Prevention of post-burn scarring esophageal strictures, strategies of surgical treatment

Experience of treatment of 52 patients with oesophageal chemical burn in acute and early postburn period was analyzed, as well as in 649--with oesophageal postburn cicatricial stricture (OPCS). In 18 patients perforation of esophagus had occurred during performance of bougienage. Rational complex of diagnostic and therapeutic measures in such patients was determined. The results of bougienage in patients with OPCS were summarized. Causes of the oesophageal perforation occurrence during bougienage were analyzed. Tactics of surgical treatment of esophageal perforation was determined. Analysis of the treatment results and of the main causes, which conditioned upon the postoperative complications occurrence, was conducted.     

食管癌和贲门癌术后吻合口重度瘢痕狭窄的外科治疗

目的总结食管癌和贲门癌术后吻合口重度瘢痕狭窄外科治疗的经验。方法对24例重度吻合口瘢痕狭窄并下咽困难的患者行二次手术治疗。其中,原发肿瘤为食管癌17例(9例为颈部食管胃吻合,8例为胸内食管胃弓上吻合),贲门癌7例(6例为胸内食管胃弓下吻合,1例为经腹食管胃膈下吻合);狭窄段长0,3～0．5cm、在瘢痕基础上形成蹼状者18例,狭窄段长0．5～1．0cm、环形狭窄呈收缩状者6例。二次手术解剖吻合区的吻合口上下各1—2cm范围,在距吻合线上下各2～4mm处分别切开一半食管腔和胃腔,然后切除部分瘢痕狭窄环组织,再行食管-胃单层吻合。结果24例成功地完成二次手术,1例出现颈部吻合口瘘,无手术死亡。术后随诊2—3年,患者可顺利进软食和普食,未发生二次吻合口狭窄,生活质量明显提高。结论食管癌和贲门癌术后发生的吻合口重度瘢痕狭窄,可行二次手术切除部分瘢痕狭窄环再吻合,效果较好。     

Shunting esophagocolonoplasty in the treatment of postburn cicatricial esophageal stricture

The prospective analysis of the results of treatment of postburn cicatricial esophageal stricture (PCES) in 338 (32%) patients, using shunting retrosternal esophagocolonoplasty (SRECP), constituting 76.1% of esophagoplasties performed, was conducted. Postoperative mortality was 4.7% (16 patients died). Early postoperative complications had occurred in 116 (34.5%) patients and the late--in 68 (24.9%). SRECP constitutes the method of first choice in patients, suffering tubular PCES and in formation of fistula, diverticulum and false ways. The standard variant of the procedure includes the performance of wide one-raw esophago-colonoanastomosis in end-to-end fashion with isoperistaltic passage of transplant. Such a tactic owes significant advantages, such as the lower risk of specific severe early and late postoperative complications occurrence, and also secures the esophagoplasty functional adequacy.     

An improved antireflux esophageal-intestinal anastomosis in gastrectomy]

An improved method for the formation of a cuff-like end-to-side vertical anastomosis between the esophagus and intestine with antireflux properties was applied in gastrectomy in 142 patients with predominantly stage III gastric carcinoma. The postoperative mortality was 3.5%. Microincompetence of the sutures of the esophago-intestinal anastomosis, which did not result in death, was encountered in 2.1% of patients. Reflux esophagitis occurred in the late-term period in 9.3% of patients, cicatricial strictures of the anastomoses developed in none of the cases. The method suggested for the formation of an esophagointestinal anastomosis is simple, reliable, and may be successfully used in gastrectomy.     

Experience of surgical treatment of the patients with post-burn cicatricial gastric stenosis

Experience of surgical treatment of 48 patients with postburn cicatricial gastric stenosis was presented. In 28 of them the combined gastric and esophageal stricture were reveal. Gastric resection according to Billroth-I was performed in 26 patients, gastroduodenostomy according to Finney--in 4, gastric resection according to Hoffmeister-Finsterer--in 5, gastroenterostomy according to Belfler-Brown--in 10 and other operations--in 3. One patient died. For the treatment of combined stricture esophageal passability was restored using bougienage, optimally--along the ring-like thread-guide, conducted, while performing gastric operation, through the mouth, esophagus, stomach and brought out via microgastrostomy.     

236例横结肠代食管术的经验

对２３６例横结肠代食管术治疗食管烧伤瘢痕狭窄８９例及食管癌１４７例的临床经验进行报道。总并发症率１１％，吻合口瘘发生率４．７％，吻合口狭窄发生率２．５４％。横结肠是全食管的理想替代物。横结肠有足够的长度，利用左结肠动脉升支能提供良好血运，横结肠段顺蠕动移植更符合生理要求而易游离。行食管、结肠套入式吻合可减少吻合口瘘发生。对食管瘢痕狭窄病例应尽早进行手术。     

Management of corrosive esophageal burns in 149 cases

OBJECTIVES: We sought to present our experience in the management of esophageal burns. METHODS: From April 1976 through October 2003, 149 patients with corrosive esophageal burns were included in this study. Treatment modalities consisted of modified intraluminal stenting in 28, colon interposition in 71, gastric transposition in 25, repair of cervical stricture with platysma myocutaneous flap in 17, and miscellaneous operations in 12 patients. Eleven of these patients underwent the above procedures twice at our institute. The remaining 7 patients were treated with conservative therapy. RESULTS: Twenty-three patients recovered from intraluminal stenting, and 5 experienced stricture after stent removal. One of the 5 patients with failed stents responded to bougienage, and the remaining 4 patients required esophageal reconstruction later. Of the 71 colon interpositions, 5 patients died postoperatively, and complications consisted of proximal anastomotic fistula in 17, anastomotic stenosis in 6, and abdominal incision dehiscence in 2 patients. Postoperative complications in the 25 patients with gastric transpositions comprised anastomotic stricture in 2 patients and empyema in 1 patient. There was a cervical leak in 1 of the 17 patients undergoing the repair of cervical esophageal or anastomotic stricture with a platysma myocutaneous flap. One of the patients in the group undergoing 12 miscellaneous procedures died 8 months after surgical intervention. All the survivors currently eat regular diets. CONCLUSIONS: Intraluminal stenting can prevent the formation of caustic esophageal stricture. The location of the cicatricial esophagus dictates whether to perform concomitant esophagectomy during esophageal reconstruction. Platysma myocutaneous flap repair is an excellent method for the treatment of severe cervical esophageal or anastomotic stricture.     

Endoprosthesis of rigid and extended cicatricial strictures of the esophagus]

The article describes treatment of 65 patients with postburn, extended, rigid cicatricial strictures of the esophagus by the method of temporary endoprosthetics. Most patients had an extended stricture. In 44 patients the diameter of the stenosed segment measured no more than 4 mm. Stage endoprosthesis of the esophagus was carried out in 32 patients. Devices by which intraoperative dilatation of the stricture can be achieved and its rigidity measures are shown, as well as designs of esophageal endoprostheses and an extractor of the endoprosthesis. The method suggested by the authors produced good results in 60 patients, esophagoplasty had to be undertaken in the remaining 5 patients. There were no fatal outcomes.     

Iatrogenic esophageal perforation in forcing bougienage of its post-burn cicatricial stricture

While performing forceful esophageal bougienage for postburn cicatricial stricture its wall perforation have occurred in 9 of 57 patients. All the patients were operated on. For perforation of thoracic esophagus transabdominal transdiaphragmatic mediastinal drainage was performed and for subdiaphragmatic perforation--closure of the defect with Nissen fundoplication, gastrostomy with temporary conduction of ring--like guide fishing-line. One patient died.     

横结肠代食管术治疗小儿食管化学烧伤后瘢痕狭窄

目的 了解横结肠代食管术治疗小儿食管严重化学烧伤后瘢痕狭窄的应用价值.方法 回顾分析1972年11月-2008年9月笔者单位收治的46例食管严重化学烧伤患儿的临床资料.患儿均采用保留左结肠动脉升支、经胸骨后隧道顺蠕动方向间植横结肠的方法重建食管,其中行颈食管-横结肠吻合32例、咽-横结肠吻合14例.结果 46例患儿术后无一例死亡,其中7例出现并发症:颈部吻合口瘘4例、吻合口狭窄2例、术后呼吸困难1例.均经再次处理后痊愈.39例患儿随访1～26年,生长、发育、进食情况与同龄儿童无异.结论 左结肠动脉升支供血、横结肠顺蠕动方向、经胸骨后径路作结肠与下咽或颈食管吻合术,是治疗小儿食管化学烧伤后瘢痕狭窄的较佳方法.     

先天性食管闭锁的外科治疗

目的 总结32例先天性食管闭锁手术治疗经验。方法 手术均采用食管上盲端前壁肌层U形翻转，即经胸膜外入路充分游离食管上端及瘘管，近气管侧缝扎切断瘘管。用剪刀将远端食管前壁纵行剪开5min，吻合前距吻合口上方10min处行食管上下两端浆肌层缝合3针，然后距吻合口上方15～20min处将食管前壁肌层切开，从切开处向吻合口方向从两侧纵行切开肌层至吻合口约5mm，轻轻分离前壁肌瓣，形成U形向下翻转，缝合在食管远端浆肌层上。结果 32例中17例采用此方法未发生吻合口瘘，1例吻合口狭窄。2例成功行一期胃代食管术。结论 食管上盲端前壁肌瓣U形翻转能有效预防吻合口瘘及狭窄。Ⅰ、Ⅱ型食管闭锁采用一期胃代食管术，可避免二次手术。     

Characteristics of surgical treatment of benign bifurcation strictures of the hepatic ducts

Experience in the treatment of 195 patients with benign bifurcation stricture of the hepatic ducts is discussed. This group was made up of patients with the cicatricial process involving the region of the bifurcation or continuing to one or both lobar hepatic ducts. Two basic methods of bile--diverting operations were used: with carcass drainage (mono- and bilateral) of the anastomosis and hepatic ducts (n-155) and without a carcass drainage with the formation of a widecholecysto- intestinal anastomosis (through inclusion of the left lobar hepatic duct) by means of interrupted sutures without grasping the mucous membranes of the hepatic ducts and intestine (h-36). A combined method was used in 4 patients with an isolated stenosis of the right hepatic duct and an intact left hepatic duct. Intubation of both lobar hepatic ducts is considered necessary in patients with a bifurcation stricture in the existence of indications for carcass drainage of the bile-diverting anastomosis. Analysis of the immediate and late--term results showed that the postoperative period was more favourable in patients with bilateral carcass drainage of the bile-diverting anastomosis and in those with a precision anastomosis that in patients with monolateral drainage (complications occurred, respectively, in 16.3% and 46.6% of patients, and a good late-term results was encountered, respectively, in 78.5% and 55% of patients). The stricture did not recur in patients with a precision anastomosis and in those with bilateral carcass drainage.     

58例结肠代食管术治疗食管良性狭窄

目的 总结结肠代食管手术治疗食管良性狭窄的经验及效果.方法 58例中男39例,女19例.年龄16～67岁,平均36岁.先天性食管狭窄2例,创伤性3例,瘢痕性狭窄53例(均为腐蚀剂烧伤).行一期游离空肠,咽空肠吻合术,远端空肠旷置,二期结肠代食管术3例次;胸骨后途径食管结肠颈部端侧吻合转流术56例次.结果 无手术死亡,手术经过较为顺利.术后出现全结肠坏死2例、吻合口瘘7例、吻合口狭窄2例、左喉返神经损伤3例.52例随访1～16年,1级(效果极好)40例、2级(很好)9例、3级(满意)2例、4级(不满意)1例.结论 结肠代食管术是治疗食管良性狭窄较为理想的手术.     

食管化学烧伤后狭窄的手术治疗

目的 探讨食管化学烧伤后狭窄的外科治疗及横结肠代食管手术的应用价值。方法 106例食管化学烧伤后狭窄的病人均采用横结肠代食管手术、保留结肠左动脉升支、胸骨后顺蠕动吻合，除横结肠咽腔吻合32例外，均横结肠食管颈部吻合。结果 无手术死亡。手术后发生颈部吻合口瘘12例、吻合口狭窄8例、气管切开3例，经治疗后均痊愈。结论 食管化学烧伤后应积极采取胸骨后横结肠代食管术，行横结肠食管颈部吻合或结肠咽腔吻合都是适宜的。     

Collis-Nissen gastroplasty for shortened esophagus: long-term evaluation.

OBJECTIVE: The authors studied the short- and long-term results of an esophageal lengthening procedure (Collis gastroplasty) combined with a Nissen fundoplication in the management of patients with shortened esophagus and stricture secondary to gastroesophageal reflux disease. Summary Background Data There are several options for managing a shortened esophagus. There have been few long-term series with analysis of results regarding a lengthening procedure combined with a total fundoplication. METHODS: A personal series of 52 patients was examined with complete follow-up available for an average of 7 years. RESULTS: There were no deaths, esophageal leaks, or esophageal complications in the early postoperative period. Control of reflux was excellent and all patients had their dysphagia improved. The majority of patients with preoperative strictures required at least one postoperative dilation, but in most the need for dilation was short term. CONCLUSIONS: The Collis-Nissen procedure is a safe and reasonable alternative in the small subset of patients with severe reflux disease causing a shortened esophagus and stricture.     

食管胃、空肠唇状吻合术的临床应用

目的探讨食管胃空肠吻合术对预防食管癌、贲门癌术后并发症的影响。方法54例食管癌、贲门癌患者采用食管胃、空肠唇状单层Gambee法吻合,食管胃吻合43例,食管空肠吻合11例。结果全组术后恢复顺利,无吻合口瘘、吻合口狭窄及明显反流性食管炎发生。术后3～12月钡餐检查示吻合口口径平均1.6(1.2～2.0)cm。54例平均随访5.8(1.5～8.0)年,术后3年、5年生存率分别为47.6%(20/42)和14.3%(14/28)。结论单层唇状吻合重建消化道有单层吻合和套入式吻合的双重优点,可防止吻合口瘘、吻合口狭窄和反流性食管炎的发生。     

Esophagogastrectomy for benign esophageal stricture. Fate of the esophagogastric anastomosis.

Eighty-nine patients who had resection of benign esophageal stricture with esophagogastrostomy were reviewed through medical records and by mailed questionnaire. The 30-day mortality rate was 8.9%. Seventy-six patients were available for follow-up for an average of 66.4 months (Group 1). Forty-three of these patients were followed up for longer than 5 years (Group 2). The incidence of postoperative heartburn in Groups 1 and 2 was 7.9% and 7.0%, respectively. The incidence of postoperative dysphagia in Groups 1 and 2 was 39.4% and 30.2%, respectively, with most episodes occurring within 2 years of operation. The vast majority of these patients required multiple esophageal dilatations over a long time. The high rate of restricture precludes support for the routine use of an esophagogastric anastomosis after resection of benign esophageal stricture.     

The outcome of conservative treatment for anastomotic leakage after surgical repair of esophageal atresia

ObjectiveThe aim of this study was to evaluate the clinical outcome of conservative management of anastomotic leakage (AL) after surgical repair for esophageal atresia.MethodsData from 85 neonates with esophageal atresia who underwent surgical correction were retrospectively analyzed. Conservative treatment had been adopted for AL. The incidence and severity of postoperative AL as well as its effects were analyzed.ResultsAmong the 85 neonates, postoperative AL occurred in 21 (25%) cases, with major leaks in 15 cases and minor leaks in 6. The stricture index of the 21 neonates with AL (0.615 ± 0.032) was significantly different (P = .008) from that of the 64 neonates without leakage (0.509 ± 0.018). The overall incidence of gastroesophageal reflux (GER) was 36%. Esophageal dysmotility and clinically significant tracheomalacia were observed in 69 and 7 infants, respectively, of the 80 surviving patients. The incidence of GER, dysmotility, and tracheomalacia in patients with or without AL was similar. The severity of GER in patients with different numbers of sessions of dilation was significantly different (P = .0015).ConclusionsPostoperative esophageal AL is effectively treatable by conservative methods in most neonates. The occurrence of AL may aggravate the severity of esophageal stricture but does not affect the incidence of GER, esophageal dysmotility, and tracheomalacia.     

Gastric tube interposition for corrosive esophagitis associated with pyloric stenosis

Corrosive esophagitis, caused by swallowing corrosive acid or alkali, results in cicatricial stricture of the esophagus. The stricture is often accompanied by pyloric stenosis because strong acids act synergistically with gastric juice. Resection of both the esophagus and stomach is usually necessary, and the colon or jejunum is used as an esophageal substitute. We describe how we successfully treated corrosive esophagitis associated with pyloric stenosis, by performing gastric tube interposition for the esophageal reconstruction. After resecting the injured distal part of the stomach, we pulled the pedunculated gastric tube up to the cervix after anastomosis to the jejunal limb in a Roux-en-Y fashion. This reconstruction procedure prevented excessive organ sacrifice and was minimally invasive. Thus, esophageal reconstruction by interposition using a pedunculated gastric tube can be used effectively to treat corrosive esophagitis associated with pyloric stenosis.     

瘢痕食管切除胃代食管治疗腐蚀伤后瘢痕狭窄

收治食管及胃腐蚀伤１０５例，对病变位于食管中下段１２例采用瘢痕食管切除胃代食管术治疗。术中解剖较松动，出血少，无术后并发症；２例病变明显高于术前估计，切除食管至颈部吻合，手术甚为困难。结论：中下段的瘢痕狭窄可行瘢痕食管切除，胃代食管也甚方便，对中段以上狭窄，仍以旷置狭窄段食管结肠代食管为宜。