageal Neoplasms / Q000601:surgery; D016629:Esophagectomy / Q000379:methods*; D004945:Esophagoscopy / Q000379:methods*; D004946:Esophagostomy; D005260:Female; D018530:Gastric Stump / Q000098:blood supply / Q000473:pathology* / Q000601:surgery; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000209:etiology / Q000473:pathology / Q000601:surgery; D007582:Jejunostomy; D010535:Laparoscopy / Q000379:methods*; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D011183:Postoperative Complications / Q000097:blood / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery; D011446:Prospective Studies; D012720:Severity of Illness Index; D013274:Stomach Neoplasms / Q000601:surgery; D013908:Thoracotomy
D002097:C-Reactive Protein