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Chronic symptoms after subtotal or partial oesophagectomy: diagnosis and treatment

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In the great majority of patients, subtotal or partial oesophagectomy is performed because of malignancy, for which wide local excision and additional lymphadenectomy are indicated. Except in patients with early lesions, the vagal nerves have to be sacrificed bilaterally, which can induce a great variety of functional abnormalities. The continuity of the gastrointestinal tract is preferably restored by using a whole-stomach interposition or gastric tube. The oesophago-gastric anastomosis is critically vascularized and carries a significant risk of benign fibrotic stricturing, especially when it is located in the neck. Acid or biliary reflux may result in persistent oesophagitis and the development of Barrett's metaplasia in the remnant oesophagus. The reservoir capacity of the gastric tube is limited, whereas the emptying rate can vary considerably, leading to complaints of either gastric retention or intestinal dumping. It is not clear whether or not gastric drainage procedures are beneficial.

Recurrent nerve damage with vocal cord paralysis may result in aspiration and recurrent pulmonary infection. The permanent threat of recurrent disease combined with the substantial physical impact of an extensive surgical procedure inducing a wide range of functional disturbances of the gastrointestinal tract has a great influence on quality of life, at least temporarily. The late complications of anastomotic stricturing and the functional consequences of bilateral vagotomy, gastric tubulization and gastric pull-up will be reviewed. Moreover, the general and specific changes in quality of life will be addressed.

Section snippets

Anastomotic stenosis

Many factors, both local and systemic, influence the process of wound healing and thus the incidence of anastomotic complications.

When using the stomach as a substitute, the entire vascularization depends on the right gastroepiploic artery and vein. Approximately 60% of the gastric tube is supplied directly by this vessel, another 20% being more cranially supplied by the minute connections between the right and the left gastroepiploic vessels, whereas the most cranial 20% of the tube is

Reflux

Despite a significant reduction of acid output related to truncal vagotomy, persistent acid secretion has been reported. Hölscher et al10 found only a 30% reduction in peak acid output after pentagastric stimulation compared with controls. Gutschow et al11 noted that early after oesophagectomy and reconstruction with a denervated whole stomach, intraluminal acidity decreased in approximately two-thirds of the patients, although the stomach recovered its normal pH profile over time. Hashimoto et

Gastric emptying-related symptoms

Vagal denervation can result in chronic dysmotility of the gastric remnant and an outlet dysfunction of the pylorus, which may cause delayed emptying. This may induce a wide spectrum of symptoms: early satiety, postprandial fullness, heartburn, high dysphagia, aspiration and pneumonia.

The addition of a gastric drainage procedure has been advocated (in analogy with bilateral truncal vagotomy plus pyloroplasty in the treatment of duodenal ulcer disease). However, the need for such drainage

Gastric tube versus whole stomach

The individual variations in gastric tube activity may be related to different access routes, possible effects of torsion, the size and width of the gastric tube, elasticity and individual patterns of gastric dysmotility.

Finley et al20 studied the effect of different access routes, comparing right-sided, left-sided and transhiatal oesophagectomies. Oesophagectomy carried out through a right-sided posterolateral thoracotomy with cervical oesophagogastric anastomosis had a high incidence of

Treatment of gastric outlet obstruction

Irrespective whether or not a pyloric drainage procedure has been performed, a number of patients may suffer from gastric outlet obstruction. Balloon dilatation of the pylorus can be an effective procedure to solve this problem in some patients. Bemelman et al21 reported a successful outcome with balloon dilatation in 6 out of 18 patients.

An alternative is to administer erythromycin. Erythromycin is a motilin agonist and has been demonstrated to improve gastric emptying in normal subjects and

Intestinal metaplasia and gastric drainage procedures

The combination of biliary and acid reflux is commonly believed to play a central role in the pathogenesis of Barrett's metaplasia in patients suffering from gastro-oesophageal reflux disease. The ablation of the lower oesophageal sphincter mechanism at the time of oesophagectomy and the vagotomy-induced pyloric dysfunction with possible enterogastric biliary reflux are of increasing concern in relation to the risk of development of Barrett's metaplasia, especially in long-term survivors.

As

Dumping diarrhoea

After oesophagectomy followed by gastroplasty, many patients complain of diarrhoea and dumping (-like) symptoms, with a reported incidence of between 10 and 50%.14., 31., 32. These symptoms are early postprandial abdominal and vasomotor symptoms resulting from osmotic fluid shifts and the release of vasoactive neurotransmitters, and late symptoms secondary to reactive hypoglycaemia. Diarrhoea, abdominal cramps, nausea, dizziness, postprandial sweating and hypotension are the main complaints.

Vocal cord paralysis

Vocal cord paralysis is a well-known complication after subtotal oesophagectomy, causing hoarseness, dysphagia, weight loss, aspiration, dyspnoea and pneumonia. The dissection alongside both recurrent nerves, at the time of either thoracotomy or bilateral lymphadenectomy, may cause recurrent nerve damage followed by a temporary or definitive vocal cord paralysis. This paralysis can be unilateral or even bilateral. Precise data in relation to origin, incidence and associated morbidity are scarce.

Quality of life after oesophagectomy

Apart from substantial perioperative morbidity and even mortality, surgical therapy for oesophageal carcinoma can be accompanied by severe long-term functional disturbances, with a large impact on quality of life. The results of cancer treatment should be measured not only in terms of increased length of survival and therapy-induced morbidity: the broader effects on the patient's quality of life should also be taken into account. However, a review of the literature by Gelfand and Finley in 1994

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