Surgical Palliation

A palliative bypass may be useful when a tumour is unresectable and severe dysphagia or tracheoesophageal fistula has occurred after radiochemotherapy. Tracheoesophageal fistula (TE) has a survival of weeks to months. The quality of life with a TE may be improved with a palliative bypass. Constant aspiration of food, liquids, and saliva cause an extremely unpleasant death. Bypass should be proposed for younger, healthier patients. The operative mortality is 11-40%. Delay in treatment is the main reason for the high death rate.  Postoperative death rates are much higher in patients with cervical or tracheoesophageal fistulas (which many patients undergoing bypass have) compared with those who don't. Complications that can arise from this procedure are wound sepsis and anastomotic leaks. Overall, of those patients returning home after surgery, most (75%) are able to eat a full diet. Nevertheless, postoperative survival has been shown to be variant between 1.5-14 months, with a mean survival of 3-6 months.

If the tumour is left in situ, a bypass can be performed by alternative routes: presternal, or retrosternal. The reterosternal route offers the most direct route to the neck. The operation consists of a retrosternal gastric bypass with either drainage or ligation of the lower esophagus.  

It allows for postoperative radiotherapy to be an option and also for the re-establishment of digestive tract continuity. One study could not reestablish enteric continuity and therefore a esophageal exclusion was also performed. The stomach is the preferred organ and can be used entirely, or by creating a gastric tube to better fit into the mediastium.