At the University of Southern California we have now performed >75 vagal-sparing esophagec-tomies. In 24 patients the indication was endstage reflux or Barrett's without cancer. Among these 24 patients, 14 had previous abdominal surgery including 5 with prior fundoplication and 1 with prior vertical-banded gastroplasty for obesity. Nearly half of the patients had an esophageal stricture that had been repeatedly dilated, and 1 patient with Barrett's had undergone photodynamic therapy. Reconstruction was with a colon graft in 22 patients (Figure 15.1) and a gastric pull-up in 2 (Figure 15.2). One colon graft was removed for ischemia. However, because the entire stomach is preserved with this procedure, the patient was later reconstructed with a gastric pull-up without difficulty. One patient with extensive prior abdominal procedures and diabetes had limited dumping symptoms, and one patient had diarrhea that resolved spontaneously. Two patients had delayed gastric emptying symptoms. One
VAGAL SPARING ESOPHAGECTOMY
had had two prior fundoplications but the other had not undergone any prior esophageal surgery. Both had a vagal-sparing esophagectomy with colon interposition, and both ultimately required revision consisting of a proximal gastrectomy with colo-antral anastomosis and pyloroplasty.
Three patients developed an ulcer in the distal colon just proximal to the colo-gastric anastomosis related to acid production by the intact and innervated stomach. For this reason we now include a highly selective vagotomy along the lesser curve of the stomach in these patients. There have been several patients that were taken for a vagal-sparing esophagectomy but during the operation dense scarring around the hiatus precluded vagal preservation and a transhiatal resection was performed. One such patient had had a congenital tracheoesophageal fistula repaired and then subsequently underwent a Nissen for severe reflux as a child, and subsequently presented to the University of Southern California with end-stage reflux. Interestingly, two other patients that had a congenital tracheoesophageal fistula repaired with subsequent end-stage reflux were successfully resected using a vagal-sparing technique, so this procedure is an option in some of these patients.
We have previously evaluated gastric function and confirmed vagal integrity in a series of 15 randomly selected patients at a median of 20 months after vagal-sparing esophagectomy and colon interposition.5 The indication for the procedure was benign disease in seven and Barrett's with high-grade dysplasia or intramucosal cancer in eight patients. Outcome was assessed on the basis of symptoms, Congo red gastric staining, basal and sham meal-stimulated gastric acid output, basal and sham meal-stimulated pancreatic polypeptide response, standardized meal consumption, and nuclear medicine gastric emptying half-time. These results were compared with the symptomatic and functional outcome in 10 patients after standard esophagectomy with colon interposition, 10 patients after standard esophagectomy with gastric pull-up, and 23 control subjects. We found that postoperative dumping and diarrhea were significantly decreased in the vagal-sparing group compared with the standard esophagectomy with colon interposition. Furthermore, secretory studies confirmed intact vagal innervation after the vagal-sparing esophagectomy, and in contrast to the other
types of esophagectomy gastric emptying studies and meal consumption were similar in normal subjects and patients after vagal-sparing esophagectomy. We concluded that vagal preservation was beneficial and warranted when possible in patients with benign disease or early esophageal cancer.
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