title: Delayed esophagogastrostomy: a safe strategy for management of patients with ischemic gastric conduit at time of esophagectomy.
abstract: BACKGROUND
  Ischemia of the gastric conduit remains an important complication of esophagectomy and is associated with an increased risk of anastomotic leak and sepsis. We report a group of patients with multiple comorbid conditions and an ischemic gastric conduit that was successfully managed by a delayed esophagogastrostomy.
  
  
  METHODS
  Between 2000 and 2007, esophagectomy with gastric pullup was performed in 554 patients. In 37 patients (7%), the combination of an ischemic graft and substantial comorbid conditions prompted delayed reconstruction to avoid an immediate esophagogastrostomy. In these patients, the gastric conduit was brought up and secured in the neck, and a cervical esophagostomy was constructed. Subsequently, a delayed esophagogastrostomy was performed through neck incision. Outcomes were analyzed at a median of 22 months (interquartile range [IQR], 13 to 30 months).
  
  
  RESULTS
  There were 29 male and 8 female patients, with a median age of 65 years (IQR, 58 to 75 years). Thirty-one patients had malignant disease; 12 received neoadjuvant therapy. All 37 patients recovered from their esophagectomy without evidence of ischemic necrosis or fistula from their gastric conduit. In 35 patients, a delayed esophagogastrostomy was performed at a median of 98 days (IQR, 89 to 110 days). At the time of reconstruction, all had well-perfused gastric conduits, and the anastomoses healed without leak, wound infection, or sepsis. A stricture developed in three patients and was treated with dilation. Delayed esophagogastrostomy was never performed in two patients because of development of recurrent malignant disease.
  
  
  CONCLUSIONS
  Delayed esophagogastrostomy is a safe strategy for management of patients with comorbidities and an ischemic gastric conduit at the time of esophagectomy.
authors.affiliation: Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA.
authors.forename: Arzu
authors.initials: A
authors.lastname: Oezcelik
authors.forename: Farzaneh
authors.initials: F
authors.lastname: Banki
authors.forename: Steven R
authors.initials: SR
authors.lastname: DeMeester
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Leers
authors.forename: Shahin
authors.initials: S
authors.lastname: Ayazi
authors.forename: Emmanuele
authors.initials: E
authors.lastname: Abate
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Hagen
authors.forename: John C
authors.initials: JC
authors.lastname: Lipham
authors.forename: Tom R
authors.initials: TR
authors.lastname: DeMeester
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D004935:Esophageal Diseases / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D004947:Esophagus / Q000601:surgery*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D013270:Stomach / Q000098:blood supply* / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome