Chronic symptoms after subtotal or partial oesophagectomy: diagnosis and treatment

In the great majority of patients, subtotal or partial oesophagectomy is performed because of malignancy, for which wide local excision and additional lymphadenectomy are indicated. Except in patients with early lesions, the vagal nerves have to be sacrificed bilaterally, which can induce a great variety of functional abnormalities. The continuity of the gastrointestinal tract is preferably restored by using a whole-stomach interposition or gastric tube. The oesophago-gastric anastomosis is critically vascularized and carries a significant risk of benign fibrotic stricturing, especially when it is located in the neck. Acid or biliary reflux may result in persistent oesophagitis and the development of Barrett's metaplasia in the remnant oesophagus. The reservoir capacity of the gastric tube is limited, whereas the emptying rate can vary considerably, leading to complaints of either gastric retention or intestinal dumping. It is not clear whether or not gastric drainage procedures are beneficial. Recurrent nerve damage with vocal cord paralysis may result in aspiration and recurrent pulmonary infection. The permanent threat of recurrent disease combined with the substantial physical impact of an extensive surgical procedure inducing a wide range of functional disturbances of the gastrointestinal tract has a great influence on quality of life, at least temporarily. The late complications of anastomotic stricturing and the functional consequences of bilateral vagotomy, gastric tubulization and gastric pull-up will be reviewed. Moreover, the general and specific changes in quality of life will be addressed.