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Address for reprints: Jian-Yong Ding, MD, PhD, Department of Thoracic Surgery, The Affiliated Zhongshan Hospital of Fudan University, No. 180 Fenglin Rd, Shanghai 200032, China.
Endoscopy after esophagectomy is helpful, but safety concerns restrain its application in early stages. Can we do endoscopy or not is the doctors' dilemma.
Complications after esophagectomy significantly affect outcomes, including perioperative mortality and costs. Anastomotic leak and conduit ischemia remain the most serious complications, and early recognition and appropriate initial treatment are essential. Computed tomography scan, contrast esophagography, and endoscopy will be the candidate options to assess the situation.
Of particular importance is endoscopy after esophagectomy to differentiate leaks to conduit ischemia. Endoscopy also can be used therapeutically to introduce stents into a leaking anastomosis.
The application of endoscopy varies among institutions and doctors, with limitations mostly owing to safety concerns (Figure 1).
Figure 1Potential risks of endoscopy examination after esophagectomy. A, Mechanical injury from endoscopy examination. B, Air insufflation injury to the anastomasis and staple lines of gastric conduit, as well as compromising blood flow.
The timing of endoscopy after esophagectomy is a critical factor for safety concerns. Generally speaking, it is almost undisputable for an endoscopy examination to be performed 3 weeks after esophagectomy, which is also widely used in actual clinical practice owing to its relative safety. The anastomasis and conduit are vulnerable early after esophagectomy. Most morbidity, including anastomasis leakage and necrosis of the conduit, occurs 2-7 days after esophagectomy.
Indeed, few relevant studies have reported an endoscopy examination within 3 weeks after esophagectomy, whereas some clinical retrospective studies from single institutions have indicated that it is a safe procedure.
Nevertheless, it is not sufficiently convincing and cannot eliminate the safety concerns of doctors. Moreover, there has been no previous animal model or clinical trial to determine the safe parameters of insufflation for esophagectomy endoscopy in early stages. When problems occur early after esophagectomy, it is the doctors' dilemma as to whether the endoscopy should be performed.
reports an interesting study on an in vivo porcine model. In the first part of the study, the authors assessed the potential mechanical risk to the anastomasis or the stapled lines of gastric conduit of endoscopy. In 15 models, they did not see any overt visible disruption to the anastomasis, conduit staple lines, or gastric mucosa. With progressive insufflation, the intralumen pressure reached a plateau that was far below the risky pressure that we defined in previous study. In the second part of the study, the authors investigated the flow and perfusion of the gastric conduit with endoscopy insufflation after esophagectomy. Endoscopy examination did not disturb blood flow and oxygen saturation of the conduit. The results of that study give us great confidence in the safety of gastroscopy after esophagectomy.
We also note some limitations of the study. First, the tests were conducted immediately after esophagectomy, and we wonder if the anastomasis is strong and the conduit ischemia time is adequate. In the model, all cases were chest-abdominal approaches, and the anastomasis is in the chest with an open procedure, which can mimic the Ivor–Lewis procedure, but not the McKeown procedure. The air insufflation time in this study is short, and we did not know about the situation when the procedure extended a longer time. We also have to keep in mind that research is limited.
In conclusion, this study provides insight into the safety parameters of endoscopy examination after esophagectomy with an in vivo porcine model, thereby paving the way for studies aimed at understanding how and when endoscopy can be safely performed in an early stage in patients undergoing esophagectomy.
I thank Ai-Wu Ke for his assistance in creating the figure.
References
Crestanello J.A.
Deschamps C.
Cassivi S.D.
Nichols F.C.
Allen M.S.
Schleck C.
et al.
Selective management of intrathoracic anastomotic leak after esophagectomy.
Endoscopy is useful in assessing conduit ischemia and anastomotic leaks after esophagectomy but poses a theoretical threat of anastomotic disruption. We used a porcine model to evaluate the safety of endoscopy after esophagectomy.
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