Esophagectomy is an important component in the treatment of esophageal cancer but significantly disrupts upper gastrointestinal anatomy (1, 2). As many as two-thirds of patients can experience gastrointestinal dysfunction with detrimental impact on health-related quality of life (HRQOL) (2–6). Postoperative complications may also adversely affect long-term QOL (7–9). Poor postoperative QOL has additionally been identified as a predictor of late mortality (10–12).

While perioperative QOL has previously been studied, long-term HRQOL has primarily been reported after a variety of esophagectomy techniques making interpretation of outcome data challenging (2). The stomach conduit typically utilized for reconstruction is passively relying on gravity for drainage. Any resistance to flow through the stomach conduit, therefore, has potential to significantly impact long-term HRQOL. We have previously described a novel esophagogastric anastomotic technique associated with low leak and stricture rates, which also includes wide surgical pyloric drainage (13). In this study, we aimed to evaluate the long-term HRQOL and esophageal-specific QOL in consecutive cancer patients who underwent this consistently performed surgical approach, including the impact of demographic and oncologic factors, postoperative complications, and conduit function.

Assessing long-term HRQOL and esophageal-specific QOL after esophagectomy is essential to understand the impact of treatment in cancer patients. Comparing outcomes between esophagectomy techniques and identifying patients at risk of poor QOL outcomes is important in this regard. Previous reports have demonstrated a significant decline in HRQOL immediately following surgery, with gradual improvement before reaching a plateau which is often not equivalent to preoperative status (3, 19–21). Specific symptoms, such as reflux, eating difficulties, loss of appetite, and diarrhea can impact QOL for up to ten years following surgery (1). After this esophagectomy approach, a majority of patients in our cohort reported very favorable long-term HRQOL and esophageal-specific QOL outcomes.

Emptying of the primarily passive stomach conduit, promoted largely by gravity, can be optimized by the creation of a narrow but adequately sized conduit with a uniform diameter and no redundancy (22). One may speculate that creation of a gastric conduit with a relatively narrow diameter promotes good conduit emptying at the “price” of early satiety which is common after esophagectomy; 45% of our cohort responded negatively to “I am able to eat as much as I want”, consistent with prior studies (2, 3, 5, 6, 23) Deldycke evaluated 322 patients who underwent an Ivor Lewis approach utilizing a whole stomach conduit and a routine pyloroplasty and found a 60% incidence of early satiety up to 5 years after surgery (6). While surgical pyloric drainage may promote conduit function, it may also promote dumping. Boshier reported an 87% incidence of early satiety in 171 patients at least 3 months post-esophagectomy (2). Inclusion of intraoperative pyloric drainage or postoperative pyloric dilation was associated with a decreased incidence of early satiety but higher rates of dumping symptoms. Although early satiety was the most common symptom in our study, the incidence was notably lower than the 87% and 60% reported by Boshier and Deldycke. None of the patients in our series required postoperative pyloric dilation, suggesting that surgical pyloric drainage can be beneficial to conduit function.

A unique aim of our study was to explore the relationship between postoperative fluoroscopic conduit function and long-term symptomatology. Clinically relevant DE occurs in 10%–20% of patients and may be affected by surgical technique (24). Using our technique, DE in the immediate postoperative period did not appear to impact long-term HRQOL. We speculate that DE identified in 27% of our series, despite wide surgical pyloric drainage, may be attributable to temporary conditions such as pyloric swelling or narcotic use. It is also possible that minor emptying delay if chronic, does not significantly impact perceived QOL. Dedicated prospective study of long-term QOL outcomes with respect to conduit function after various esophagectomy techniques would be of interest.

Long-term HRQOL in our study compares favorably to findings reported by Gutschow, with approximately half of their 147 patient cohort reporting QOL similar to a healthy reference population after Ivor Lewis esophagectomy (25). The patients in our study reported mean scores on the FACT-G and subscales similar to, and in some cases, higher than those previously reported in a healthy population (26). The consistent surgical approach in the current series may explain the concentration of scores within a narrow range on QOL subscales. There were, however, a distinct minority of outlier patients reporting poor QOL in multiple or isolated subscales without obvious trends. Further investigation is needed to identify patients with the potential to be outliers with respect to HRQOL and efforts made to minimize these outcomes.

Anastomotic technique is an important consideration as anastomotic complications can impact long-term symptomatic outcomes. Reported rates of anastomotic leak and stricture after end-to-end circular anastomotic stapling averages 15% and 17% respectively (14, 27, 28). In comparison, we have previously reported leak and stricture rates which are three- to four-fold lower, 4% and 5% respectively, in patients undergoing the side-to-side anastomosis technique utilized in the current study (14). Significantly lower leak rates after linear stapled as compared to end-to-end circular stapling anastomotic techniques are consistent with several other reports (29–31). While mortality from anastomotic leaks may be decreasing, strictures occur in up to 56% of anastomotic leaks and can influence long-term symptoms (21, 28). Low rates of dysphagia and choking with swallowing in our series are arguably reflective of a technique that optimizes long-term function by minimizing anastomotic narrowing or stricture.

While our technique has remained consistent over time, we have recently introduced minor modifications. First, an approximate 45-degree angled wedge is removed from the lesser curve conduit tip using a double row GIA stapler, creating a more vascularized three to four cm “platform” for the future site of the intrathoracic anastomosis. We have also been closing the open end of the triangulated anastomosis with two to five sequential fires of an endo GIA tristapler, utilizing staples on only one side of the stapler knife to minimize the amount of tissue resected, then oversewing the staple line. Both are relatively minor modifications intended to further reduce anastomotic leaks. Since our publication in 2018, we have additionally been utilizing cryotherapy to the interspace entry site and two intercostal nerves above and below which has significantly improved postoperative analgesia and recovery after thoracotomy. Although there is a trend towards minimally invasive esophagectomy approaches as short-term QOL outcomes appear to be superior, we believe that intercostal cryotherapy has greatly mitigated any increased pain issues related to this open approach.

Existing literature fails to agree regarding the impact of postoperative complications on QOL (8, 9, 20). The LASER study found that the absence of 30-day postoperative complications was associated with improved physical and social functioning after 4.3 years (23). Alternatively, a prospective cohort study by Jezerskyte identified no overall QOL differences comparing patients with and without complications up to 24 months following surgery (20). While our univariate analysis identified an association of grade 2 or higher complications with lower scores in multiple FACT-E subscales, this did not remain significant by multivariable analysis. Rather, more advanced clinical tumor stage and the presence of disease recurrence were associated with lower scores on the Swallowing subscale. Increasing age was associated with better scores in multiple domains which may reflect the subjectivity of QOL and how perception of symptoms can change with age. Further study in this regard would be of interest.

Our study has limitations. As we measured QOL in long-term survivors, a selection bias for patients with lower mortality risk and, thus, better QOL is possible. While possible biases may exist between participants and non-participants, such as differences in anastomotic leak or stricture, the absolute numbers of these complications were small and, therefore, unlikely to influence overall outcomes. Patients surviving longer may establish a “new normal”, subjectively perceiving fewer symptoms over time, an evolution of symptoms which is not captured by our cross-sectional study (32).

As advances in multimodality therapy and immunotherapy continue to improve the prognoses of esophageal cancer patients, optimizing long-term QOL becomes increasingly important. Esophagectomy techniques which minimize complications and promote conduit function likely hold promise to improve long-term esophageal-specific QOL. In this series, our surgical approach to esophagectomy led to very favorable patient-reported long-term QOL which arguably can be attributed to the good function of a passive conduit. Future studies evaluating long-term QOL would benefit from a focus on other consistently performed surgical approaches for comparison.