Background: Gastric tube decompression is an important aspect of patient management following esophagectomy, reducing gastric ischemic distension and pulmonary complications. The standard nasogastric approach is associated with reduced patient comfort, mobility, and impaired hypopharyngeal function predisposing the patient to sinusitis, pharyngitis and the risk of aspiration. In this study we evaluate the results of transcervical gastric tube drainage in the setting of esophagectomy.
Methods: Cervical esophagostomy was performed on 137 consecutive patients undergoing transhiatal-THE (n=122) and Ivor Lewis (n=15) esophagectomy between 2003 and 2006. Standard 16F Salem sump gastric tubes were inserted through the sternocleidomastoid muscle anterior to the carotid sheath, advanced through an esophageal purse string suture 2 centimeters distal to the cricopharyngeus, and directed into the gastric conduit prior to anterior closure of a stapled anastomosis. For Ivor Lewis esophagectomy, transoral insinuation of a large right angled forceps allows for percutaneous pharyngostomy access slightly lateral to and superior to the greater cornu of the thyroid cartilage. The drain is then directed through the intrathoracic EEA anastomosis and into the mid-stomach. Post-operative outcome variables analyzed include local cervical morbidity and overall patient hospital outcomes.
Results: The male:female ratio was 95:42; mean age was 62. There were two postoperative deaths (1.5%). Major complications included 4 anastomotic leaks (2.9%), 3 pneumonias (2.2%) one myocardial infarction (0.7%) and one pulmonary embolism (0.7%). No gastric tip necrosis was encountered. Anastomotic stricture requiring dilation occurred in 21 patients (16.5%). Median cervical gastric decompression was 5 days. Median time to resumption of oral intake was 6 days. Median length of stay was 8 days. There was one purse string site abscess managed successfully with drainage via the cervical incision. Three patients were treated for cellulitis near the tube site. Patient compliance to mobilization and pulmonary physiotherapy was excellent beginning the first postoperative day. There were no nasopharyngeal complications, and complaints related to the salem sump occurred only in the 4 patients mentioned above (2.8%).
Conclusions: Transcervical gastric tube decompression is easy to perform, permits accelerated patient mobilization, greater patient comfort, and is associated with a low rate of gastric ischemic, nasopharyngeal, pulmonary and local cervical complications. Transcervical drainage should be considered as an alternative to nasogastric decompression following esophagectomy.