Management of inflammatory tracheoesophageal adhesions during transhiatal esophagectomy

Purpose. Mediastinal adhesions, caused by the transerosal spread of disease, inflammatory diseases, or preoperative chemoradiotherapy, can result in difficulties and major complications during transhiatal esophagectomy (THE). However, few studies have specifically addressed the incidence and management of inflammatory adhesions encountered during THE. Methods. We retrospectively analyzed the operative details and postoperative outcome of 70 patients who underwent THE between 1998 and 2000. Patients with inflammatory tracheoesophageal adhesions were identified and their operative records were reviewed for operative findings, intraoperative management, morbidity, and mortality. Patients with upper thoracic esophageal tumors and direct tumor spread to the airways were excluded from the analysis. Results. Eight (11.4%) of the 70 patients had inflammatory adhesions and esophagectomy was possible in 7 of these 8 patients. Due to poor pulmonary status, one patient required conversion to the trnsthoracic approach, but the other six were managed transhiatally. Three patients underwent subtotal esophagectomy, the esophagectomy was completed by the inversion extraction technique in two, one required extended transhiatal dissection, and esophagectomy could not be completed in one due to dense inseparable adhesions between the trachea and esophagus. There was no major airway injury or bleeding. Conclusions. Inflammatory tracheoesophageal adhesions may be encountered in patients undergoing THE in developing countries. Thus, an awareness of the possibility of these adhesions and suitable modifications of the operating procedures are necessary to prevent major complications.