Advanced Esophageal Cancer Palliative Surgical Therapy Using Isoperistaltic Gastric Tube

Abstract

Although malignant neoplasms of the esophagus remain a very common disease, their diagnosis might often come late, which explains why 50% of patients require palliative treatment. The ideal scenario would be the performance of procedures that provided an adequate quality of life and satisfactorily restored swallowing. This chapter aims to describe the results of palliative methods, discussed with emphasis on the technique of the isoperistaltic greater curvature gastric tube (IGCGT). About 143 patients with unresectable squamous cell carcinoma of the esophagus (T4b) were evaluated at this facility. In the early postoperative evaluation, 64 patients (44.7%) presented systemic complications, with pulmonary infection being the most frequent; 51 patients (35.6%) presented local complications, with cervical esophagogastric anastomosis leak being the most frequent. Thirteen patients (9.1%) died as a result of postoperative complications. Out of 112 patients who were adequately followed up, 91 (81.2%) achieved good palliation with this procedure, as they had adequate restoration of swallowing function, with a median survival of 3 years in 63 patients (69.2%). With these results, it is possible to conclude that despite showing non-negligible morbidity, IGCGT can be performed quickly and safely, offering adequate palliation and survival rate.

1. Introduction

Malignant esophagus neoplasia continues to be a very frequent condition, ranking third among the most frequent tumors of the gastrointestinal tract and the eighth most prevalent in the world [1, 2, 3, 4]. Recent studies have demonstrated that these tumors have increased approximately 10% per year, causing an estimated 400,000 deaths per year and being the sixth leading cause of cancer patients’ death [5, 6, 7].

In Brazil, it is the seventh most common malignant neoplasm with an estimate of 13,550 new cases in 2018; its higher incidence occurs in the south and southeast regions of the country [8, 9].

Diagnosis is almost always delayed because dysphagia, its main symptom, only occurs when 50% or more of the esophageal lumen is clogged by the tumor. Delayed diagnosis, excessive weight loss due to dysphagia, and the association of cardiopulmonary diseases resulting from tobacco abuse make clinical control of patients with this disease rather difficult, leaving the doctor with few therapeutic options [3, 4, 10, 11].

This reflects in the indication of esophagectomy, because although this surgical procedure continues to be the best therapeutic indication for the potential cure of this condition, in most cases, due to the advanced stage of the disease and to the great nutritional clinical impairment in those patients, only 30–40% of the patients are able to undergo this treatment, which causes the prognosis to be quite unfavorable [1, 5, 11, 12, 13].

Thus, a palliative treatment is required in more than 50% of patients plagued with this neoplasm. Ideally, we should have procedures available that would provide a more adequate quality of life and satisfactorily restore swallowing, without further hospitalizations and with lower complications rates [14, 15, 16, 17].

Choosing the best therapeutic options while trying to fulfill these requirements is a difficult task, since all methods have limitations and often contraindications due to the high potential for disease morbidity.

2. Palliation methods

In practice, the palliative therapy can be classified into two groups:

2.1 Nonsurgical

The current recommended methods are endoscopic techniques that are indicated for:

• Patients who have an indication for final chemoradiation, but who present severe dysphagia in the initial evaluation, thus requiring such previous intervention [5, 18].

• Failure to resolve dysphagia palliation with the initial therapy [5, 18].

• Recurrent dysphagia due to locoregional failure [5, 18].

• Recurrent dysphagia due to benign stenosis in patients who experienced successful chemoradiation [5, 18].

• Patients with clinical comorbidities, particularly cardiovascular and pulmonary diseases, which contraindicate surgical treatment and/or chemoradiation [5, 18].

Among the recommended endoscopic methods, the self-expandable metallic endoprosthesis stands out, which, although expensive, has shown adequate results, with satisfactory recovery of swallowing, low morbidity rate, and 6–10 months median survival in most of the series that have used this method [19, 20]. On the other hand, the use of endoscopic dilation, alcoholization, and laser has little application nowadays, because it, in addition to the poor resolution outcome, must be performed several times, increasing the morbidity potential [18, 20, 21].

2.2 Surgical

Palliative surgical therapy is mainly indicated for patients with satisfactory clinical conditions, but with unresectable tumors. Surgery can be performed using the following procedures:

2.2.1 Gastrostomy and jejunostomy

This type of procedure performed alone should be discarded as a palliative method of choice in the treatment of advanced esophageal neoplasia. Although easy to perform, including with local anesthesia, it does not bring any relief of the symptoms exhibited by those patients; in addition, patients must endure the presence of a probe inserted into the abdominal wall, which invariably presents leaks of digestive fluid around the tube, as well as exuberant growth of granulation tissue. The patient still does not intake food by mouth and is predisposed to saliva aspiration into the tracheobronchial tree, due to the permanence of esophageal obstruction. Thus, the method does not favor quality of life and fails to comply with the principles of an adequate palliative therapy. In addition, complications are frequently associated such as bronchopneumonia invariably due to aspiration, abdominal wall dehiscence, bleeding, and digestive fistula with consequent mortality potential and low survival [5, 22, 23].

Thus, the works reported in the literature serve only as a background review, since they date from the 1960s, 1970s, and early 1980s, when the endoscopic methods available today were not well-known. Meniconi [22], in a review of the literature involving 967 patients submitted to this type of procedure, reports complications ranging from 15 to 50%, with a mortality rate of up to 33% with survival time usually not exceeding 90 days in most of the patients studied and without having achieved a satisfactory quality of life.

Thus, gastrostomy/jejunostomy are exceptional procedures nowadays and are restricted only to cases of unresectable cervical esophageal cancer or as the first stage of another palliative or non-palliative procedure.

2.2.2 Resection

For several years now, it has been demonstrated that the best form of palliation for patients with unresectable advanced esophageal neoplasia, but with low clinical comorbidity, is the esophageal resection, because in addition to preventing the course of the esophageal disease, tumor hemorrhage, aspiration pneumonia, fistula in the respiratory tree, and mediastinitis, it also provides adequate dysphagia relief, a fact rarely observed with any other palliative method [1, 2, 4, 5, 24]. It also allows an increase in survival with an improved quality of life [11, 15, 25].

Over the years, a number of literature series have shown that palliative resections have caused higher morbidity and mortality than curative resections. In this connection, the work by Muller et al. [26] stands out. In an extensive review, these authors were able to review 13,061 curative and 16,024 palliative resection cases and demonstrated that the mortality associated with the curative and the palliative procedure was 11% and 18%, respectively. This finding was statistically significant and was confirmed by Law et al. [24] who reported 9% mortality for curative resections and 20% for palliative ones.

However, in recent years, with more appropriate postoperative care, with teams trained and accustomed to esophageal surgical procedures, a decrease in morbidity and mortality has ensued [14, 15, 19, 23].

Furthermore, with the evolution of radiotherapy and chemotherapy, it has been possible to enhance the survival to those patients, on average 24 months, compared to those who did not undergo any kind of treatment [2, 5, 11, 13].

As a result, palliative resection has a well-established position despite yielding suboptimal survival. It provides, however, an adequate quality of life by making the patient swallow naturally.

2.2.3 Bypass surgeries

This method is indicated for patients who have advanced cancer with extensive mediastinal invasion.

However, as it is a medium-major surgery, patients should have satisfactory clinical and nutritional conditions, which is quite uncommon in advanced stages of the disease.

This fact has been well demonstrated in the experience of Aquino et al. [27] where, out of 318 inoperable/unresectable patients from a series of 789, only 34.9% were able to undergo some kind of bypass surgery. In the other 2/3, another type of nonsurgical palliative treatment or even no procedure at all was undertaken due to the patients’ poor clinical conditions.

The most used viscera include:

2.2.3.1 Jejunum

This reconstruction was designed by Wullstein [28] and Roux [29] and was used in isolated cases for more than one hundred years and is not used routinely today. The biggest obstacle to its use is the difficulty for the jejunum to reach the cervical region without tension or ischemia.

However, patients with tumors in the distal third of the esophagus that present spreading to the aorta and/or spine due to contiguity can have their swallowing rescued by the latero-lateral esophago-jejunal shunt, above the tumor area, through the abdomen with median frenotomy [30].

The literature is scarce in relation to this type of procedure, with the exception of the review by Meniconi [22], which, in 93 patients who had unresectable cancer of the distal third of the esophagus and submitted to this type of procedure, showed 30% morbidity, with 25% death in the immediate postoperative period and median survival of 6 months.

2.2.3.2 Colon

Based on past reports, palliative colonic interposition is quite an old technique, since it was used already in 1911 by Keeling and Vullet who recommended this type of reconstruction in patients with advanced unresectable esophageal tumor. In the few cases reported, the patients died also due to the limited resources available at that time [22].

Even today, with more resources, that procedure is not widely used, because it is a major surgery, with extensive mobilization of the colon, multiple anastomoses, and many complications.

Meniconi [22] demonstrated the experience that the Esophageal Surgery Service of the Hospital das Clínicas of the University of São Paulo School of Medicine (USP) has by operating 13 patients with palliative intent; the surgery outcome included a high incidence of complications with 23% deaths, 38% anastomotic fistulas, and 15% pulmonary complications. Thus, Meniconi [22] concluded that such a procedure should no longer be performed, due to the high morbidity rate. Postlethwait [31] also had the same opinion after assessing the high rate of complications in 690 patients who underwent this type of reconstruction.

Thus, the use of coloplasty for the palliative treatment of patients with advanced esophageal neoplasia should be viewed today with great caution and used with parsimony; it should be indicated only as an exception, when there are no technical conditions to perform other types of reconstruction.

2.2.3.3 Stomach

In this type of procedure, several authors recommend burial of the cervical and abdominal esophagus, with transposition of the stomach via a retrosternal route, seeking to shorten the time of the surgical procedure [5, 22, 25, 31, 32].

However, as this surgery is most often performed on patients with poor nutritional conditions and clinical morbidities, this procedure presents a number of local or systemic complications, such as dehiscence of the proximal and distal esophagus stump, fistula of the cervical esophagogastric anastomosis, and pulmonary infection.

Meniconi [22], in a review of the literature, found that in 483 patients submitted to this procedure, morbidity varied from 27 to 63.3% and mortality from 4 to 37%, with a median 7.5 months survival, but most patients obtained a satisfactory swallowing.

Another fact that has been always discussed is the possibility of this procedure producing mucocele, with potential mediastinitis due to the complete exclusion of the esophagus; however, the studies reviewed do not present any consistent casuistry that evidences this fact [14, 22, 31, 32, 33]. To prevent this complication, some authors indicated drainage of the thoracic esophagus with a tubular probe, which is also not free of complications, such as the tube escaping from its insertion site with consequent mediastinitis and peritonitis and fatal evolution in most patients [22, 27, 31].

Based on these facts, some authors, mainly from the Chinese school, led by Wong et al. [34], recommended the use of the surgery proposed by Kirschner, already back in 1920, for benign esophageal stenosis secondary to the ingestion of caustic agents. The procedure consists of transposing the stomach to the cervical region, anastomosing the cervical esophagus, and draining the abdominal esophagus through a jejunal loop (Billroth II or Roux Y), thereby allowing drainage of the esophageal content and thus preventing the potential development of mucoceles in the thoracic esophagus.

In Brazil, this type of procedure is undervalued. Only the work by Brandalise et al. [35] stands out, according to which, a total of 13 patients assessed presented a morbidity rate of 40%, mortality of 15.3%, and median survival of 8.5 months.

Aquino et al. [27] assessed 17 patients with unresectable esophageal cancer who underwent total gastric transposition; three of them with whom the Kirschner procedure was used also demonstrated that this procedure has a high morbidity rate. A total of 47% of all the patients experienced complications, mostly cardiopulmonary, and three patients died due to clinical and/or local complications. With regard to palliation, it was adequate in 70% of the patients, who reported satisfaction with the surgery because they managed to recover swallowing, although with a 7 months mean survival.

Considering the non-negligible morbidity rate and the new techniques available today, palliative total gastric transposition is not indicated as the first option for surgical treatment, being only an exception procedure aiming at those patients in whom other procedures cannot be used.

2.2.3.4 Greater curvature gastric tube

This technique was developed with the aim of resolving the dysphagia of patients with esophageal stenosis. Its principle is to minimize the complications that commonly affect surgical procedures on the esophagus, intending to be simple and causing low morbidity and mortality.

The great advantage is that it simultaneously drains both the esophagus and the stomach, thus avoiding potential esophageal mucoceles.

Historically, Beck and Carrel [36] demonstrated continent gastrostomy in cadavers and experimental animals, using a tube made from the greater gastric curvature irrigated by the left gastroepiploic artery. They also envisaged the possibility of esophagoplasty using this long, highly curved tube.

Subsequently, Carter et al. [37], in experimental animals, demonstrated the possibility of constructing the gastric tube with a greater curvature nourished by both the left and right gastroepiploic arteries. They named the gastric tube according to the direction of peristalsis: the part nourished by the right gastroepiploic artery and with a free end close to the gastric body-fundus junction, isoperistaltic gastric greater curvature tube, and the one nourished by the left gastro-epiploic artery and free end close to the antrum-pyloric gastric junction, anisoperistaltic gastric greater curvature tube.

In a clinical experience in 1951, Dan Graviliu reported having successfully constructed the first gastric tube with anisoperistaltic greater curvature in a cervical bypass in the treatment of esophageal stenosis [38].

At a later date, Heimlich [39] demonstrated his experience with gastric tube of greater anisoperistaltic curvature in cervical derivation in the treatment of esophagoplasties that failed with the use of stomach, colon, jejunum, or even prostheses. A total of 67 patients underwent this procedure with only 3 fatal cases.

Almost at the same time, Postlethwait [40], in the United States, referred to the use of the gastric tube with a greater curvature in an isoperistaltic direction in the treatment of a benign stenosis and in 29 unresectable malignant neoplasms of the esophagus with a 13% mortality rate.

In Brazil, Speranzini [41] reported the first national experience in the palliative treatment of esophageal neoplasia using an isoperistaltic greater curvature gastric tube in cervical bypass. Out of 13 patients who underwent this procedure, no death occurred.

From that time on, and especially with the advent of mechanical suturing, both linear and circular, several authors began to demonstrate greater experience with this procedure, as it is fast, simple, and yields acceptable morbidity rates [14, 19, 27, 42, 43, 44].

3. Surgical technique

The surgical technique involves the creation of a tube using the greater gastric curvature of about 2.5 cm in width, with preservation of the right gastroepiploic vessels.

To obtain this tube, the stomach is divided in a line parallel to the greater curvature, extending from the fundus to the gastric antrum, with the aid of a cutting linear mechanical suture (Figure 1).

Figure 1.

Longitudinal incision approximately 2.5 cm from the greater gastric curvature. Source: Aquino et al. [23].

The sectioned stomach resembles a “V,” whose part corresponding to the lesser curvature drains the distal esophagus in relation to the tumor (Figure 2).

Figure 2.

Sectioned stomach resembling a “V,” with preservation of the right gastroepiploic artery. Source: Aquino et al. [23].

Transit reconstruction is performed by transposing the isoperistaltic tube via a retrosternal route, with manual anastomosis in two planes or circular mechanical performed in the cervical region (Figure 3).

Figure 3.

Gastric tube transposed by retrosternal route. Source: Aquino et al. [23].

In all patients, a jejunostomy is performed for enteral feeding, to be continued until the release of the enteral diet.

Aquino et al. [14], in a report of their experience with 112 patients submitted to palliative retrosternal transposition of the greater curvature gastric tube, demonstrated that such procedure was beneficial. This is because although this procedure was not free of complications, these were quite acceptable in view of the profile of the patient who was with advanced cancer, with 25.7% of systemic complications and 34% of local complications that were mainly related to dehiscences and stenoses of the cervical esophagogastric anastomosis. They also demonstrated that dehiscence was significantly more frequent with manual suture (p31/83 = 37.3%) than with mechanical suture (p4/29–13.8%).

In order to increase survival, the advantages of performing palliative surgery before radiotherapy and chemotherapy have recently been demonstrated, even using a minimally invasive technique, since patients who recover swallowing exhibit a better nutritional status, which helps preventing the drawbacks and complications of radiotherapy and chemotherapy [45, 46, 47].

This had already been demonstrated by Aquino et al. [27] who assessed 36 patients submitted to chemoradiation; 80.5% of those patients, after palliative transposition of the gastric tube, obtained a median 18 months survival; in patients who after the transposition were not submitted to chemoradiation, survival was 39.5%.

Some authors have also demonstrated in recent reports that in patients submitted to exclusive chemoradiation with a palliative purpose because they have advanced tumors, often a regression of the disease stage at the mediastinal level occurs, and therefore, it is possible to perform a rescue esophagectomy [3, 4, 13, 48, 49].

Aquino and Leandro-Merhi [50] also demonstrated the validity of rescue esophagectomy. Out of 82 patients who underwent radiotherapy and chemotherapy after prior creation of the palliative gastric tube, 37 experienced tumor regression, with rescue esophagectomy performed by thoracotomy. Although 2 patients eventually died due to postoperative complications, in the others, survival was quite adequate in relation to time: from 36 to 48 months in 26 patients and 3 patients died due to the metastatic disease within 9–15 months after rescue surgery.

4. Experience of the surgery service at the Hospital PUC-Campinas, Brazil

During the period from January 1993 to December 2022, 1614 patients were diagnosed with squamous cell carcinoma of the esophagus; a palliative large-curved isoperistaltic gastric tube was inserted in 143 of them because they had unresectable tumors (T4b) but with clinical conditions that allowed them to be subjected to this type of procedure. In the early postoperative evaluation, 64 patients (44.7%) had systemic complications, particularly cardiovascular and pulmonary; 51 patients (35.6%) developed local complications, the cervical esophagogastric anastomosis fistula being the most frequent, and 13 patients (9.1%) died due to complications.

Out of 112 patients, we were able to perform a follow-up in 91 patients (81%); the isoperistaltic gastric tube provided good palliation, as these patients restoration adequate swallowing, including the ingestion of solid foods.

Regarding the median survival, out of the 112 patients evaluated, all presented different evolution according to the association of complementary treatment or not:

In 30 patients in whom no complementary treatment was associated to the palliative surgical procedure, the median survival was 14 months.

In 45 patients treated with chemoradiation after the palliative surgical procedure, the median survival was 29 months, and in the 37 patients in whom palliative surgery was associated with rescue esophagectomy due to tumor regression, in addition to chemoradiation, the median survival was 42 months.

5. Final considerations

It is difficult to decide on the best palliative surgical therapy indication, due to the great impairment of the general conditions of patients with advanced esophageal neoplasia. Thus, some measures ought to be emphasized:

1. Careful patients’ selection, since over 50% are unable to undergo any surgical procedure due to clinical comorbidities, particularly cardiopulmonary, besides an impaired nutritional status

2. Careful selection of the palliative surgical procedure, because although all of them can cause potential complications, the isoperistaltic gastric tube with greater curvature seems to be the technique that causes the lowest morbidity rate, besides being fast and safe to perform, particularly after the advent of the mechanical suture, offering palliation and quite adequate survival

3. Association of radiotherapy and chemotherapy after construction of the palliative gastric tube in well-selected patients, as those therapies seem to provide a higher survival rate, in addition to being able to allow the performance of rescue esophagectomy.

Acknowledgments

To hospital PUC-Campinas.

Conflict of interest

The authors declare no conflict of interest.