Minimally invasive oesophagectomy for corrosive oesophageal strictures – A single-centre experience from central India

Abstract

Introduction:

Corrosive ingestion is a common cause for benign oesophageal stricture in the developing countries. There is limited literature available on the minimally invasive surgical approach for the management of this condition. This study analyses our experience of managing corrosive oesophageal strictures by combined thoraco-laparoscopic approach.

Patients and Methods:

A retrospective analysis of 24 patients (22 - gastric conduit and 2 - colonic conduit) who underwent minimally invasive oesophagectomy for corrosive oesophageal strictures from January 2019 to December 2023 was done.

Results:

The median age of the patients in the study group was 30.5 years (range 18–60 years). Eighteen patients had a history of accidental corrosive ingestion, and 6 patients with suicidal intent. Post-operative complications included chest infections in 6, recurrent laryngeal nerve paresis in 2, anastomotic leak in 2 and anastomotic stricture in 4 patients. There was one mortality.

Conclusion:

Minimal invasive oesophagectomy for corrosive stricture is technically challenging and needs expertise. It not only permits the native and physiological route for conduit placement but also avoids complications related to retained diseased oesophagus.

INTRODUCTION

Corrosive ingestion is one of the leading causes of oesophageal strictures in the developing countries and has emerged as a public health concern. The consumption may be accidental or suicidal, but it results in long-lasting, devastating consequences.[1] Acute complications range from perforation to death, while long-term sequels include oesophageal stricture, oesophageal and gastric cancer. Endoscopic stricture dilation (mechanical/balloon) and medical methods such as intralesional steroid injection are the primary line of management.[2] However, surgical management is warranted upon failure of endoscopic methods. Historically, the surgical management of this condition has undergone an evolution, from open surgery with oesophageal bypass to laparoscopic-assisted to a total laparoscopic oesophagectomy. There is limited literature regarding the minimally invasive approach, and hence, this study was conducted to analyse our experience in the surgical management of corrosive oesophageal stricture by the combined thoraco-laparoscopic approach.

PATIENTS AND METHODS

The study was conducted in the Department of Surgery, Government Medical College, Nagpur. A retrospective review of case records of 24 patients with corrosive stricture oesophagus, managed over a 5-year period from January 2019 to December 2023, was done. Of these patients who underwent minimally invasive oesophagectomy, 22 patients had a gastric conduit and two patients had colonic conduit. All the patients in the study underwent thoraco-laparoscopic oesophagectomy with cervical anastomosis.

Surgical technique

The procedure started with the right thoracoscopic approach first. The patient was placed in the prone position with a double-lumen endotracheal tube in situ providing single lung ventilation. Three ports were used with a 10-mm camera port at 2 cm below the inferior margin of the scapula in the 6^th intercostal space and two working ports of 5 mm at the 4^th and 9^th intercostal space, respectively, along the mid axillary line [Figure 1]. The oesophagus was circumferentially dissected after making an incision at the level of the inferior pulmonary ligament. The boundaries of dissection were the thoracic inlet superiorly [Figure 2] and the crus of the diaphragm inferiorly [Figure 3]. Dorsal dissection exposes the aorta and its branches which were preserved along with the thoracic duct and the vagus nerve which lie in the fat dorsally. Inferiorly, the dissection was done to the level of the hiatus, with visualisation of the right and left crus of the diaphragm. Superiorly, the azygos vein was encountered and preserved. Thus, the dissection was carried out in two parts – the supra-azygos and infra-azygos. Care was taken to identify bilateral pleura, and in case of injury, intercostal drainage tube was inserted on the left side as well. At the end of the thoracoscopic approach, the oesophagus was mobilised circumferentially.

Figure 1.

Port position during thoracoscopy

Figure 2.

Superior boundary of thoracoscopic dissection up to the thoracic inlet

Figure 3.

Inferior boundary of the thoracoscopic dissection up to visualisation of both crus of the diaphragm

After mobilisation of the oesophagus, the patient was placed in the supine position for the laparoscopic part of the procedure. Simultaneously, a second team of surgeons began the dissection at the cervical region for the anastomosis. The port placement for the laparoscopic approach consisted of a supraumbilical 10-mm camera port, with two 5-mm working ports at bilateral midclavicular line and a 5-mm working port at the epigastrium for liver retraction. Later, the right-sided working port was converted to a 12-mm port to enable use of the endostapler [Figure 4]. The stomach was mobilised by dissecting along the greater omentum. Pre-operative endoscopy and contrast study provided details about the condition of the stomach. In cases where a gastric conduit was not feasible, a colonic conduit was done. The stomach was mobilised, sacrificing the left gastric artery and preserving the right gastroepiploic arcade. The endostapler was used to create a conduit along its entire length, ending at the hiatus, which was then pushed cranially to the thoracic cavity, to be pulled up from the cervical incision [Figure 5]. A feeding jejunostomy was done. The specimen was excised, and the gastric conduit was anastomosed at the neck to form a hand-sewn end to side oesophagogastric anastomosis.

Figure 4.

Port position during laparoscopy

Figure 5.

Stomach tube pushed into the thoracic cavity and pulled through the cervical incision

RESULTS

The clinicodemographic information of the patients is shown in Table 1. The study group comprised of 16 males and 8 females. The median age of the patients was 30.5 years (range 18–60 years). Eighteen patients (75%) had accidental ingestion of corrosives. The post-operative morbidity is summarised in Table 2. The most common post-operative complication was chest infection, occurring in six patients (25%), which was managed conservatively with antibiotics and chest physiotherapy. Two patients with high stricture had high cervical anastomosis with recurrent aspiration in the post-operative period requiring a tracheostomy for tracheal toileting. Three patients had persistent regurgitation in the post-operative period which was managed conservatively. Two patients had recurrent laryngeal nerve paresis in the early post-operative period which recovered within 6 weeks. Two patients had anastomotic leak which was managed conservatively. Four patients developed post-operative anastomotic stricture, all belonging to the gastric conduit group and managed by stricture dilatation. None of the patients had conduit necrosis. One patient died on post-operative day 3 due to pulmonary embolism. The median follow-up of the patients in this study was 24 months.

Table 1.

Clinicodemographic profile of the patients

Variables	Value, n (%)
Age (years)	Mean age - 32 years
18–30	12 (50)
31–40	5 (20.83)
41–50	6 (25)
51–60	1 (4.16)
Gender
Male	16 (66.6)
Female	8 (33.3)
Male:female	2:1
Intent
Accidental	18 (75)
Suicidal	6 (25)
Conduit used
Gastric	22 (91.6)
Colonic	2 (8.3)

Table 2.

Post-operative morbidity and mortality

Morbidity	Number of patients
Early post-operative
Chest infection	6 (25)
Vocal cord paresis	2 (8.3)
Anastomotic leak	2 (8.3)
Post-operative tracheostomy	2 (8.3)
Late post-operative
Regurgitation	3 (12.5)
Anastomotic stricture	4 (16.6)
Mortality	1 (4.16)

DISCUSSION

The consequences of the corrosive ingested depend on the quantity consumed, chemical concentration, state (liquid/solid), duration of exposure and the immediate management.[3] Over a period of time, majority of these patients develop stricture and present with difficulty in swallowing, increased salivation and weight loss.[4] Primary evaluation includes an upper gastrointestinal endoscopy which determines the type of stricture, nature and extent. Endoscopic stricture dilatation can be attempted in the same setting and is usually the primary line of management. Furthermore, barium swallow or contract-enhanced computed tomography (CECT) with oral contrast may be useful in differentiating simple and complex strictures and in formulating a detailed surgical plan.[5]

The available literature regarding the surgical management of corrosive strictures is limited to isolated case reports and only a few case series. A retrospective observational study of 25 patients of corrosive stricture of the upper gastrointestinal tract conducted by Vaidya et al., outlined the potential options of the conventional surgical management in these patients.[6] The traditional surgical treatment of choice for the corrosive oesophageal stricture is the colonic pull-through, leaving behind the native diseased oesophagus in place, to avoid the risk of the tracheobronchial injury during resection.[7] Large series of surgical colonic bypass with a 30-year follow-up has shown the good long-term relief of dysphagia and a negligible risk of oesophageal mucocele formation in the native oesophagus.[8] However, there are case reports of malignancy developing in the scarred native oesophagus after a variable time period following exposure.[9,10] In a study by Kim et al., the incidence of cicatricial carcinoma was reported to be 13%.[11] Such high incidence of malignancy which cannot be overlooked has forced several surgeons to safely perform resection of the oesophagus simultaneously with the reconstructive surgery.[12,13,14] Thus, in our department, whenever a gastric conduit is possible, a total oesophagectomy is preferable, thereby excluding the possibility of both the mucocele formation and malignant transformation of the native oesophagus. With technological advancement, these complex procedures are feasible even by minimally invasive surgery with different modifications. A case report by Tharavej et al., in 2010, is one of the first studies that establishes the thoracoscopic approach for oesophageal surgery in corrosive stricture.[15] They described two cases in which thoracoscopic mobilisation of oesophagus was done using four ports, following which a laparotomy was done for a left colonic interposition. This technique was found to be feasible and safe with reduced morbidity.[14] Another case report by Obitsu et al. from Japan,[16] describes the thoracoscopic approach in a semi-prone position. This report discusses the advantages of semi-prone position such as ease in converting to thoracotomy in case of unexpected bleed. Our procedure began in prone position as it provided better oxygenation, and the lungs, blood and fluid fall by gravity thereby improving the exposure of the posterior mediastinum. The same case report also suggests that bilateral lung ventilation may be more beneficial, with shorter anaesthesia and fewer intraoperative complications.[15]

Nayar et al.[17] chose to divide the azygos vein to aid mobilisation during the thoracoscopic oesophagectomy, while our protocol was to preserve the vein meticulously. Theoretically, leaving the azygos arch intact helps maintain the gastric conduit in the posterior mediastinum. The preservation of the azygos arch during thoracoscopic oesophagectomy, maintains the natural venous system, thus facilitating postoperative refilling and avoids postoperative fluid excess.[18]

In most of the studies reported in literature, the abdominal part was performed with an upper midline incision, and an open approach was adopted to create the gastric conduit.[14] However, in our study, the abdominal component of the procedure was carried out laparoscopically, and endostaplers were used to create a gastric conduit. However, in two patients who had a colonic conduit, a laparoscopic-assisted approach was adopted, wherein after the initial laparoscopic mobilisation of the colon, a upper abdominal incision was taken to complete the rest of the procedure.

Our study consisted of patients with ages ranging from 18 to 60 years. Majority of the patients (50%) were in the 18–30 age group. This statistics is in line with various studies, such as the one published by Park,[19] and may be attributed to the higher probability of suicidal and accidental consumption in younger age groups. Karaman et al.[20] implicated the higher incidence of accidental consumption in children and hence found the prevalence of stricture to be higher in the age group below 18. Furthermore, an interesting point to correlate is that at such a productive period of their lives, younger patients tend to find minimally invasive surgeries more beneficial.

Our study reports a higher ratio of accidental consumption to suicide. Kalayarasan et al.[21] suggest that suicidal consumption may be more common, but this may be variable, and dependent on the study population. Accidental consumption leads to intake of higher quantities of corrosive resulting in more widespread damage, with higher morbidity and mortality. The male:female ratio in our study is 2:1, which is in tandem with a study published by Anand et al.[22] In this study, they theorise that the prevalence of psychiatric disorders leading to the consumption of corrosives is higher in men. However, on the contrary, the same study states that females have a higher rate of suicidal consumption. Therefore, the ratio may very well be incidental.

The choice between the usage of gastric and colonic conduit is made based on pre-operative imaging and endoscopy. For patients in whom a pre-operative endoscopy was not feasible, the condition of the stomach was assessed based on CECT thorax with abdomen with oral contrast. The condition of the stomach was also assessed during the pre-operative feeding jejunostomy for the patients who underwent the procedure at our institute. Consumption of corrosive acid or even large quantities of alkaline substances can result in widespread damage to the stomach, leading to scarring. In such cases, a colonic conduit was preferred. In our study, we constructed 22 gastric and 2 colonic conduits. The principle followed during conduit creation was that it must have adequate length, adequate vascular supply and intrinsic motility to allow swallowing and must allow for restoration of gastrointestinal continuity.[22] An ideal oesophageal replacement conduit does not exist. Most studies[23,24] advocate the use of gastric pull-up as a reliable oesophageal replacement as it provides adequate length, vascularity, involves only a single anastomosis and is observed to be a relatively simpler procedure with lesser operative time. However, literature also states that it has disadvantages such as reflux oesophagitis and stricture formation.[25]

The profile of complications was divided as – early and late. In our study, two patients had anastomotic leak which was managed conservatively. Post-operative leak is one of the most common and feared complications.[26] Our patients remained vitally stable, and timely management prevented the development of sepsis. Alternatively, options for the management of anastomotic leak and gastric conduit defects may be the use of oesophageal stents or endoluminal vacuum-assisted closure.[27,28]

Two of our patients were reported to have vocal cord paresis, probably due to handling of the recurrent laryngeal nerve during dissection. This may be due to mechanical stress or vascular compromise intraoperatively. It was managed conservatively in our patients and recovered over 6 weeks, but if this injury is irreversible, it serves as an independent risk factor for the development of respiratory tract infections.[29,30]

Six patients developed chest infections which were managed with higher antibiotics and chest physiotherapy. Out of these, two patients required temporary tracheostomy for tracheal toileting.

Other early complications such as massive haemorrhage, wound infections, arrhythmia, barotrauma and myocardial infarction have been reported in literature.[31] Our study group did not have any of these complications. However, one patient died on the third post-operative day due to pulmonary embolism.

The late complications included stricture formation, regurgitation, formation of broncho-oesophageal fistula and perforation. Four patients developed a stricture at the anastomotic site, all of these had a gastric conduit. They were managed with endoscopic dilatation. Studies suggest that adjusting the diameter of the gastric conduit significantly reduces the chance of stricture formation.[32,33,34]

Our study focused primarily on minimal invasive surgical management of corrosive oesophageal stricture. The thoraco-laparoscopic approach especially in younger age groups will prove to be advantageous with respect to reduced post-operative morbidity, shorter hospital stay and reduced risk of incisional hernias. On the other hand, it is a technically challenging procedure that needs expertise. However, this study showcases the feasibility and safety of minimally invasive surgery even in complex benign disorders of the oesophagus.

The study has many limitations, such as the small sample size and short follow-up. Hence, a larger multicentric study with longer follow-up is mandated to make this procedure representative in the surgical forum.

CONCLUSION

Minimally invasive oesophagectomy for corrosive stricture is technically challenging due to widespread scarring and distorted anatomy. However, if it is performed expertly, it is a versatile procedure which far surpasses the traditional open methods. Oesophagectomy additionally facilitates the removal of the native diseased oesophagus, thereby, avoiding malignant transformation, and also creates a physiological route for conduit placement.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.