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Eur J Cardiothorac Surg 2001;20:1-6
© 2001 Elsevier Science NL

Is it necessary to resect the diseased esophagus in performing reconstruction for corrosive esophageal stricture?

Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea

Received 4 October 2000; received in revised form 22 February 2001; accepted 4 April 2001.

Corresponding author. Tel.: +82-2-760-3637; fax: +82-2-764-3664
e-mail: swsung{at}plaza.snu.ac.kr

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
Objective: The incidence of carcinoma of the esophagus among patients with chronic esophageal stricture caused by ingestion of corrosive agents is reported to be significantly higher than that of the general population. The question of whether or not a resection of the diseased esophagus should be included in the surgical reconstruction procedure of the undilatable esophageal stricture continues to be a controversial. Methods: During the 12 year period from 1988 to 1999, a total of 54 consecutive patients with caustic stricture of the esophagus were treated in our department. We retrospectively reviewed these cases and analyzed the incidence of cicatrical carcinoma among the patients and the risk of esophagectomy according to the procedures performed. Results: We found seven cases of esophageal cancer among these patients. There was no significant increase in mortality or morbidity related to esophagectomy. Conclusions: Considering the high incidence of cicatrical carcinoma from the stricture sites as well as the possible chance of hidden malignancy, we concluded that the simultaneous resection of the esophagus with reconstruction for patients with chronic intractable caustic stricture would give the patients a better probability of being completely cured of the disease.

Key Words: Esophageal stricture • Corrosive stricture • Esophageal cancer

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
The incidence of carcinoma of the esophagus among patients with chronic esophageal stricture caused by ingestion of corrosive agents is reported to be significantly higher than that of the general population [1]. The question as to whether or not a resection of the diseased esophagus should be included in the surgical reconstruction procedure of the undilatable esophageal stricture remains a controversy. Advocates of simple bypass reconstruction point out that synchronous resection of the diseased esophagus is not justified, because the risk of malignant degeneration is lower than the risk of the additive procedure and the danger of malignant transformation decreases after bypass surgery [2]. However, a high incidence of malignancy forces several surgeons to perform resection of the esophagus simultaneously with the reconstructive surgery [3,4].

To clarify this question, we reviewed our cases for past 12 years who were managed surgically for chronic corrosive esophageal stricture in our hospital. We analyzed the incidence of cicatrical carcinoma among the patients and the risk of esophagectomy according to the procedures performed.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
During the 12-year period from 1988 to 1999, a total of 54 consecutive patients with caustic stricture of the esophagus were included for this study. Most of patients had attempted suicide by swallowing corrosive liquids. Their age at the time of surgery ranged from 2 to 68 years (mean, 39 years). Seventeen were males (32%) and 37 were females (68%).

The location and extent of the lesions varied; one in the cervical esophagus and 16 in the upper, 13 in the middle, and seven in the lower one-third of the thoracic esophagus. In 17 patients the lesions were extensively distributed along the whole length of the esophagus. Among the patients whose lesion was extensive, the stomach was also involved in eight patients. The strictures were caused by lye in 28 patients (52%), hydrochloric acid in 21 patients (39%) and other corrosive agents in the remaining five patients (9%). The ingestion of hydrochloric acid frequently caused more extensive injuries to the esophagus.

Only palliative treatments were performed in eight patients such as feeding jejunostomy, gastrostomy, or esophageal dilatation. Patients were evaluated preoperatively with esophagography and esophagoscopy. Once the need for colonic replacement was determined, a double-contrast barium colon study was performed to evaluate the anatomic structure of the colon. Mesenteric angiography was also performed when the evaluation of the vasculature is needed.

Reconstruction procedures were performed in 46 patients when the stricture was so severe that swallowing foods were difficult and when the dilatation of the stricture failed. The age of these patients varied from 2 to 63 years (mean, 39 years). The interval between the ingestion and the reconstructive procedures ranged from 1 month to 47 years (mean, 11 years). Three different operative methods were used depending on each surgeon’s preference: (1) substernal esophageal bypass surgery without esophagectomy in 12 patients; (2) esophageal resection and replacement surgery through thoracotomy in nine patients; (3) transhiatal esophagectomy and esophageal replacement procedure through the esophageal hiatus in 21 patients. In two patients the esophagus was resected by transthiatal method as a first stage operation followed by a second stage replacement procedure with the substernal approach. Two patients were underwent transthoracic esophagectomy and the reconstructions were made through posterior mediastinal route. The organ used for a substitute for the esophagus was the left colon anastomosed in an isoperistaltic direction in 34, left colon anastomosed in antiperistaltic direction in two, stomach in nine patients. In one patient whose left colonic vasculature was determined inadequate, we used right colon in antiperistaltic direction.

A gastrograffin contrast study of the esophagus was performed on the seventh postoperative day, and oral feeding was begun if no leak was confirmed.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
3.1. Early results
Among the 46 patients who underwent reconstructive operation, one patient died (2.2%) of sepsis soon after the substernal bypass operation. The cause of sepsis was related to the leakage at the proximal anastomosis site. An advanced cicatrical carcinoma was detected during the investigation of the cause of sepsis. As the patient's condition deteriorated so rapidly, we could not attempt esophagectomy and the patient could not recover from the sepsis.

A total of 30 complications developed in 23 patients (Table 1). Five leaks at the proximal anastomosis site (10.9%) occurred within the first week following reconstruction. Two of which occurred in the group where the diseased esophagus was not resected and substernal bypass was performed using colon. The other three happened after transhiatal esophagectomy and subsequent reconstruction using colon. The anastomoses of the esophagus in these five patients were made at the cervical area.

There were 10 unilateral recurrent laryngeal nerve palsies, nine of which developed after esophageal resection whereas only one vocal cord palsy developed in the group where the esophagectomy was not performed. However, it is not clear whether this complication is related to the esophagectomy per se. It might be related with the injury during the cervical manipulation because all of them happened in patients in whom the cervical anastomoses were performed. Five patients recovered spontaneously within several months.

Eight patients developed wound infections. Pneumothorax developed in two patients one in esophagectomy group and the other in bypass group. Postoperative ileus developed in three patients. One patient developed hemorrhage at the cervical wound after repair of the leakage site. In one patient, the posterior wall of trachea was lacerated during the attempt of thranshiatal esophagectomy. To repair the trachea and to resect the remaining esophagus, we performed thoracotomy after finishing substernal bypass reconstruction. The injured trachea was repaired successfully. However, as the diseased esophagus was so severely adhered to the surrounding mediastinal structures that the esophagectomy was not feasible. In two additional patients, we were not able to resect the diseased esophagus even under the thoracotomy because of dense adhesion. None of the patients showed graft necrosis.

3.2. Late results
Excluding a patient who died during early postoperative period, the remaining 45 patients were followed from 1 month to 9.7 years. There were two late deaths. One patient died at 8 months after the transhiatal procedure. This late death was caused by acute peritonitis probably due to infection via the jejunostomy site. This patient had not visited the hospital for regular follow-ups, and only came after the acute peritonitis had developed. The remaining one long-term mortality happened in a patient who had been underwent substernal bypass procedure. This patient returned hospital at 9 months after operation with emaciated state and pneumonia. There was high suspicion of broncho-neoesophageal fistula. Unfortunately, the patient developed respiratory failure and eventually died.

Postoperative anastomosis site stenosis developed in nine patients; four after transhiatal procedure, two after transthoracic esophagectomy, and three after substernal bypass. One patient required free jejunal graft interposition for the stenosis. Instrumental dilatation was required in eight patients (Table 2). One pediatric patient required feeding jejunostomy for poor oral intake despite of repeated dilatation. Nine patients complained postoperative gastric regurgitation, five after the transhiatal procedure, two after the transthoracic method and two after the substernal bypass. One patient developed bronchoesophageal fistula at 9 months after substernal bypass. One patient developed acute peritonitis and the patient died as described above. One patient developed laryngeal stenosis.

View larger version (16K): [in this window] [in a new window]   Fig. 1. Seven patients who developed cancer from the corrosive esophagitis.

View larger version (104K): [in this window] [in a new window]   Fig. 2. Pathology specimen from a patient underwent Ivor Lewis esophagogastrectomy. Note gross tumor and characteristic squamous cell carcinoma in microscopic finding. (H&E x400).

View larger version (93K): [in this window] [in a new window]   Fig. 3. Resected esophagus from a patient underwent transhiatal esophagectomy. Microscopic finding revealed carcinoma in situ. (H&E x40).

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

Interestingly, all these patients who developed carcinoma had ingested lye. None of patients who had swallowed acid developed cancer. The interval between the time of injury and the time when the cancer was found ranged from 29 to 46 years. This finding suggests that the cause of corrosive injury as well as the time interval might be an important factor for cancer development. It has been suggested that the esophageal cancer developing from the stricture site is related to the chronic irritation. With this concept it had been suggested when the stricture is complete, the esophagus need not to be resected [7]. In our patients, there were only three patients who had undergone repeated dilation before the operation either with balloon or bougie. Two patients had a single history of dilation, one in recent history and the other at 15 years ago. Two patients had not undergone dilation preoperatively. None of these seven patients had complete obstruction, which suggest the diseased esophagus might be chronically exposed to the irritation.

It is generally accepted that the prognosis of cicatrical carcinoma is much better than that of usual esophageal carcinoma because the dense scar tissue tends to prevent early invasion of malignant cells to the adjacent mediastinal structures [8]. In such cases, symptoms of luminal obstruction are more apt to occur before the extrinsic spread of the neoplasm. This newly aggravated dysphagia can bring the patient to the hospital before the cancer advances. Obviously, cure depends on early diagnosis. However, it is often difficult to establish a diagnosis of carcinoma in these patients because symptoms due to carcinoma may be erroneously attributed to the original disease, and also because the malignant process begins in a location that is often inaccessible to standard esophagoscopic examination and biopsy. It has been our routine practice to perform endoscopic examination of the esophagus for the patients with chronic corrosive esophageal stricture when they are scheduled for operation. We made a diagnosis of cancer preoperatively in three patients. However, we missed four cancers even after the careful endoscopic examination. Two of them had advanced carcinoma, which might have been detected if we had performed chest CT scan preoperatively. This experience forced us to add chest CT scan as a routine preoperative study. Even with these efforts of seeking for hidden malignancy, there is still high chance of missing cancer if it is small enough or is located at the distal portion of the stenosis where the endoscopy in inaccessible. Our two cases of in situ carcinoma would have not been diagnosed if we had not performed esophagectomy. We experienced three operation-related mortalities, which were not related to the esophageal resection itself. There was no significant difference in early morbidity, regardless of whether we had performed esophageal resection or not. Based on our experience, we strongly recommend resecting diseased esophagus whenever it is feasible.

It is our current approach for corrosive esophageal stricture to perform extensive preoperative examination to find hidden malignancies. If the malignancy is detected preoperatively, we perform esophagectomy through the lateral thoracotomy and then perform an appropriate reconstruction. If there is no evidence of malignancy, still we recommend resecting the diseased esophagus to avoid any chance of hidden malignancy and to prevent future development of cancer.

It is still uncertain which approach of esophagectomy would be better for this particular group of patients. We experienced one patient, in whom the diseased esophagus was so severely adhered to the surrounding mediastinum that the attempt of transhiatal resection made a tracheal tear. In this patient, we performed lateral thoracotomy to repair the tracheal injury and to resect the remaining esophagus. However, even with thoracotomy, severe adhesion around the esophagus prevented complete esophagectomy. Similarly, we have two additional cases where we failed esophagectomy through the thoracotomy because of severe adhesion. Although we could achieve successful esophagectomy with transhiatal method in 22 out of 23 patients, there must be some cases where the safe esophagectomy would not be possible through this method. It has been accepted that the transhiatal method has its advantages to the transthoracic approach such as less pain, simlple operative procedure, and less respiratory complications by avoiding thoracotomy [5]. We, thus, had preferred transhiatal approach to avoid unnecessary thoracotomy. However, given our experiences of several cases where the blunt esophagectomy would have been risky, we cannot conclude which method is better.

In our series there was no difference of morbidity between transhiatal method and transthoracic esophagectomy, except for the more frequent development of vocal cord palsy after transhiatal esophagectomy. However, we are not sure whether it is caused by the transhiatal esphagectomy per se or is related to the cervical anastomosis. All 10 either transient or permanent vocal cord paralysis developed after cervical anastomosis. We think that more cautious manipulation of the esophagus during the cervical dissection could have reduced this complication.

During the follow-up period, regurgitation of gastric contents was another major complaint of patients. The vagotomy performed concomitantly with the esophagectomy may have contributed to this complication, which might have been solved by vagal nerve-sparing esophagectomy [9].

Considering that there was no significant increase of morbidity, regardless of performing esophagectomy, we suggest that the synchronous resection of the esophagus with the esophageal reconstruction for patients with chronic intractable caustic esophageal stricture is mandatory. This is due to high incidence of scar carcinoma from the stricture sites ranging from in situ carcinoma to advanced neoplasm. Though we could not show clearly, we can speculate that the concomitant esophagectomy may give the patient an excellent chance of completely escaping from esophageal carcinoma, despite the usually dismal prognosis of this disease. We also suggest that the risk of cancer development would be high if the patients are suffering from lye corrosive esophagitis more than 25–30 years.

Based on our studies, we arrived at the conclusion that the resection of the esophagus is indicated in a patient with chronic caustic stricture; (1) if the stricture is tight enough to require reconstructive surgery, (2) or if there is any finding suggestive of malignancies such as long duration of the lesions of more than 30 years, or mass-like lesions, (3) or sudden aggravation of preexisting dysphagia.

	Acknowledgments

 
This research was supported in part by Seoul National University Hospital grant (96-0590).

	Footnotes

 
Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 

1. Kiviranta U.K. Corrosion carcinoma of the esophagus, 381 cases of corrosion and nine cases of corrosion carcinoma. Acta Otolaryngol 1952(42):89-95.
2. Hopkins R.A., Postlethwait R.W. Caustic burns and carcinoma of the esophagus. Ann Surg 1981(194):146-148.
3. Csikos M., Horvath O., Petri A., Petri I., Imare J. Late malignant transformation of chronic corrosive oesophageal stricture. Langenbecks Arch Chir 1985(365):231-238.
4. Ti T.K. Oesophageal carcinoma associated with corrosive injury-prevention and treatment by oesophageal resection. Br J Surg 1983(70):223-225.
5. Gerzic Z.B., Knezevic J.D., Milicevic M.N., Matic V.D. Pharyngoesophageal post-corrosive stricture treated by one stage substernal by-pass coloplasty. Dis Esophagus 1994(7):47-52.
6. Jung H.Y., Kim H.J., Kim S.B., Lee H.K., Kim J.H., Kim D.K., Yang S.K., Park S.I., Kim H.R., Song H.Y., Hong S.W., Chang H., Kim S.H., Min Y.I. Esophageal cancer in an esophagus remaining after colonic interposition for lye stricture. Endoscopy 1999(31):S1.
7. Ogura J.H., Roper C.L., Burford T.H. Complete functional restitution of the food passage in extensive stenosing burns of the esophagus. J Thorac Cardiovasc Surg 1961(42):340-345.
8. Appelquist P., Salmo P. Lye corrosion carcinoma of the esophagus: a review of 63 cases. Cancer 1980(45):2655-2658.
9. Akiyama H., Tsurumaru M., Ono Y., Udagawa H., Kajiyama Y. Esophagectomy without thoracotomy with vagal preservation. J Am Coll Surg 1994(178):83-85.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Young Tae Kim Joo Hyun Kim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kim, Y. T. Articles by Kim, J. H. Search for Related Content PubMed PubMed Citation Articles by Kim, Y. T. Articles by Kim, J. H. Related Collections Esophagus - other