Background: Ischemia of the gastric conduit is a rare but devastating complication of esophagectomy. Fear of iatrogenic injury to the anastomosis by early endoscopy has resulted in use of CT scan for diagnosis of this complication which may lead to delay in diagnosis. The aim of this study was to assess the role of CT scan vs. early upper endoscopy to assess ischemia of the gastric conduit following esophagectomy.
Methods: Between 2002 and 2007, 704 patients underwent an esophagectomy and gastric pull up at the University of Southern California. Records were reviewed to identify patients who underwent endoscopy for suspicion of ischemic conduit at a median of 7 days (IQR 5-9) and a CT-scan within 24 hours of the endoscopy. The accuracy of CT-scan and endoscopy were compared.
Results: Seventy six patients had endoscopy and a CT-scan performed for clinical suspicion of graft ischemia. Endoscopy showed evidence of ischemia in 52 patients. There were no complications associated with early endoscopy. CT-scan showed evidence of ischemia in 10/52 patients (19%). Seven of these patients had air in the soft tissue of the neck/mediastinum, 3 had a perianastomotic or mediastinal fluid collection and all 10 had graft ischemia on endoscopy. The remaining 42 patients (81%) with graft ischemia on endoscopy had normal findings on CT-scan. Seven of these patients had graft necrosis and were all missed on CT-scan. The ischemic conduit was removed in these 7 patients. The remaining patients responded to conservative therapy.
Conclusion: A normal CT scan does not rule out the possibility of an ischemic conduit following esophagectomy. Early endoscopy is safe and remains the diagnostic test of choice.
Program Number: P352