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The main indications for esophageal reconstruction after esophagectomy includes tumor excision, corrosive injury, radiation damage, and congenital disease. This activity describes esophageal reconstruction and explains the role of the interprofessional team in evaluating, treating, and improving care for patients who undergo esophageal reconstruction. Objectives: Identify the indications for esophageal reconstruction. Describe the technique of esophageal reconstruction. Review the clinical significance of esophageal reconstruction. Collaborate with the interprofessional team to improve patient care. Access free multiple choice questions on this topic.

The esophagus is a muscular tube that actively transports food boluses from the hypopharynx to the stomach. This complex organ is essential for enteral feeding. When issues arise within the esophagus, whether benign or malignant, alternative methods for obtaining nutrition must be evaluated, such as gastrostomy tubes or jejunostomy tubes, however, if the esophagus is removed, then esophageal reconstruction must be considered.

Esophagectomy with esophageal reconstruction is a large, complex operation. Complications after esophageal reconstruction are common. In a large systematic review with over 17,000 patients after esophagectomy, the overall morbidity was 50.8%, and mortality was 8.7%.[36] The most common complications were pulmonary at 29.9%, followed by gastrointestinal (14.9%), cardiovascular (10.4%), procedure-specific (7.8%), and infection (7.0%). The overall mortality was 8.7%. There was a significant decrease in overall mortality when comparing high volume to low volume centers (5.8% vs. 10.6% (p<0.001)). Procedure specific complications include anastomotic leak, conduit ischemia, or anastomotic stricture. The incidence of anastomotic leak after esophagectomy varies but is reported around 10%.[37] Cervical anastomosis has a higher percentage of leakage compared to mediastinal anastomoses.[38] In the large STS trial, the leak rate was higher in patients with cervical anastomosis compared with those with intrathoracic anastomosis, 12.3% versus 9.3%, respectively (p = 0.006). This is likely due to the length of the esophageal conduit required for the anastomosis tends to lead to higher rates of ischemia. Once an anastomotic leak is identified, it is critical to make sure the fluid collection is properly drained. If the leak is well-drained, the patient can be observed on broad-spectrum antibiotics, nil per os (NPO), and enteral feeding through a jejunostomy tube. If the patient is properly drained, most leaks will resolve over the course of weeks to months. If the leak does not spontaneously resolve, the standard of care is to place an endoscopic stent.[39] Patients with large undrained leaks or patients who become septic will likely need reoperation with thoracotomy for repair and drainage of the esophageal leak. If the esophageal conduit has large dehiscence, then the patient will need esophageal resection and diversion with a cervical esophagostomy and jejunostomy.

Procedure specific complications include anastomotic leak, conduit ischemia, or anastomotic stricture. The incidence of anastomotic leak after esophagectomy varies but is reported around 10%.[37] Cervical anastomosis has a higher percentage of leakage compared to mediastinal anastomoses.[38] In the large STS trial, the leak rate was higher in patients with cervical anastomosis compared with those with intrathoracic anastomosis, 12.3% versus 9.3%, respectively (p = 0.006). This is likely due to the length of the esophageal conduit required for the anastomosis tends to lead to higher rates of ischemia. Once an anastomotic leak is identified, it is critical to make sure the fluid collection is properly drained. If the leak is well-drained, the patient can be observed on broad-spectrum antibiotics, nil per os (NPO), and enteral feeding through a jejunostomy tube. If the patient is properly drained, most leaks will resolve over the course of weeks to months. If the leak does not spontaneously resolve, the standard of care is to place an endoscopic stent.[39] Patients with large undrained leaks or patients who become septic will likely need reoperation with thoracotomy for repair and drainage of the esophageal leak. If the esophageal conduit has large dehiscence, then the patient will need esophageal resection and diversion with a cervical esophagostomy and jejunostomy. Conduit ischemia after esophagectomy is reported to be around 10%. Ischemia can be avoided by limiting hypotension and tension on the anastomosis. Ischemia can lead to anastomotic leakage and stricture. Anastomotic strictures occur in roughly 20-25% of patients. These strictures can be safely managed with serial dilation. Most strictures present within the first several months.[40] Late strictures could be concerning for cancer recurrence, and biopsies should be taken. When using colonic interpositions for esophageal reconstruction, the most common late complication is colonic redundancy. This leads to mechanical dysfunction of the neo-conduit, causing disabling symptoms that may develop decades after the original surgery. When symptoms caused by food retention in the colonic loop occur, surgical correction may be necessary.[41]

Esophageal reconstruction requires a multidisciplinary approach to treatment. Patients will likely be evaluated by several types of doctors, including hospitalists, cardiologists, oncologists, radiation oncologists, thoracic surgeons, general surgeons, and plastic surgeons. Besides physicians, these patients may need to meet with physical therapists, occupational therapists, dietitians, and even psychologists. They will also be cared for by numerous nurses, care managers, and ancillary staff. Every member of the team is required to care for these patients after esophageal reconstruction.