Quality of palliation and possible benefit of extra-anatomic reconstruction in recurrent dysphagia after resection of carcinoma of the esophagus

BACKGROUND: After "curative" resection of carcinoma of the esophagus, late secondary dysphagia almost invariably indicates locoregional tumor recurrence. The retrosternal reconstruction route is advocated to prevent ingrowth of tumor recurrence in the neoesophagus. STUDY DESIGN: To evaluate the quality of palliation after "curative" resection of carcinoma of the esophagus and the possible benefit of the retrosternal reconstruction route, we retrospectively analyzed the records of patients who had resection of a malignant tumor of the esophagus, or the gastroesophageal junction, and a prevertebral reconstruction. The extra-anatomic route would have been only beneficial for patients with intrathoracic tumor recurrence distant from the anastomosis and causing gastrointestinal symptoms. RESULTS: Between 1983 and 1989, 209 patients (mean age of 61.3 years at the time of operation) had "curative" resection and prevertebral reconstruction in the institution of this study. Seventy-three patients (35 percent) had locoregional tumor recurrence. Univariate and multivariate analysis of various risk factors for locoregional recurrence showed that the presence of positive lymph nodes (pN1), especially if located at the celiac trunk (pM1), and a macroscopically non-radical R2 resection were the most important risk factors. Forty-six patients (22 percent) had secondary dysphagia as a result of locoregional tumor recurrence, mostly (18 percent) within two years postoperatively. Dysphagia lasted on average 5.3 months (range of 0.3 to 21.5 months) before the patients died. In 27 patients (13 percent), dysphagia would probably have been prevented by using a retrosternal reconstruction route. CONCLUSIONS: These data are an argument in favor of the extra-anatomic, retrosternal reconstruction route after limited transthoracic or transhiatal resection in the presence of positive lymph nodes. This method seems especially indicated if the nodes are located at the celiac trunk and in case of a macroscopically nonradical R2 resection.