Influence of the route of reconstruction on morbidity, mortality and local recurrence after esophagectomy for cancer

Background: A choice of retrosternal or orthotopic route for reconstruction exists after three-phase esophagectomy with cervical anastomosis. Whether the route of reconstruction affects postoperative morbidity, mortality and recurrence patterns remains controversial.

Study design: Patients with cancer of the thoracic esophagus who underwent three-phase esophagectomy between 1990 and 1999 were studied. Postoperative outcome, recurrence patterns and survival were analyzed from a prospectively collected database.

Results: Seventy-five patients underwent three-phase esophagectomy. There were 46 patients in the retrosternal group and 29 in the orthotopic group. The mean age of the retrosternal group was younger than the orthotopic group, 60 and 66 years, respectively (p = 0.004). The retrosternal group also had more advanced disease; 24% of patients had curative resection compared with 59% in the orthotopic group (p = 0.003). There was no significant difference in postoperative complications except that the retrosternal group had more blood loss, median 800 ml compared with 700 ml (p = 0.04). Hospital mortality was 13% in the retrosternal group and 3.4% in the orthotopic group (p = 0.24). Multivariate analysis showed that age (odds ratio 1.16, p = 0.035) and pulmonary risk (odds ratio 10, p = 0.01) were predictive of hospital mortality, but not the route of reconstruction. No patient in the retrosternal group developed recurrence in the gastric conduit compared to 4 of 28 patients (14%) in the orthotopic group (p = 0.03). Two of these patients were symptomatic with bleeding from the intragastric recurrence. Survival was worse in the retrosternal group, 5-year survival was 29.8 vs. 8.2% (p < 0.01), reflecting the more advanced disease and higher prevalence of palliative resections.

Conclusions: Cardiopulmonary complications and hospital mortality were not significantly different in the two groups. Recurrent tumor infiltration of the gastric conduit occurred in 14% of patients when the orthotopic route was used.