Esophagectomy and staged reconstruction

Objective: Esophageal resection with diversion and staged reconstruction of the upper gastrointestinal (GI) tract is an option in the management of complex problems. This study characterizes circumstances, indications, outcomes and their predictors for staged reconstruction, and estimates the optimal timing for reconstruction. Methods: Between October 1981 and March 1999, 43 patients were identified with planned staged reconstruction. Twenty-six had esophageal cancer, and 17 had complications of benign disease. Primary diversion with esophageal resection was needed in 16 patients, and secondary diversion with takedown of previous esophageal reconstruction was needed in 27. Common indications were failed esophageal anastomosis and esophageal perforation. Death before and death after reconstruction were considered as competing risks. Multivariable analyses were used to estimate the optimal timing of reconstruction. Results: The survival was 75, 21 and 9% at 3 months, 5 and 10 years, with survival only somewhat better (P=0.06) among patients having benign versus malignant disease. A similar proportion of patients died before reconstruction as underwent reconstruction, resulting in only 17 reconstructions, typically 9 months after diversion. The risk factors for death included cancer and primary diversion. The survival was best for benign disease when reconstruction was early. The survival was poor after reconstruction in the few patients with malignant disease. Conclusions: Patients requiring staged esophageal reconstruction are heterogeneous, with malignant or benign disease, and primary or secondary diversion. The outcome is poor, and is influenced by the pathology and timing of diversion. Patients with benign disease should be reconstructed as early as feasible; reconstruction is rarely indicated for patients with cancer.