PERIOPERATIVE OUTCOMES AND QUALITY OF LIFE AFTER LEFT THORACOABDOMINAL ESOPHAGOGASTRECTOMY: CONTRASTING ESOPHAGOGASTROSTOMY WITH ESOPHAGOJEJUNOSTOMY
James Tankel*, Devangi Patel, Yehonatan Nevo, Sara Najmeh, Jonathan Spicer, Carmen L. Mueller, Lorenzo E. Ferri, Jonathan Cools-Lartigue
Thoracic Surgery, McGill University Health Centre, Montreal, QC, Canada
Introduction: The left thoracoabdominal (LTA) incision offers excellent exposure for bulky Siewert II/III tumors of the esophagogastric junction. We explore how either esophagogastrostomy or esophagojejunostomy performed during LTA esophagogastrectomy effect postoperative outcomes and quality of life (QoL).
Methods: From 01/07-01/22 all patients undergoing LTA were identified from a single center's prospectively maintained database. Following esophagogastrectomy or extended total gastrectomy an esophagogastrostomy (GAS) or Roux-En-Y esophagojejunostomy (R-Y) was fashioned. Patients were stratified according to the method of reconstruction and postoperative outcomes compared including complications and clinical/endoscopic reflux. If available, the Functional Assessment of Cancer Therapy – Esophagus (FACT-E) questionnaire was used to compare QoL at various timepoints through the patient journey.
Results: LTA was performed in 147 patients of whom 135 (92%) were included. There were 97 GAS (72%) and 38 R-Y patients (28%). Most were male (110/135,81%) aged 66 years (range 27-90). The most common pathology was adenocarcinoma (115/135, 85%), with an equal incidence of ypT3/4 lesions between GAS and R-Y patients (64/97 vs 30/38 NS) whilst ypN+ was higher in the latter (31/38 vs 57/97 p=0.012). Clavien Dindo grade 3-4 complications and reoperation were similar between the groups (26/97, 27% vs 9/38, 24% and 8/97, 8% vs 3/38, 8% NS). Anastomotic leak and 30-day readmission were significantly higher among GAS patients (14/97, 14% vs 1/38, 3% p=0.040 and 16/97, 16% vs 1/38, 3% p = 0.029). Following LTA, 90/147 patients had QoL data available including 68/97 (70%) GAS and 22/38 (58%) R-Y patients. FACT-E scores were available for 80/21/24/18/23/24 patients at diagnosis, preoperatively and postoperatively at 1, 3-6 months, 1-3 and 3+ years respectively. At each time interval, there was no difference in the scores when comparing GAS with R-Y (79/91/72/84/89/114 vs 79/107/71/73/80/100 NS). As a whole, FACT-E improved between baseline and preoperatively (79, 34-124 vs 102, 81-123, p = 0.027) with baseline scores only being exceeded at 3+ years after surgery (79, 34-124 vs 102, 62-124 p=0.001). Similarly, preoperative FACT-E scores significantly higher than scores for the first 3 years. Only at 3+ years were the FACT-E scores equivalent to preoperative values (102, 62-124, p = NS). Clinical reflux and endoscopic esophagitis was significantly higher >6 months postoperatively among GAS compared with R-Y patients (15/28, 54% versus 0/5, 0.0% , p = <0.001 and 15/27 47.8% versus 0/7, 0.0%, p = 0.008).
Conclusion: The type of reconstruction did not affect QoL however it did affect the postoperative course. It took 3+ years for QoL scores to equal or exceed preoperative values. Clinicians and patients should be aware of these outcomes when planning operative intervention.
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