title: Mucosal damage in the esophageal remnant after esophagectomy and gastric transposition.
abstract: OBJECTIVE
  To assess development of mucosal damage in the esophageal remnant in regard to the level of the esophagogastrostomy reconstruction either in a right chest or in a left neck position.
  
  
  BACKGROUND
  Esophagectomy with gastric interposition creates an in vivo human model of pathologic esophageal reflux with the potential for long-term reflux disease complications.
  
  
  METHODS
  Eighty-four esophagectomy patients were assessed over time by symptoms, endoscopy and biopsies of their esophageal remnant after the operation. The anastomosis was in the right upper chest (n = 36) or in a left cervical position (n = 48). Visual quantification of damage, details of histopathology, and time period since surgery were recorded.
  
  
  RESULTS
  Twenty-nine patients (81%) with a right chest reconstruction had reflux symptoms when compared with 25 patients (53%) with a neck reconstruction (P = 0.007). Visualized reflux esophagitis was observed in 31 patients (81%) with chest anastomoses and in 22 patients (46%) with cervical anastomoses (P = 0.006). Documented mucosal damage and columnar lined metaplasia were significantly more frequent in the chest anastomosis group than the cervical group. The median of all mucosal damage and columnar lined metaplastic-free evolution were 13 +/- 3 and 20.5 +/- 6 months for the intrathoracic anastomosis, and 22 +/- 6 months and 40 +/- 8 months for the cervical anastomosis (P = 0.087). Two factors affecting the development of metaplasia were included in the multivariate analysis: an intrathoracic anastomosis (P = 0.018) and the presence of a previous Barrett esophagus (P = 0.064).
  
  
  CONCLUSIONS
  When a gastric transplant is used after esophagectomy, a high prevalence of mucosal damage is observed in the esophageal remnant independently of the level of reconstruction. A left cervical anastomosis favors less reflux symptoms, less visualized damage, and delays the development of mucosal damage over time.
authors.affiliation: Departments of Surgery and Pathology, Centre Hospitalier de l'Université de Montréal, Quebec, Canada.
authors.forename: Xavier Benoit
authors.initials: XB
authors.lastname: D'Journo
authors.forename: Jocelyne
authors.initials: J
authors.lastname: Martin
authors.forename: Georges
authors.initials: G
authors.lastname: Rakovich
authors.forename: Cecile
authors.initials: C
authors.lastname: Brigand
authors.forename: Louis
authors.initials: L
authors.lastname: Gaboury
authors.forename: Pasquale
authors.initials: P
authors.lastname: Ferraro
authors.forename: André
authors.initials: A
authors.lastname: Duranceau
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D001706:Biopsy; D016629:Esophagectomy / Q000009:adverse effects*; D004945:Esophagoscopy; D004947:Esophagus / Q000293:injuries / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009092:Mucous Membrane / Q000293:injuries; D013270:Stomach / Q000637:transplantation*