Gastric conduit necrosis following esophagectomy: is conduit salvage feasible?

Conduit necrosis (CN) typically requires operative reintervention with resection of the conduit and reconstructive surgery. We describe the outcomes of managing CN both surgically and endoscopically with a focus on conduit salvage. A retrospective, single center, cohort study of a prospectively maintained database was performed. All patients undergoing esophagectomy with gastric conduit reconstruction between 01/2010 and 01/2024 were identified following which all patients with a documented history of anastomotic leak were excluded. Patients with clinically impactful CN were allocated to the study group. The remaining patients who had no immediate conduit related complications were allocated to the control group. The outcomes of various treatment options for CN were described and variables associated with CN identified. Overall, of the 1043 patients that were identified, 37 (3.5%) were allocated to the study group and 850 (81.5%) to the control group. Comparing to control group patients, CN was more common in cervical compared to intrathoracic anastomoses (13/135 vs 20/598, P ≤ 0.001) and among recipients of neoadjuvant chemoradiotherapy (8/112 vs 13/506, P = 0.009). On multivariable analysis, peripheral vascular disease, cervical anastomosis, and chronic obstructive pulmonary disease were independently associated with CN (odds ratio 8.0, 3.2, and 2.5, respectively). In the 397 patients with CN, endoscopic treatment with selfexpanding metal stents (SEMS), debridement and reanastomosis, early conduit replacement, and cervical esophagostomy was used in 14/12/7/4 patients (37.8%/32.4%/18.9%/10.9%). Salvage treatment was successful in 10/14 treated endoscopically with stents (71.4%), 8/12 re-anastomoses (66.7%), 3/7 replaced conduits (42.9%), and 3/4 esophagostomies (75.0%). Overall mortality from CN was 12.8%, with no difference in management approach. In sum, among appropriately selected patients with significant clinically impactful CN post esophagectomy, endoscopic SEMS is an effective means to salvage the conduit.