Surgical treatment for upper or middle esophageal carcinoma occurring after gastrectomy: a study of 52 cases

Fifty-two patients presenting with upper or middle esophageal carcinoma after gastrectomy between 1980 and 2003 were analyzed retrospectively. Among them, there were five cases of total gastrectomy, six cases of proximal partial gastrectomy and 41 cases of distal subtotal gastrectomy. The interval between gastrectomy and the diagnosis of esophageal carcinoma ranged from 2 to 22 years. Surgical procedures included resection of the esophageal lesion with esophageal replacement using non-reversed or reversed gastric tubes (2 and 3 cases respectively), and short or long segment colon (5 and 40 cases respectively); two cases underwent a palliative procedure (jejunostomy). Complications included cervical anastomotic leaks (3 cases), pulmonary infection (3 cases), atelectasis (2 cases) and cordis arrhythmia (5 cases), all of which responded to treatment. In our group, resection of the esophageal lesions and reconstruction of the esophagus was performed in 45 cases (86.5%), exclusion and bypass procedure of esophageal carcinoma and following radiotherapy and chemotherapy in four (7.7%), eternal jejunostomy for intestinal nutrition in two (3.9%) and death occurred in one case (1.9%) due to multiple organ dysfunction syndrome (MODS). Esophageal resection combined with lymph node dissection is indicated for the treatment of upper or middle esophageal carcinoma following gastrectomy. While esophageal substitutes can include non-reversed or reversed gastric tubes as well as short or long segment colon interpositions, we usually recommend the use of colon interposition. The 1-, 3- and 5-year survival rate of cases with resection of the esophageal lesions and reconstruction of the esophagus was 84.6%, 57.7% and 26.7% respectively.     

贲门胃底切除后余胃食管直接吻合术治疗残胃贲门癌(附10例报告)

为减少残胃贲门癌全国切除术后常见并发症的发生，采用贲门胃底切除、余胃食管再吻合术治疗10例残胃贲门癌。结果全组术后均无吻合口瘘、胃食管反流和吻合口狭窄等并发症发生，病理检查均未发现切缘癌残留。表明该术式比全胃切除更符合解剖生理功能，可有效减少全胃切除术后的多种并发症，且不影响疗效。     

Surgical management of corrosive strictures of stomach.

BACKGROUND: Corrosive injuries of the upper aero-digestive tract are a frequent cause of morbidity in India. We report here our institution's experience in managing patients with corrosive strictures of the stomach. METHODS: Records of 28 patients who underwent definitive surgery for corrosive strictures of the stomach in our institution over a 15-year period were reviewed. RESULTS: The main presenting complaints were vomiting (75%), dysphagia (46%) and significant weight loss (100%). Pre-operative evaluation included barium and endoscopic studies. Most patients had antro-pyloric strictures (n=22); in 6 patients, however, near-total or total gastric involvement was observed. Thirteen (46%) patients had associated strictures of the esophagus; of these, 7 responded to esophageal dilation. Strictures of the stomach were managed with resectional procedures like distal gastrectomy (n=16), subtotal gastrectomy (1) or total gastrectomy (3) and esophagogastrectomy (1) in 21 (75%) patients. The remaining 7 patients underwent bypass procedures like gastrojejunostomy (5), stricturoplasty (1), and colonic bypass of esophagus and stomach (1). Three patients had entero-cutaneous fistulae in the postoperative period. One patient died in hospital of septicemia and malnutrition. CONCLUSIONS: In patients with corrosive strictures of the stomach, surgery, tailored according to the extent of gastric involvement and presence of associated esophageal strictures, gives excellent results.     

Efficacy of endoscopic surveillance of the upper gastrointestinal tract following distal gastrectomy for early gastric cancer

BACKGROUND/AIMS: How endoscopy can be used in the follow-up of the upper gastrointestinal tract in patients who underwent gastrectomy for early gastric cancer remains unclear. METHODOLOGY: Two-hundred and ten patients (137 males and 73 females, aged at initial gastrectomy 27-86, average age 56.5) were followed in the present study. Results of follow-up endoscopy of all patients, pathologic diagnoses of secondary tumors and interval between gastrectomy and detection of secondary tumor were reviewed. Cumulative incidence rate of second tumors in the upper gastrointestinal tract was then analyzed. RESULTS: Secondary tumor was observed by follow-up endoscopy in 7 patients including two gastric, one esophageal, one duodenal carcinoma and 3 gastric adenomas. The interval between initial gastrectomy and diagnosis of secondary tumor ranged from 20 to 71 months (average 51.7 months). All carcinomas were early stage and localized within the mucosa. Three patients with secondary cancer were successfully treated by endoscopic mucosal resection. The cumulative incidence rate of secondary cancer in the gastric remnant, esophagus and duodenum at six years after initial gastrectomy was 1.0, 0.8 and 0.5%, respectively. The overall incidence rate of secondary tumors of the upper gastrointestinal tract at six years after distal gastrectomy was 4.1%. CONCLUSIONS: The present findings indicate that annual follow-up endoscopy of the upper gastrointestinal tract after gastrectomy for early gastric cancer can be introduced to detect carcinoma at an early stage, thus improving the survival rate of gastrectomy patients.     

Esophageal cancer after distal gastrectomy

The effect of gastrectomy on the subsequent development of esophageal cancer was investigated. Duodenogastroesophageal reflux is thought to be common in patients after distal gastrectomy, but whether this contributes to the development of esophageal cancer in such patients is controversial. We retrospectively evaluated 153 patients who underwent subtotal esophagectomy for thoracic esophageal cancer between January 2002 and July 2005. They were divided into two groups, according to whether or not they had previously undergone a gastrectomy: group 1, comprising 14 patients who had undergone gastrectomy and group 2, comprising 139 patients who had not. Clinical profiles of the patients were obtained from the medical records and the whole resected esophagus was histopathologically examined. The interval between gastrectomy and esophagectomy in group 1 was significantly shorter in the patients who had undergone gastrectomy for gastric cancer (10.5 +/- 4.2 years) than in those who had undergone gastrectomy for a peptic ulcer (28.9 +/- 3.0 years). The interval was also somehow shorter in the patients for whom anastomosis had been performed by Billroth I (21.3 +/- 5.6 years) compared with Billroth II (29.7 +/- 3.2 years), although the difference did not reach its statistical significance (P = 0.11). Moreover, the proportion of lower third tumors in patients after gastrectomy was significantly higher compared with that of the patients with intact stomach. These findings suggest that a history of gastrectomy is associated with more lower-third squamous cell esophageal carcinoma.     

Surgical management of carcinoma of the hypopharynx and cervical esophagus.

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 with a carcinoma of the cervical esophageal region that developed after laryngectomy for laryngeal cancer. The mean age of the patients was 57.5 years (range: 41-73). One hundred and sixty-seven patients underwent surgical exploration (operability rate 59.5%), and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). In 33 cases a laryngopharyngo-cervical segmental esophagectomy with free intestinal loop transplantation was performed, with an operative mortality of 6.1%. One hundred and three patients underwent laryngo-pharyngo-total esophagectomy, and the digestive tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus who refused laryngectomy, with an hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded in patients operated on for carcinoma of the hypopharynx than in patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs. 26% and 43% vs. 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)     

Four cancer cases after esophageal atresia repair: Time to start screening the upper gastrointestinal tract

Esophageal atresia(EA) is one of the most common congenital digestive malformations and requires surgical correction early in life. Dedicated centers have reported survival rates up to 95%. The most frequent comorbidities after EA repair are dysphagia(72%) and gastroesophageal reflux(GER)(67%). Chronic GER after EA repair might lead to mucosal damage, esophageal stricturing, Barrett's esophagus and eventually esophageal adenocarcinoma. Several long-term follow-up studies found an increased risk of Barrett's esophagus and esophageal carcinoma in EA patients, both at a relatively young age. Given these findings, the recent ESPGHAN-NASPGHAN guideline recommends routine endoscopy in adults born with EA. We report a series of four EA patients who developed a carcinoma of the gastrointestinal tract: three esophageal carcinoma and one colorectal carcinoma in a colonic interposition. These cases emphasize the importance of lifelong screening of the upper gastrointestinal tract in EA patients.     

A case of using the remnant stomach as substitute after esophagectomy for esophageal cancer with history of distal gastrectomy

A 63-year-old man who had a distal subtotal gastrectomy and retrocolic end-to-side gastrojejunostomy was admitted because of a mid-thoracic esophageal cancer. He underwent a two-stage subtotal esophagectomy and reconstruction using the remnant stomach without microvascular anastomosis. We preserved the splenic artery, splenic vein, and the short gastric artery. The remnant stomach was pulled up together with the pancreas through the anterior sternal route. The superiority of this technique is that microvascular anastomosis is not needed because a sufficient blood supply from the splenic artery and only two anastomoses are needed, compared with three or four anastomoses when using the colon. This technique is also likely to be safer for patients requiring an esophagectomy after a distal gastrectomy.     

Preserved esophagogastric manometric motility in patients after distal gastrectomy.

BACKGROUND/AIMS: A prospective study resolved whether commonly employed distal gastrectomies could influence the esophagogastric manometric measurements and the role of vasoactive intestinal polypeptide in mediating motility after surgery. METHODOLOGY: Studied groups consisted of 20 patients following radical subtotal gastrectomy for gastric cancer, 20 patients after subtotal gastrectomy for duodenal ulcer and 20 controls. Fasting blood was obtained to measure serum vasoactive intestinal polypeptide levels. A pneumohydraulic infusion system measured esophagogastric motility parameters. RESULTS: Measured lower esophageal sphincter pressures in subjects of gastric cancer surgery, duodenal ulcer surgery and controls were 15.3 +/- 4.7, 13.1 +/- 5.3 and 12.6 +/- 5.0 mmHg, respectively (NS), while the sphincter lengths were 3.15 +/- 0.81, 3.22 +/- 0.79 and 2.86 +/- 0.85 cm, respectively (NS). In addition, other parameters including lower esophageal body remained unchanged. The serum vasoactive intestinal polypeptide levels of three groups were 24.1 +/- 10.8, 22.5 +/- 9.5 and 21.3 +/- 7.8 pg/ml, respectively (NS). CONCLUSIONS: Neither gastric cancer nor duodenal ulcer in distal stomach removal can alter the lower esophageal body and LES manometric motilities. Unchanged serum VIP levels after gastric surgery are likely one of the mechanisms preserving esophagogastric integrity.     

Metastasis of an esophageal carcinoma to a giant gastric ulcer.

In patients with esophageal carcinoma it is considered that stomach metastasis is induced mainly via the lymphatic route rather than via the bloodstream route that is common in other types of distant organ metastasis. A 56 year-old patient is reported who underwent synchronous subtotal esophagectomy and total gastrectomy for a middle third esophageal carcinoma and a giant peptic ulcer within the gastric fundus. The final histopathologic examination revealed a squamous cell carcinoma of the esophagus with concomitant squamous tumor implantation within the gastric ulcer. The increased cell proliferation in the ulcer margin can serve as a "biological background or base" for implantation.     

Early esophageal cancer in patients with a history of gastrectomy for gastric cancer

To detect early esophageal cancer effectively, it is important to select high-risk groups. Because we often see early esophageal cancer after gastrectomy for gastric cancer, we investigated 11 early esophageal cancers treated endoscopically in 7 patients who had undergone gastrectomy for gastric cancer. Their average age was 70.8 ± 5.2 years. Median interval between previous gastrectomy and the diagnosis of esophageal cancer was 10 years. Endoscopic examination revealed mild bile reflux into the remnant stomach and esophagitis, but there was no case of Barrett's esophagus. Histological types were all squamous cell carcinoma. Although it has been reported that cancer development is most frequent in the lower esophagus after gastrectomy, we noticed that the majority of these were located in the middle thoracic esophagus (6/11, 55%), similar to general esophageal cancer. As all cases were detected by a regular checkup, it is important to follow up patients after gastrectomy for gastric cancer.     

Comparison of gastroesophageal reflux in 100 patients with or without prior gastroesophageal surgery

Background and purpose  The role of duodenogastroesophageal reflux (DGER) in gastroesophageal reflux disease (GERD) remains controversial. Few studies of reflux have compared patients with an intact stomach to those without intact stomach after gastroesophageal surgery. This study aimed to investigate differences of the refluxate between patients with and without prior gastroesophageal surgery and to assess the role of DGER in GERD. Methods  One hundred patients (34% with reflux symptoms) were divided into four groups: 23 with an intact stomach, and 27, 42, and 8 with esophagectomy followed by gastric tube reconstruction, distal gastrectomy, and total gastrectomy, respectively. Reflux symptoms were evaluated, and endoscopy and simultaneous 24-h monitoring of esophageal pH and bilirubin were performed. Results  Of 44 patients with increased DGER but without increased acid reflux, three had severe reflux esophagitis and seven had Barrett’s esophagus. DGER was most frequent under weakly acidic conditions in the intact stomach, esophagectomy, and distal gastrectomy groups. Pure acid reflux and DGER at any pH were elevated in GERD patients with an intact stomach, while weakly acidic and alkaline DGER were elevated in GERD patients after gastrectomy. Esophagectomy patients had reflux with the combined characteristics of those in the intact stomach and gastrectomy groups. Weakly acidic or alkaline DGER was correlated with symptoms and esophageal mucosal changes in gastrectomy patients. Conclusion  The refluxate causing GERD differed between patients with and without prior gastroesophageal surgery. Weakly acidic or alkaline DGER may cause both symptoms and esophageal mucosal damage.     

残胃胸内移植治疗胃大部切除术后食管、贲门癌(附26例报告)

目的 探讨胃大部切除术后食管、贲门癌26例的外科治疗方法和效果。方法 26例均采用经左胸后外侧切口癌切除，将残胃连同脾脏、胰尾移于胸腔，行食管残胃吻合术。主动脉弓上吻合10例，弓后吻合9例，弓下吻合7例；手工吻合5例、器械吻合21例。结果 全组无吻合口瘘和手术早期死亡，术后并发症率为15．4%(4／26)。1年生存率73．9％(17／23)，3年生存率53.3％(8／15)，5年生存率28．6%(2／7)。结论 采用将残胃、脾脏和胰尾移入胸腔，行食管残胃吻合，可增加残胃上移高度，保证食管残胃的无张力吻合。此术操作简单、创伤小、并发症少，可作为消化道重建的方式之一。     

Prevalence of Helicobacter pylori in the residual stomach after gastrectomy for gastric cancer

BACKGROUND/AIMS: In recent years, the role of Helicobacter pylori in gastritis of the residual stomach has attracted much attention. We investigated the prevalence of Helicobacter pylori in the residual stomach after distal gastrectomy for gastric cancer, as well as the correlations between Helicobacter pylori positivity and clinical characteristics or the severity of gastritis in the residual stomach. METHODOLOGY: The subjects were 66 patients with gastric cancer who underwent distal gastrectomy with Billroth I reconstruction at our department. Helicobacter pylori was detected by the 13C-urea breath test, and patients were considered to be Helicobacter pylori-positive if the delta 13C value was > 2.5@1000. RESULTS: The overall Helicobacter pylori positivity rate of the gastrectomy patients was a high 80.3%, with the rate being especially high in patients under 60 years of age and in those tested less than 5 years after surgery. There was a close relationship between Helicobacter pylori positivity and the severity of gastritis. CONCLUSIONS: Helicobacter pylori infection appears to cause the development of gastritis. Helicobacter pylori eradication needs to be taken into consideration in the management of Helicobacter pylori-positive patients after gastrectomy.     

Telescopic esophageal anastomosis: operative technique, clinical experiences

The authors reconstructed the continuity of the alimentary tract by performing telescopic esophagogastrostoma in 208 patients who underwent either esophageal resection or total gastrectomy. The substance of the telescopic technique is to invaginate the distal section of any oral tubular organ to the lumen of an aboral tubular one and to fix it there. In case of telescopic esophageal anastomosis a 10-15 mm long esophageal segment is invaginated into the gastric tube or jejunum. A 3-4 mm wide serosal surface of the wall of the distal anastomosing organ straps the esophagus circularly. Ninety-six transthoracic and 12 transhiatal esophagectomies, 19 partial esophageal resections, four esophageal bypasses, and 77 total or extended total gastrectomies were reconstructed using telescopic anastomosis. Undisturbed healing could be observed in 67 patients after esophageal operations and in 46 patients of total gastrectomies. Anastomosis leakage occurred in 12 of 108 patients (11.1%) after cervical esophagogastrostomy. Leakage could be observed in 7 of 44 patients (15.9%) after end to side and in 5 of 64 patients (7.8%) in case of end to end esophago gastrostoma. There were no failures after two cases of cervical esophago-ileocolostoma and 21 of esophagogastrostomas in the thoracic position. All of the 59 intra-abdominal anastomoses healed without complication. Thirteen of 131 patients (9.9%) died after esophageal operations and four of 77 (5.2%) after gastrectomies. There were no mortal complications due to anastomotic leakage. The telescopic anastomosis is a safe alternative method in cases of total gastrectomy or esophageal operation.     

Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for squamous cell carcinoma of the lower thoracic esophagus

AIM： To evaluate the clinical outcome of Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for patients with squamous cell carcinoma of the lower thoracic esophagus. METHODS： From January 1998 to December 2001, 73 patients with lower thoracic esophageal carcinoma underwent Ivor-Lewis subtotal esophagectomy with two-field lymphadenectomy. Clinicopathological information, postoperative complications, mortality and long term survival of all these patients were analyzed retrospectively. RESULTS： The operative morbidity and mortality was 15.1% and the mortality was 2.7%. Lymph node metastases were found in 52 patients （71.2%）. Nodal metastases to the upper, middle, lower mediastini and upper abdomen were found in 13 （17.8%）, 15 （20.5%）, 30 （41.1%）, and 25 （34.2%） patients, respectively. Postoperative staging was as follows： stage Ⅰ in 5 patients, stage Ⅱ in 34 patients, stage Ⅲ in 32 patients, and stage Ⅳ in 2 patients, respectively. The overall 5-year survival rate was 23.3%. For NO and N1 patients, the 5-year survival rate was 38.1% and 17.3%, respectively （X^2 = 22.65, P 〈 0.01）. The 5-year survival rate for patients in stages Ⅱ a, Ⅱ b and Ⅲ was 31.2%, 27.8% and 12.5%, repsectively （X^2 = 29.18, P 〈 0.01）. CONCLUSION： Ivor Lewis subtotal esophagectomy with two-field （total mediastinum） lymphadenectomy is a safe and appropriate operation for squamous cell carcinoma of the lower thoracic esophagus.     

Outcomes of endoscopic and surgical resection for a second primary cancer in the residual cervical esophagus after thoracic esophagectomy

Patients who have received subtotal esophagectomy for thoracic esophageal cancer must be closely monitored for second primary malignancies. The purpose of this study is to review and assess patients who developed a second primary esophageal cancer in the residual cervical esophagus. Between 1996 and 2010, 10 patients were diagnosed in our hospital with esophageal squamous cell cancer in the residual cervical esophagus after undergoing thoracic esophagectomy and were treated with endoscopic or surgical resection. Data from these patients were reviewed retrospectively. Seven of the 10 patients (70%) had multiple primary carcinoma lesions at the time of their esophagectomy. A second primary cancer in the residual cervical esophagus was detected in eight patients during follow-up endoscopic examinations while the patients were still asymptomatic. Seven of the patients underwent endoscopic resection for a superficial cancer. None of those patients experienced any complications, and all are currently alive and cancer-free. The remaining three patients underwent resection of the cervical esophagus with regional lymph node dissection. Two of those patients experienced severe complications; one subsequently died (hospital death) from pneumonia, 12 months after surgery, while the other died from recurrence of his cancer. The third patient is alive and cancer-free. Early detection of a second primary malignancy in the residual cervical esophagus followed by endoscopic resection is the best treatment strategy for patients who previously received subtotal esophagectomy for thoracic esophageal cancer. Surgical resection puts patients at high risk of mortality or morbidity.     

Synchronous gastric tumors associated with esophageal cancer

Objective: Synchronous gastric tumors (including benign and secondary tumors) associated with esophageal cancer present diagnostic and therapeutic issues. We investigated this synchronous association, and retrospectively determined the frequency of the gastric tumors and the clinical characteristics.
Methods: In a series of 208 patients with esophageal cancer, we investigated the synchronous gastric tumors, as well as the frequency of association, clinicopathological characteristics, diagnosis, treatment, and the clinical outcome after surgery.
Results: Twenty-eight gastric tumors were found in 24 patients. Adenocarcinoma was most frequent. Most of these tumors were located at the upper or middle third of the stomach. Eight gastric tumors in six patients could not be detected preoperatively. Six of these tumors including a gastric remnant cancer were detected in the resected stomach, and two leiomyomas were detected during the operation. In one patient in which an endoscope could not pass through the esophagus, a leiomyoma was detected in the resected stomach. For the gastric cancers, total gastrectomy or proximal gastrectomy with lymph node dissections was performed. For the benign tumors, partial resection of the stomach was performed, and endoscopic resection was performed preoperatively for an adenoma. In both the postoperative hospital mortality rate and the survival rate after surgery, there were no significant differences between the patients with and without gastric tumors.
Conclusions: Synchronous gastric tumors associated with esophageal cancer are not rare. When an endoscope cannot pass through the esophagus before surgery, other techniques must be performed to explore the stomach. For these patients, surgical treatment should be adapted positively.     

Survival after curative resection for stage IE and IIE primary gastric lymphoma

BACKGROUND/AIMS: There is considerable controversy regarding the optimal treatment of patients with primary gastric lymphomas. However, surgery still plays an important role in the management of stage IE and IIE gastric lymphomas. We aimed at assessing survival of primary gastric lymphoma cases with stage IE or IIE that were surgically treated at the Surgical Oncology Department. METHODOLOGY: Thirty-seven patients with stage IE and IIE primary gastric lymphoma who were surgically treated and had complete follow-up from January 1990 to September 1998 were reviewed retrospectively. Patients' age, gender, tumor location, tumor grade, histologic type, depth of tumor invasion, regional lymph node status, tumor stage, type of gastrectomy (total/subtotal), combined resection, extensive lymphadenectomy, adjuvant chemotherapy were used as the clinicopathologic variables. RESULTS: Five-year survival rates for stage IE and stage IIE disease were 75% and 37%, respectively. The overall 5-year survival rate of the patients was 57%. Univariate analysis demonstrated that age, tumor stage, and type of gastrectomy were associated with prognosis, but only type of gastrectomy (subtotal gastrectomy) and tumor stage were found to be independent prognostic factors (P < 0.05). CONCLUSIONS: To obtain prolonged survival we recommend radical resection with extensive lymphadenectomy for malignant lymphoma stages IE and IIE. Patients with small distal lymphomas of the stomach can be treated with subtotal gastric resection.     

Is the surgical stress associated with worse survival in patients with esophageal cancer?--Analysis of colon substitution for 37 patients with remnant stomach

BACKGROUND/AIMS: Colon substitution is a standard method of reconstruction, although an aggressive surgery, for patients with esophageal carcinoma who have remnant stomach. Presence of postoperative complication was reported to be a risk factor for worse survival in the patients with esophageal cancer. We evaluated the affect of this surgical stress on the postoperative course and long-term survival of patients with esophageal carcinoma. METHODOLOGY: Between 1980 and 2002, a total of 37 patients with primary thoracic esophageal squamous cell carcinoma, who had history of gastrectomy due to gastric ulcer, underwent R0 esophagectomy followed by colon substitution (colon group). The clinical affect of colon substitution was retrospectively evaluated in comparison with gastric substitution as the control group (stomach group). RESULTS: The postoperative hospital morbidity rate was significantly higher in the patients with remnant stomach than in the control group. Although the clinicopathological features in both groups were similar, except operative time and bleeding volume, the overall and cause-specific survival of the remnant stomach group were significantly worse than those of the control group. Multivariate analysis suggested that remnant stomach was an independent risk factor for a worse survival. CONCLUSIONS: Surgical stress and postoperative complications, resulted by colon substitution for the patients with remnant stomach, might be associated with worse survival of patients with esophageal cancer.