Objective: In patients with esophageal cancer who need enteral access, preoperative gastrostomy (G-tube) is usually avoided in favor of jejunostomy to preserve the gastric conduit. However, G-tubes are easier for providers to place and for patients to manage. Moreover, patients may present with a gastrostomy placed for a reason not associated with their cancer. We sought to characterize this population of patients, determine if preoperative G-tube precludes the use of the gastric conduit, and to determine if preoperative G-tube in patients who receive a gastric conduit is associated with poor operative outcomes.
Methods: Patients who presented for esophagectomy for malignancy who had previously undergone a gastrostomy from 2009-2023 were identified from our institutional database. Clinicopathologic and demographic data were recorded. Descriptive data was calculated as a percentage of the group.
Results: A total of 29 patients had a G-tube prior to their esophagectomy. Of these, 5 were aborted due to unresectable disease, and 2 were aborted due to metastases at their G-tube site. 17/22 patients who underwent a completed esophagectomy were for curative intent. 7 of these patients underwent salvage esophagectomy. The median clinical stage at diagnosis was 3 (range I-IVB). These patients underwent esophagectomy with an Ivor Lewis (63%, 14/22), Mckeown (27%, 6/22), or transhiatal approach (9%, 2/22). The median time to surgery from gastrostomy placement was 141 days (IQR: 93-185). All but 2 patients had their gastrostomy in place at the time of surgery.
20 of these 22 patients received a gastric conduit. One patient had colon interposition due to tumor extension on the lesser curve, and one patient underwent an R2 resection with cervical esophagostomy. The rate of anastomotic leak in those with gastric conduit was 10% (2/20), with one of these patients dying in the hospital. The rate of stricture was 5% (1/20). The rate of grade 3 or higher complications in these patients was 35% (7/20).
Conclusions: The presence of a gastrostomy tube in this cohort is associated with advanced disease, with a high percentage of patients who underwent salvage esophagectomy, and a high percentage with unresectable disease. Additionally, though the NCCN guidelines recommend jejunostomy in patients who require enteral access prior to esophagectomy, the rate of leak and stricture in patients with a G-tube who received a gastric conduit does not exceed historical average. The high complication rate in this cohort is most likely reflective of the advanced disease state of these patients rather than the gastrostomy tube itself. Therefore, a gastrostomy tube can be used prior to esophagectomy in patients needing preoperative nutrition.
