FUNCTIONAL ASSESSMENT OF THE CERVICAL ESOPHAGUS AND OROPHARYNX AFTER GASTRIC TRANSPOSITION AND CERVICAL ESOPHAGOGASTROSTOMY

P Koh, G Turnbull, EL Attia, PG LeBrun, AG Casson

Departments of Surgery, Medicine and Radiology, Dalhousie University, Halifax, Nova Scotia

Quality of swallowing after reconstruction of the upper gastrointestinal tract is quite variable and subjective. The aim of this exploratory study was to investigate function of the oral and pharyngeal phases of deglutition, and of the cervical esophagus following gastric transposition and esophagogastrostomy. Nine patients (8 male, 1 female; median age 63 years), who had a potentially curative subtotal esophageal resection for primary esophageal adenocarcinoma, were studied from 6 to 40 months (median 18 months) postoperatively. For all patients, the upper gastrointestinal tract was reconstructed by transposing a narrow gastric tube (greater curvature of stomach, based on the right gastroepiploic artery) through the posterior mediastinum to the left neck, where a semimechanical anastomosis to the cervical esophagus was performed. Swallowing and quality of life (FACT-E) were evaluated clinically, and objective studies comprised video barium swallow, esophagogastroscopy, velopharyngeal examination, manometry and balloon dilation of the cervical esophagus. The median length of the cervical esophagus was 5cm (range, 3-7cm), with no anatomic obstruction to swallowing or stricture demonstrated. Mild reflux laryngopharyngitis, characterized by hyperemia and thickening of the posterior commissure and arytenoids, was seen in all patients. Although all patients had an objective functional dysphagia measurement of 7 (normal), five reported subjective dysphagia. Four (of 5 symptomatic) patients were found to have high pressure peristalitic activity (mean >100 mmHg) following balloon distention (10-30ml) of the cervical esophagus, which was painful in 2 cases. We conclude that in the absence of an anatomic cause for dysphagia after cervical esophagogastrostomy, a functional etiology may be explained by hypertensive peristalsis resulting from distention of the remaining cervical esophageal remnant. These findings may further explain anecdotal reports of the efficacy of empiric dilation after upper gastrointestinal reconstruction where no anatomic esophageal obstruction is demonstrated.