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Ann Thorac Surg 2000;70:1799-1802
© 2000 The Society of Thoracic Surgeons

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Original article: general thoracic

Esophageal reconstruction for benign disease: self-assessment of functional outcome and quality of life

^a Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
^b Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Address reprint requests to Dr Deschamps, Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, 200 First St, SW, Rochester, MN 55905
e-mail: deschamps.claude{at}mayo.edu

Presented at the Thirty-sixth Annual Meeting of the Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.

	Abstract

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Background. Little information exists regarding functional outcome and quality of life after esophagectomy and subsequent esophageal reconstruction for benign disease as evaluated by the patients themselves.

Methods. Eighty-one patients completed a combined two-part questionnaire regarding esophageal function and quality of life (MOS SF-36) a median of 9.8 years (range, 10 months to 18.9 years) after esophageal reconstruction for benign disease. There were 43 men (53.1%) and 38 women (46.9%). Median age at time of esophageal reconstruction was 51 years (range, 6 to 78 years). Intestinal continuity was established with stomach in 58 patients (71.6%), colon in 16 patients (19.8%), and small bowel in 7 patients (8.6%).

Results. Dysphagia to solids was present in 48 patients (59.3%) and 27 patients (33.3%) required at least one postoperative dilatation. Heartburn was present in 50 patients (61.7%) which required medication for control in 37 patients (45.7%). The number of meals per day was three to four in 58 patients (71.6%), more than four in 15 patients (18.5%), less than three in 6 patients (7.4%), and unknown in 2 patients (2.5%). The size of each meal was smaller than preoperatively in 46 patients (56.8%), larger in 22 patients (27.2%), unchanged in 12 patients (14.8%), and unknown in 1 patient (1.2%). The number of bowel movements per day increased in 37 patients (45.7%), was unchanged in 36 patients (44.4%), and decreased in 8 patients (9.9%). Resection for perforation was associated with smaller postoperative meals compared with resection for stricture (p < 0.05). Age, sex, and type of esophageal reconstruction did not affect late functional outcome. Regarding quality of life, physical functioning, social functioning, and health perception were decreased (p < 0.05). No significant change was observed in role-physical, mental health, bodily pain, energy/fatigue, and role-emotional scores.

Conclusions. Self-assessment of postoperative esophageal symptoms after esophagectomy and reconstruction for benign disease demonstrates that symptoms are frequently present at long-term follow-up and unaffected by the type of reconstruction.

	Introduction

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Esophagectomy for end-stage benign disease is performed infrequently. Consequently, little information exists regarding long-term symptomatology and quality of life after esophageal reconstruction. The purpose of this review is to analyze long-term esophageal function and quality of life in patients who underwent esophagectomy and subsequent reconstruction for benign disease as evaluated by the patients themselves.

	Material and methods

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From August 1977 to October 1997, 202 patients underwent esophageal reconstruction for benign esophageal disease at the Mayo Clinic in Rochester, Minnesota. Patients with Barrett’s dysplasia or those with esophageal varices secondary to portal hypertension were excluded. Eighty-one of these patients (40.1%) completed and returned a combined two-part questionnaire regarding esophageal function and quality of life after esophageal reconstruction [1]. The records of these patients were analyzed for age, sex, initial diagnosis, indication for esophageal resection, type of reconstruction, operative morbidity, and factors affecting both functional outcome and quality of life. Data were obtained from the patient’s medical record chart and the survey.

The esophageal function and quality of life survey used in this review was a two-part mail survey. Part one evaluated subjective digestive function and specifically addressed the qualitative and quantitative estimates of dysphagia, the need for esophageal dilatation, the presence of heartburn, and the need for medication. Also queried were signs and symptoms of aspiration, the size and frequency of daily meals, presence of dumping symptoms, bowel habits, and weight change.

Part two consisted of the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS SF-36) [2]. This national standardized questionnaire is a self-administered health assessment tool that permits group comparisons in eight conceptual areas covering general health (health perception), daily activities (physical functioning), work (role-physical), emotional problems (role-emotional), social activities (social functioning), nervousness/depression (mental health), pain (bodily pain), and vitality (energy/fatigue). A numerical score is derived from the answers in each of the conceptual areas. An overall median score is determined for each area and compared with national norms matched for age and sex.

Relationships between variables were assessed using ² tests for discrete factors and Wilcoxon rank-sum tests for continuous factors [3]. Evaluation of the patients’ responses relative to a matched population was done using the signed-rank test [4]. Patient age at operation was compared with the ordinal functional outcomes using the Spearman rank correlation and with the discrete functional outcomes using the Wilcoxon rank-sum test. A value of p < 0.05 was considered significant.

The two-part written survey was sent to all patients known to be alive at the time of the survey.

	Results

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Clinical findings
Surveys were sent to 202 patients. No response was heard from 67 patients, 46 were later found to have died, and 8 patients were excluded for institutional reasons. Complete data were obtained in 81 patients for a response rate of 40.1%.

There were 43 men and 38 women. The median age at the time of esophageal reconstruction was 51 years (range, 6 to 78 years). Esophagectomy was performed for a motility disorder in 38 patients (46.9%), stricture in 28 patients (34.6%), esophageal perforation in 6 patients (7.4%), hiatal hernia in 5 patients (6.2%), and other in 4 patients (4.9%). Fifty-seven patients (70.4%) had had a prior esophageal operation before esophagectomy (Table 1). Twenty-six patients (32.1%) had one previous procedure, 19 patients (23.5%) had two, 10 patients (12.3%) had three, 1 patient (1.2%) had four, and 1 patient (1.2%) had six. Ten patients (12.3%) had been previously diverted with a cervical esophagostomy. Eighty patients were symptomatic before esophagectomy. Dysphagia was present in 56 patients (69.1%), regurgitation in 25 patients (30.9%), pain in 11 patients (13.6%), pyrosis in 9 patients (11.1%), and episodic aspiration in 3 patients (3.7%). Weight loss was observed in 21 patients (25.9%).

All esophageal reconstructions were performed at our institution. Intestinal continuity was established with stomach in 58 patients (71.6%), colon in 16 patients (19.8%), and small bowel in 7 patients (8.6%). The proximal anastomosis was to the cervical esophagus in 38 patients (46.9%), upper thoracic esophagus in 22 patients (27.2%), and lower thoracic esophagus in 21 patients (25.9%). The conduit was placed in the esophageal bed in 66 patients (81.5%), substernally in 14 patients (17.3%), and subcutaneously in 1 patient (1.2%). Complications occurred in 35 patients (43.2%) (Table 2). Median postoperative hospitalization after reconstruction was 13 days (range, 7 to 51 days).

Factors affecting late functional outcome were analyzed. Resection for perforation was associated with smaller postoperative meals compared with resection for stricture (p < 0.05). Age, sex, initial diagnosis, type of reconstruction, and postoperative morbidity did not influence late functional outcome (NS).

Quality of life
Self-assessment on quality of life was available in all 81 patients (100%). Quality of life scores were computed for each patient in each of the eight conceptual areas (Table 3). Physical functioning (daily activities), health perception (general health), and social functioning (social activities) were decreased compared with the national norm (p < 0.05). Bodily pain (pain), role-physical (ability to work), energy/fatigue (vitality), role-emotional (emotional problems), and mental health (nervousness/depression) scores were similar to the national norm (p > 0.05, NS).

	Comment

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Esophagectomy for benign disease is generally considered a treatment of last resort [5]. Although the primary objective of reconstruction is to restore normal swallowing with minimal morbidity and mortality, potential complications of dysphagia, delayed gastric emptying, reflux, aspiration, and dumping can all adversely influence long-term functional outcome [6–8].

Several reports have shown postoperative functional results as excellent or good in the majority of patients after esophagectomy and reconstruction for benign disease [9–15]. However, comparisons with these reports are difficult because of the heterogeneity of the different tools used to grade the functional outcome. Moreover, only a few of these tools use self-assessment [11, 14].

A patient’s perspective on quality of life is crucial. We are in an era in which health care outcome will increasingly be evaluated from the patient’s point of view [2]. J. D. Kirby [16], who founded the Oesophageal Patients Association, suggested nine elements of a good quality of life after esophagectomy (Table 4).

Our data demonstrate that when queried, the majority of patients were symptomatic a median of 10 years after esophageal reconstruction. Although upper digestive symptoms of reflux and dysphagia were present in most patients, the observation that less than 50% used antacids and less than 40% required dilatation would suggest that the symptoms were not severe in many. Similarly, whereas symptoms of dumping were common, only 46% had some degree of diarrhea. Moreover, more than half of our patients regained preoperative weight. Quality of life scores demonstrated that our patients scored below the national norm in three conceptual areas. This might reflect the fact that a majority of these latter patients had been symptomatic for years before reconstruction and had undergone countless prior therapeutic procedures. More than two thirds of our patients had had a prior esophageal operation before esophagectomy. In addition, the type of reconstruction did not affect functional outcome or quality of life. Our findings suggest that after reconstruction for benign disease symptoms are present for an extended period of time, are rarely severe, and the quality of life scores do not correlate with the type of reconstruction.

There are limitations to our study. Our sample size is small and constitutes only a fraction of the entire population of patients who underwent esophagectomy and subsequent reconstruction for benign disease during the time period covered by the survey. Also, because this group of patients is heterogeneous, these patients are submitted to a wide variety of treatment options before esophagectomy. Similarly, reconstruction is also more diverse than reconstruction in cancer patients.

We conclude that most patients are symptomatic after esophagectomy and esophageal reconstruction for benign disease when evaluated with a self-administered questionnaire. Dysphagia, heartburn, and gastric dumping are common. Most symptoms are mild or moderate and less than half of patients require medication or dilatation. Quality of life, as assessed by the patients themselves, is adversely affected in three of eight con-ceptual areas. Long-term functional outcome and quality of life scores are not affected by age, sex, type of reconstruction, or postoperative complications.

	Discussion

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DR NICHOLAS J. DEMOS (Jersey City, NJ): I thoroughly enjoyed the presentation by Dr Young from the Mayo Clinic, and I have to congratulate you for the excellence of the presentation and the excellence of the slides, and this is a common phenomenon when we hear papers from the Mayo Clinic. I rise also to make a small point. These unfortunate patients, many of them had cancer, but your presentation is on benign disease. I noticed from your numbers that about 60% of them had heartburn, and 22 patients, which is about 30%, I believe, had chronic cough, and another 25 patients suffered from hoarseness. Now, this is a considerable disability in patients when we operate on them, especially for benign disease. A surgeon from Massachusetts General Hospital—I am sorry, I forgot the surgeon’s name—tells me that they do not see heartburn and reflux in their patients, yet the follow-up data from their institution state that at least 38% of them died from respiratory complications. We have seen similar numbers in a large series from China.

In the last 30 years we have applied an intercostal pedicle to raise the esophagogastric anastomosis in the chest, and it has completely prevented reflux from stomach to esophagus to mouth and the nasal cavity in more than 95% of patients (Dis Esophagus 1995;8:142–4). At least half a dozen of my 100 patients had benign disease, and I followed them for many years and they have been free of reflux, in contradistinction to those 5 or 6 patients in whom for some reason or another we did not place an intercostal pedicle to prevent postoperative reflux, and they had a miserable life. At least 1 of them died from respiratory complications of bile reflux.

Thank you very much for the privilege of discussing your paper.

	References

Top Abstract Introduction Material and methods Results Comment Discussion References

 

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