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Salvage oesophagoplasty using a free jejunal transplant is the ultimate reconstruction possible after repeated failures using the classic procedures of oesophagoplasty. The free jejunal transplant appears to be the best choice. Twenty-five free jejunal transplants were performed by the same surgeon for such reconstructions including 13 cases involving benign lesions and 12 cases of cancer. There were no post-operative death and none of the transplantations was a complete failure although three cases of stenosis and fistulization occurred. Several recommendations can be made: save the existing digestive tract, redissect the residual digestive plasty and pull it up. The residual digestive flap can be examined by opacification or endoscopically in order to evaluate its length. An arteriography of the pediculated plasty gives information on its vascularization. A free jejunal graft can safely cover 25 to 30 cm. When possible, residual plasties should be positioned subcutaneously. The reconstruction of the cervico-thoracic oesophagus usually requires a vascular bypass with a saphene graft. In difficult cases, it may be necessary to remove a part of the sternal manubrium and the head of the clavicular bone in order to avoid compressing the jejunal graft. When the length of the reconstruction is greater than 30 cm, a long jejunal transplant with two pedicules (1 pedicule revascularized from the cervical vessels and the other pedicule from the internal thoracic vessels) is needed. An alternative technique would be a free antebrachial flap (six cases operated with two post-operative deaths at 6 weeks and two fistulas).(ABSTRACT TRUNCATED AT 250 WORDS)
Reversed gastric tube (RGT) esophagoplasty is preferred by the author as the primary procedure for esophageal replacement. Many patients undergoing RGT esophagoplasty, however, have previously had multiple operative procedures. A particularly challenging problem in esophageal reconstruction is the patient who has already had unsuccessful intestinal or prosthetic interposition operations in attempts to reconstruct the esophagus. In such patients, it has been possible to replace the esophagus by means of the RGT operation. Of 67 RGT esophagoplasties, 9 patients (13.4%) had previous interposition operations that had failed. Six had undergone colon interposition; 2 of these had strictured, 1 had partially sloughed leaving a cervical salivary fistula, and in 1 the proximal end was never patent. In each instance, bypass with RGT was performed without resecting the colon transplant. The colon had necrosed and was removed in 2 patients. Of the remaining 3 patients, in 1 a plastic esophageal prothesis had sloughed and two had free jejunal transplants, 1 of which had impaired vascularity and the other had fibrosed. The specific techniques used to reconstruct the esophagus by reversed gastric tube esophagoplasty, as they relate to this particular group of patients, are described.
The authors present their experience with 14 cases of esophagoplasty by right ileocolon interposition which were performed to re-establish the digestive continuity in 12 patients operated on for caustic burns induced esophageal strictures and 2 patients with esophageal neoplasm managed by esophagectomy. The current study aims to pin/point both the anastomotic risk and the technical difficulties related to the colon interposition graft anatomic trajectory and vascular supply. Given the utmost importance of both the preoperative correction of the nutritional deficit and the improvement of pulmonary function the authors suggest that esophagoplasty should bu preceded by a "preoperative intervention", consisting of ileocolic artery ligation, gastrostomy and pleural drainage. The acute respiratory failure was the immediate main threat following esophagoplasty, whereas cervical anastomotic breakdown was the complication which dominated the early postoperative period in terms of frequency and gravity, but the death rate was nil. When esophagoplasty by right ileocolon interposition simplicity and efficacy are taken into account it appears as the surgical therapy of choice whenever the local and general status of the patients allows it.
This study was made with the aim of specifying the general architecture of the venous system of the stomach and its mode of drainage under normal conditions, and also of investigating the role of the venous drainage in the origin of disunion, anastomotic fistula and structure after tubular esophagoplasty pedicled on the right gastroepiploic vessels. Sixty stomachs removed from fresh cadavers were studied by injection-corrosion, using colored Altufix P10 as the injection mass. 35 specimens were injected globally via the superior mesenteric v., 15 by the same route but after clamping of the splenic, left gastric and right gastric vv., which corresponds to the technique of gastrolysis performed in esophagoplasty, and 10 were injected simultaneously with media of four different colors via the left gastric, right gastric, superior mesenteric and splenic vv. to define their respective territories. Also studied were the origin, course, termination, territory and caliber of the main gastric veins. Analysis of the results confirmed the richness of the venous anastomoses of the stomach, effected on the one hand between the two extraparietal arches at the greater and lesser curvatures, and on the other by intraperitoneal communications arranged perpendicular to these two arches. It emerges that the right gastroepiploic v. cannot always ensure drainage of the entire stomach. The factors involved are discussed. The risk of venous stasis in gastric esophagoplasty must always be borne in mind.
Severe caustic injury with stricture may require esophageal reconstruction. The available methods of esophageal substitution do not satisfactorily replace the peristaltic and antireflux properties of the native esophagus. The authors report the results of two children treated with colon patch esophagoplasty and preservation of the injured esophagus. Both were 2 years of age when they accidently swallowed lye. Long esophageal strictures developed, which were resistant to repeated dilatation. Eleven and 13 months after the injury, the patients underwent colon patch esophagoplasty. A segment of the left colon was tailored to the length and shape of the opened stricture and was anastomosed side-to-side to the esophagotomy. One child later had a short recurrent stricture and diverticulum, which required revision of the distal end of the anastomosis. Follow-up endoscopic examination has shown healing of the esophagus and resolution of the strictures; both children are eating normally 3 years after surgery, without symptoms of gastroesophageal reflux. Colon patch esophagoplasty is an alternative to esophageal replacement for long caustic esophageal strictures. Its advantage is preservation of the peristaltic and antireflux mechanisms of the conserved esophagus.
An analysis of immediate and long-term results of surgical treatment of 170 patients with esophageal obstruction is presented. Esophagoplasty with different fragments of the gastrointestinal tract was used (87--ileocolon, 16--small intestine, 23--left half of the colon, 44--a stalk from the greater curvature of the stomach). The greater amount of complications due to incompetence of the esophageal anastomosis sutures was noted in patients after esophagoplasty with a fragment of the small (50%) and right half of the large (59.7%) intestine, more rarely-after plasty with a gastric stalk (15.9%) and left half of the colon (26.1%). There was no necrosis of the transplant from the left half of the colon. Severe ischemic lesions made their appearance in the fundal portion of the gastric stalk (2.2%), necrosis of the small intestine part of ileocolon developed in 16.1% of the patients. In the patients with less amount of postoperative complications one-stage esophagoplasty was performed. Reconstructive operations on the artificial esophagus were necessary in 43.6% of the patients. The main indication for it was mechanical dysphagia.
Five patients with severe reflux esophagitis were treated by retrosternal colic esophagoplasty for esophageal stenosis of caustic origin. In 4 cases there was anisoperistaltism and in one case isopersitaltism. Treatment was by antral cologastric anastomosis in all cases, with a undojejunostomy in 3 patients and a colojejunostomy on loop in Y in the 2 others. Mortality was absent and long-term results were very good. Colojejunostomy on loop in Y is a simpler procedure not requiring gastric resection and long-term results were similar. An even less complicated variant of the latter operation that does not require colic section is also described. Prophylaxis of reflux esophagitis after colic esophagoplasty is discussed, the Roux type deviation being proposed for the treatment of cologastric ulcer after esophagoplasty.
The author reports 12 cases which illustrate unusual aspects of colo esophagoplasty in post-caustic esophageal stenosis. 8 cases respresented post-caustic pharyngolaryngeal stenosis in which he recommended anastomosis of the colon with the oropharynx according to a personal technical variant. In 1 case associated with amputation of the epiglottis, he carried out a double pharyngo-colic Y-shaped anastomosis. He classified the pharyngotomy types in relation to the 3 main nerves, the lingual, hypoglossal and superior laryngeal nerves. In 3 cases the author carried out successfully retrosternal transposition of a colonic segement 6 months, 1 year and 4 years after pre-thoracic colo esophagoplasty. He reports 1 case of intrathoracic strangling of the colonic tube which occurred 1 year after retrosternal colo esophagoplasty, and wich was cured by intra-vascular vertical clectomy. In all cases the good results were maintained for a long period.
The experience of esophagoplasties in various benign diseases (566) and cancer (534) of the esophagus is outlined. The operation of choice now is extirpation of the esophagus by cervico-abdominal approach with one-state posterior-mediastinal esophagoplasty by the stomach or (in case of impossibility to form the graft from the stomach)--large bowel. If there are contraindications to such operation or in case of necessity of one-stage reconstruction of the pharynx the optimal operation is sub- and total bypass esophagoplasty by the large bowel.
A case is reported of a patient with a 9-cm stricture of the esophagus caused by ingestion of sodium hydroxide, who was treated by gastric antral patch esophagoplasty. In this procedure, a full-thickness pedicled patch of gastric antrum, based on the left gastroepiploic artery, was used to enlarge the esophageal lumen, thus allowing preservation of esophageal continuity and utilization of a functioning lower esophageal sphincter. The patient ate normally after the operation, and radiological, manometric, and esophageal pH monitoring studies indicated satisfactory esophageal function. Gastric antral patch esophagoplasty avoids the complications associated with esophageal bypass or resection. Previous long-term results of this procedure in patients with reflux-induced esophageal stricture have been good, and the technique merits consideration in the treatment of severe corrosive strictures.
From 1979 to 1996, 19 patients underwent gastric-tube esophagoplasty. There were 10 boys and 9 girls, aged between 1 year 4 months and 4 years 11 months at the time of surgery. In 1 patient the esophagoplasty was performed due to a long stenosis secondary to reflux; 3 others had caustic stenoses; and the remaining patients had esophageal atresia. In 17 cases an isoperistaltic gastric tube was brought up to the neck through the retrosternal space; in 2 an anisoperistaltic gastric tube was used, cervical mobilization being via the posterior mediastinum without a thoracotomy in 1 case and by the left transpleural route in the other. The cervical anastomosis was carried out in one surgical stage in 12 patients and in two stages in 7. In 1 patient the tube was resected due to necrosis of its proximal third; the child later underwent an esophagocoloplasty. Necrosis of the colic graft, mediastinitis, and septicemia occurred, leading to the only death in the series. There were 12 fistulas of the cervical anastomosis (63.3%) and 8 stenoses (42.1%). All fistulas, with 1 exception, closed spontaneously after 8 days to 2 months, and all stenoses were treated by endoscopic dilatation. Another patient developed a fistula of the gastric tube with chronic evolution to a stenosis of the distal third of the tube and communication with the right lower pulmonary lobe. A lobectomy and closure of the fistula were necessary. All patients were followed for a period of 1 to 16 years. At present, all of them swallow solid food normally. The evolution of the nutritional status was normal (eutrophic) in 14 of the 18 patients (77.7%) who survived the operation; 4 showed variable degrees of malnutrition. In 2 of these 4 cases the malnutrition was due to poor socioeconomic conditions, but was not related to the surgery. Redundancy, a problem associated with esophagocoloplasty, was not observed in any of the gastric tubes, which was attributed to the thickness of the gastric wall. The authors prefer the use of an isoperistaltic gastric tube (with proximal base) for esophageal replacement in children and recommend that the operation should be carried out when the child is able to swallow solid foods and walk. As in any other major surgical procedure, a good nutritional state is essential prior to operation.
Antral patch esophagoplasty is a new procedure for intractable fibrous stricture of the esophagus secondary to acid-peptic reflux. A full-thickness patch of gastric antrum, supplied by a pedicle based on the left gastroepiploic vessels, is inserted, mucosal surface to lumen, into the opened stricture. A fundoplication is done below the esophagoplasty to prevent reflux. The functional results were excellent in five of six patients. The procedure may have application also in other types of benign esophageal stricture.
PURPOSE: This is a report of 4 patients with long gap/pure esophageal atresia, who, after an initial gastrostomy and cervical esophagostomy at birth, were treated with a new technique called fundal tube esophagoplasty. METHODS: The technique consisted of mobilization of the distal esophageal stump, division of the left gastric artery, and mobilization of upper half of stomach. Both walls of the stomach were incised in the region of the fundus starting on the lesser curvature in such a way that a tube was created out of the fundus, and the native esophageal stump appears to be an extension of this neoesophagus. This neoesophagus was brought to the neck by the retrosternal route and in a second stage, esophago-esophageal anastomosis was made. Thal's fundoplication was added in 2 cases. RESULTS: All the stages have been completed successfully in 4 babies. They have been followed up for periods ranging from 8 to 24 months after restoration of esophageal continuity. All the children are thriving. CONCLUSIONS: Fundal tube esophagoplasty (1) serves to provide a neoesophagus of natural caliber, (2) utilizes native esophagus in reconstruction, (3) does not produce a space-occupying problem in the mediastinum, and (4) preserves the gastric reservoir function. In this early experience, it appears to fulfill all the requirements of a good esophageal substitute.
BACKGROUND/PURPOSE: Anastomotic leak and stricture are common causes of morbidity after esophageal repair. The authors describe a technique of patch esophagoplasty using decellularized human skin. METHODS: Twelve conditioned dogs underwent a cervical 2.0- x 1.0-cm esophagoplasty with AlloDerm. A gastrostomy tube was used for feedings until an esophagram was performed on the 10th to 14th postoperative day. Dogs were then given oral chow and followed up for leak and dysphagia. Animals were killed at 1-, 2-, and 3-month intervals and evaluated for stricture, diverticula formation, and patch histology. RESULTS: All animals survived, and none had sepsis or dysphagia. All esophagrams were without evidence of leak or stricture. At death there were no strictures or diverticula. Histologic examination of 1-month specimens showed partial reepithelialization of the patch with neovascularization. Control staining of AlloDerm was strongly positive for elastin. This was decreased in the region of the patch at 1 month. Two-month specimens showed intact epithelium and an increase in the caliber of new blood vessels. Three-month specimens showed no significant variation from 2-month animals. CONCLUSION: Decellularized human skin (AlloDerm) provides a temporary collagen framework on which esophageal healing can occur and function can be maintained.
In 136 patients with cicatrical strictures of the esophagus the author performed total esophagoplasty, using the left colon (89 cases), the right colon with terminal iliac portion (8 cases), the small intestine by Roux-Herzen-Judin technic (27 cases) and the small intestine with primary reconstruction of the graft (12 cases). The results obtained and also early and late complications of the methods of esophagoplasty employed are clinically analysed. Based on clinical examinations of the patients within the terms from 1 to 16 years, the data of roentgenokinematography and the degree of their rehabilitation, the function of a newly constructed esophagus is estimated.
The description of a modified technique of gastrostoma formation on small flexure is presented. Indications for this operation in patients with tumor and cicatrical esophageal strictures, planned for gastric esophagoplasty are formulated. The are authors regard a correctly created gastrostoma as the first stage of esophagoplasty. The main mistakes in gastrostoma creation that donTt permit to use the stomach for esophagus replacement are noted. The main principles and techniques of stoma creation on small flexure are described. The presented method is recommended for use in specialized esophageal departments and in general surgical hospitals.