食管腐蚀性烧伤后严重狭窄的外科治疗

目的探讨食管腐蚀性烧伤后狭窄的外科治疗经验及胃或横结肠代食管重建手术的应用价值。方法对98例食管腐蚀性烧伤后狭窄的患者中72例广泛食管狭窄、病变超过食管中段以上者采用横结肠代食管、保留结肠左动脉升支、胸骨后顺蠕动吻合,其中横结肠咽腔吻合18例,横结肠食管颈部吻合54例,胸段食管旷置不切除;26例狭窄位于中下段,经胸切除瘢痕段食管用胃重建食管,胃食管胸内吻合。结果结肠食管重建72例中,术后死亡4例（5．56％）,发生颈部吻合口瘘14例（19．44％）,后期出现颈部吻合口狭窄7例,经治疗后均痊愈。胃重建食管26例无手术死亡,术后发生胸内吻合口狭窄3例,经扩张治愈。结论食管腐蚀性烧伤后狭窄在伤后20～24周可积极采取食管重建术,根据食管狭窄段严重程度及位置决定是否行狭窄段食管切除、选择食管重建替代物及吻合的位置。可采用横结肠食管颈部吻合或结肠咽腔吻合术,胸内胃食管吻合术。     

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.     

Isoperistaltic left colic graft interposition via a retrosternal approach for esophageal reconstruction in patients with a caustic stricture: mortality,morbidity, and functional results

Purpose

To report our results of treating esophageal caustic stricture with an isoperistaltic left colic graft interposed via a retrosternal route.

Methods

We reviewed 70 patients who underwent substernal left colon interposition, performed retrosternally, for an esophageal caustic stricture, between January, 1999 and December, 2011.

Results

The median operative time in this series was 3 h. A pharyngoplasty was performed in 10 patients (14.28 %), the thoracic inlet was found to be enlarged in 33 patients (47.1 %), and posterior cologastric anastomosis was performed in 58 patients (82.8 %). Two patients (2.8 %) died. Minor and major postoperative complications developed in 28 patients (40 %), including graft ischemia in 2 (2.8 %) and cervical anastomotic leakage in 14 (20 %). Five patients (7.14 %) developed a cervical anastomotic stricture. The functional results were satisfactory.

Conclusion

Retrosternal isoperistaltic left colic transplant interposition is an excellent long-term replacement for an esophageal caustic stricture. If performed by experienced surgeons, this procedure is effective for esophageal reconstruction.     

Esophageal Atresia and Tracheoesophageal Fistula: Surgical Experience Over Two Decades

Background. Despite improvements in survival, for infants born with esophageal atresia tracheoesophageal fistula, or both, the morbidity associated with repair of these anomalies remains high.Methods. This report retrospectively analyzes 81 patients with esophageal atresia, tracheoesophageal fistula, or both presenting to our institution between 1975 and 1995, with a focus on anastomotic complications.Results. There were 46 male and 35 female patients with a mean gestational age of 37 weeks and mean birth weight of 2443 g. Forty-four patients underwent primary esophageal anastomoses, 7 underwent delayed primary anastomoses, 12 patients underwent staged repairs, and 5 underwent repair of H-type fistulas. Among 62 patients with anastomoses, complications included stricture in 25/62 patients (40%), leakage in 12/62 patients (19%), and recurrent tracheoesophageal fistulas in 6/62 patients (10%). Stricture rates for esophagocolonic anastomoses versus esophagoesophageal anastomoses were 4/8 cases (50%) versus 21/54 cases (39%). This difference was not statistically significant. All esophagoesophageal strictures were managed successfully with dilations; three of four esophagocolonic strictures required anastomotic revision. The leakage rate for esophagocolonic anastomoses versus esophagoesophageal anastomoses was 6/8 cases (75%) versus 6/54 cases (11%). This difference was statistically significant (p = 0.0003). Two patients required revision of their colon grafts secondary to necrosis. Eighteen of 81 patients (22%) died. Operative mortality was 9/74 (12%). Causes of death included associated anomalies (n = 15), recurrent aspiration and sepsis secondary to missed fistula (n = 1), and unknown (n = 2).Conclusions. Although the morbidity associated with surgical repair of these anomalies is high, this does not affect the overall survival. The high complication rate associated with colonic interposition suggests that one should preserve the native esophagus as a primary conduit whenever feasible.     

管状胃代食管术治疗小儿复杂型食管瘢痕性狭窄的初步研究

目的探讨管状胃代食管手术治疗小儿复杂型食管瘢痕性狭窄的临床价值。方法回顾分析2010年3月至2011年10月广州市妇女儿童医疗中心胸外科应用胸骨后管状胃代食管手术治疗复杂型食管瘢痕性狭窄7例的临床资料。结果7例患儿均为化学性食管灼伤者．长度超过2．5em的食管独段狭窄3例,多段狭窄4例。全组患儿手术过程顺利．术后机械辅助通气时间平均6h,撤机后均无通气不足表现。出现吻合口瘘1例,1周后自愈;吻合1：3瘘并幽门梗阻1例,经术中预留十二指肠管喂养,3周后吻合口瘘自愈,4周后幽门梗阻恢复通畅;出现吻合口狭窄2例,经球囊扩张术后恢复正常饮食。7例患儿平均随访10．5个月．生活质量明显改善．无其他并发症出现．结论管状胃代食管术是治疗复杂型食管瘢痕性狭窄的有效手术．近期疗效好．     

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.     

Reconstruction of the esophagus with the left colon

This report reviews our experience with 96 patients with benign or malignant stricture of the esophagus who underwent interposition of the left colon with or without esophageal resection from July 1982 to June 1987. There were 67 male and 29 female patients ranging in age from 8 to 80 years. Thirty-seven patients had fibrotic stricture secondary to corrosive injury of the esophagus, 42 had cancer of the esophagus, and 17 had cancer of the gastric cardia. The incidence of postoperative complications and surgical mortality, respectively, was 16.2% and 2.7% for patients with corrosive stricture of the esophagus, 35.7% and 11.9% for patients with cancer of the esophagus, and 35.2% and 5.8% for patients with cancer of the gastric cardia. Reconstruction resulted in good function in 75.6% of the patients with corrosive stricture of the esophagus, 66.6% of the patients with cancer of the esophagus, and 70.5% of patients with cancer of the gastric cardia. The morbidity and mortality were higher in the group with malignant esophageal strictures because of advanced age, poor general condition of the patient, and extent of the surgical procedure needed. Cervical anastomotic leakage was the most frequently encountered complication (13.5%), and all the poor-function results were caused by this complication. In our experience, reconstruction of the esophagus with left colon is a satisfactory method that can be accomplished with acceptable morbidity and mortality. The left colon is a durable and functional substitute.     

Esophageal replacement with whole stomach in infants and children

This is a report of ten patients in whom the esophagus is replaced by the whole stomach brought through the chest. It was used for children with long gap or previously failed esophageal atresia repair. It documents complications (anastomotic leak and stricture) and morbidity, and highlights precautions that must be taken.     

A further look at the gastric tube as an esophageal replacement in infants and children

Gastric tubes were constructed for infants with pure esophageal atresia as well as for “impossible” or “failed” repairs of esophageal atresia, and for children with esophageal stricture as well. More than two-thirds of the patients had the gastric tube operation before 2 yr of age (esophageal atresia). The children with esophageal strictures had the operation usually between 2 and 10 yr. The two-stage retrosternal reversed gastric tube was used most frequently. The isoperistaltic tube is an excellent alternate method should a reversed gastric tube be impossible to construct. If the gastric tube is short and used as an esophageal interposition in a patient with peptic esophagitis, there is a good possibility of developing esophagitis above the esophagogastric tube anastomosis. The most common complications that arise are related to the esophagogastric tube anastomosis (leak and stricture). We have found no correlation between the operative technique, the postoperative management as it concerns esophageal suction, and the eventual early or late anastomotic leak. Nor were these factors related to the time of eventual closure of the leak, the presence and severity of any subsequent stricture, and the results of its dilatation. The longest follow-up is $\text{7}\text{1}\text{2}$ yr. Once the esophagogastric tube anastomosis has been healed and asymptomatic for 1 yr, the child is well on the way to a life of normal swallowing.     

儿童食管腐蚀伤的外科治疗

目的　探讨儿童食管腐蚀伤后瘢痕狭窄的预防和治疗措施。　方法　 1988年 5月～ 2 0 0 0年 5月收治食管腐蚀伤儿童 32例 ,早期采用食管扩张 3例 ,食管腔内置管 8例 ;后期采用结肠代食管 14例 ,胃代食管 5例 ,颈阔肌皮瓣修复 2例。　结果　全组手术治愈 31例 ,死亡 1例 ;术后发生并发症 9例 ,其中吻合口瘘 6例 ,吻合口狭窄 2例 ,颈部瘘 1例 ,均治愈。 2 8例随访 1～ 12年 ,均恢复进普通饮食 ;3例失访。　结论　早期食管腔内置管对预防食管腐蚀伤后瘢痕狭窄有明显疗效 ,结肠代食管术是后期食管重建的主要手段 ,主动脉弓以下瘢痕食管可切除用胃重建 ,颈阔肌皮瓣修复术是治疗颈部局限性食管狭窄的理想方法     

Stapled tapering coloplasty to manage colon interposition graft redundancy for long gap esophageal atresia

Long gap esophageal atresia continues to be a therapeutic challenge for the pediatric surgeon. Although numerous methods have been described to achieve esophageal continuity in infants with esophageal atresia, esophageal replacement is often required if these methods fail. A common method of esophageal replacement in children is the use of a colon graft. Complications include cervical anastomotic leak, stricture, redundant intrathoracic colon with stasis, and cologastric reflux. We present an 11-year-old male with swallowing difficulties because of redundancy of the colon after undergoing colon interposition for long gap atresia. The patient underwent a successful transhiatal mobilization of the intrathoracic colon and stapled tapering coloplasty. The patient currently remains symptom-free.     

Colon interposition for esophagus in children

In 25 years, from 1959 to 1984, esophageal substitution was performed in 32 patients. In most, the transverse colon was used, brought through the left chest on a vascular pedicle of the left colic artery. Indications for operation included: 21, esophageal atresia; 5, caustic injury; 3, peptic stricture; 2, esophageal varices with previous splenectomy; and 1, cartilagenous hamartoma of the esophagus. Six patients had failed prior reconstructions (1, gastric tube; 2, intrathoracic stomach; 1, presternal jejunum; 1, sloughed colon segment, 1, extensive stricture after primary repair). There was one postoperative death from fluid overload early in the series. Two patients had a localized leak at the upper anastomosis in the neck; neither resulted in stricture. One patient had a side leak in the lower intrathoracic colon, probably from an anchoring suture placed too deeply. Most patients had pyloroplasty with their operation. Four who did not required one later. Four patients required late reoperation for redundancy of the lower colon segment which emptied poorly; one lower colon was revised for stricture from exstrinsic compression at the substernal hiatus and another one for an inflammatory pseudopolyp with bleeding. There was no loss of a colon segment from ischemia. There is follow-up on all but one patient. Nineteen are more than ten years postoperative (mean of 18 years). Growth was assessed in that group. In atresia patients growth correlated with weight preoperatively and the presence or absence of associated anomalies. In the others growth was excellent in all but one patient. In our experience the colon conduit provides an excellent substitute esophagus for pediatric patients. The operation should have relatively low rate of major complications, most of which are avoidable, and most of which can be corrected to give a satisfactory long-term result.     

Total gastric transposition: an alternative to esophageal replacement in children

Total gastric transposition was performed in 21 children as an alternative procedure for esophageal replacement. The age at the operation ranged from 15 months to 11 years. Half of the children were less than 2 years old. Fifteen patients had esophageal atresia. The stomach was passed toward the neck either through the esophageal bed (6 cases, with concomitant blunt esophagectomy without thoracotomy) or the retrosternal route (15 cases). There was one death in the early postoperative period secondary to an anastomotic leak and acute mediastinitis in a case of pharyngogastric anastomosis. Three other patients developed cervical leak with spontaneous closure but this ultimately led to a late anastomotic stricture (more than 6 months) requiring endoscopic dilatation. Only one child needed more than three attempts of endoscopic dilatation. None of these patients required surgical revision. The mean follow-up was 60 months (range, 10 to 122 months). Despite bulky atonic intrathoracic stomach occurring in some children, only two patients developed regurgitation and symptoms of poor gastric emptying. There were neither early nor late respiratory problems. Excellent and good functional outcome were achieved in 85% and 15% of the patients, respectively. Two patients have not undergone a weight catch-up phase. The majority of the children have been between the 20th and 80th percentile for weight. Five children remain below the 20th and two below the 5th percentile. The remarkably low morbidity and mortality combined with satisfactory functional results indicate that the total gastric transposition is a safe and easy alternative surgical procedure for esophageal replacement in children.     

Factors affecting leakage following esophageal anastomosis

Esophageal anastomotic leaks remain the most serious problem following extirpative procedures for esophageal carcinoma. We conducted a retrospective analysis of 352 patients with carcinoma in the thoracic esophagus who had undergone esophageal anastomosis following esophagectomy at the Kurume University Hospital between 1981 and 1990. Of these, 94 patients (27%) developed anastomotic leaks, and out of this subgroup, 21 (6%) died as a direct result of the leak. A further 20 patients (6%) underwent repair of the leak, after which they were able to tolerate oral intake. The anastomotic leak healed spontaneously in the other 53 patients (15%). The risk factors predisposing to leaks from esophageal anastomoses were determined as: (1) the anastomosis being performed via a retrosternal or subcutaneous route as opposed to an intrathoracic route, (2) the use of colonic interposition as opposed to a gastric pedicle, (3) performing a manual anastomosis as opposed to a mechanical anastomosis, and (4) employing an end-to-end anastomosis, as opposed to an end-to-side anastomosis, using a mechanical method. By introducing an anastomotic stapling device, a microvascular technique, a staged operation based on the preoperative risk analysis, and improvement in pre- and postoperative management, the incidence of anastomotic leakage could be decreased from 35% to 14%, and that of consequent hospital mortality, from 9% to 2%.     

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.     

Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia

OBJECTIVE: To evaluate the authors' experience with gastric transposition as a method of esophageal replacement in children with congenital or acquired abnormalities of the esophagus. SUMMARY BACKGROUND DATA: Esophageal replacement in children is almost always done for benign disease and thus requires a conduit that will last more than 70 years. The organ most commonly used in the past has been colon; however, most series have been fraught with major complications and conduit loss. For these reasons, in 1985 the authors switched from using colon interpositions to gastric transpositions for esophageal replacement in infants and children. METHODS: The authors retrospectively reviewed the records of 41 patients with the diagnoses of esophageal atresia (n = 26), corrosive injury (n = 8), leiomyomatosis (n = 5), and refractory gastroesophageal reflux (n = 2) who underwent gastric transposition for esophageal replacement. RESULTS: Mean +/- SE age at the time of gastric transposition was 3.3 +/- 0.6 years. All but two transpositions were performed through the posterior mediastinum without mortality or loss of the gastric conduit despite previous surgery on the gastric fundus in 8 (20%), previous esophageal operations in 15 (37%), and previous esophageal perforations in 6 (15%) patients. Complications included esophagogastric anastomotic leak (n = 15, 36%), which uniformly resolved without intervention; stricture formation (n = 20, 49%), all of which no longer require dilation; and feeding intolerance necessitating jejunal feeding (n = 8, 20%) due to delayed gastric emptying (n = 3), feeding aversion related to the underlying anomaly (n = 1), or severe neurological impairment (n = 4). No redo anastomoses were required. CONCLUSIONS: Gastric transposition reestablishes effective gastrointestinal continuity with few complications. Oral feeding and appropriate weight gain are achieved in most children. Therefore, gastric transposition is an appropriate alternative for esophageal replacement in infants and children.     

Long-term results of jejunal replacement of the esophagus

Since 1969, jejunal interpositions have been carried out in 19 patients for esophageal replacement. A segment of the upper jejunum was used to bridge the gap in the right thoracic cavity. The distal esophagus and its sphincteric mechanism was preserved in all but four patients, who had peptic strictures. Early postoperative complications such as total necrosis of the graft, perforation of the graft, and anastomotic leak developed in three patients (16%). There were no operative deaths but there were two later deaths (11%). We were able to follow 12 patients over a long term. Among these 12 patients there were two anastomotic strictures, one of which was dilated successfully by bouginage, and one marked redundancy of the jejunum which necessitated surgical correction. Both height and weight were lower than -2 SD on a Japanese standard growth curve in two patients who had anastomotic strictures. Transient stagnation of swallowed barium at the lower esophagus was the common finding; it was observed in seven cases (58%). Only three patients (25%) complained of occasional feelings of delay in swallowing. Stagnation with a mildly redundant jejunum was the common radiologic finding in these three patients. Reflux of the gastric content into the esophagus did not occur. All the patients, except one who still has dysphagia due to anastomotic stricture, can eat anything they wish at almost normal speed. These long-term results indicate that jejunal interposition with preservation of the lower esophagus is a recommendable procedure for esophageal replacement.     

咽结肠吻合治疗食管烧伤后瘢痕狭窄

目的 总结采用咽结肠吻合治疗食管烧伤后瘢痕狭窄的经验及效果。方法 回顾分析14例应用咽结肠吻合重建食管治疗累及下咽的广泛食管烧伤后瘢痕狭窄患者的临床资料。均采用左半结肠,旷置胸内瘢痕食管、经胸骨后隧道上提至颈部行咽结肠吻合。结果 全组无手术死亡,术后发生颈部吻合口漏4例,腹部切口裂开1例。随访半年至10年,平均4年,2例分别于术后3个月及4个月发生吻合口狭窄,1例扩张,1例行成形术治愈;1例因移植结肠腹腔段呈袋状而致进食后呕吐,行结肠胃侧侧吻合治愈。结论 咽结肠吻合治疗累及下咽的广泛性食管烧伤后狭窄成功关键是较大的下咽开口及良好的吻合技术,咽结肠吻合是安全、有效的。     

Colon interposition for benign esophageal disease

We reviewed 53 consecutive patients with benign disease who underwent esophageal resection followed by colon interposition to assess operative morbidity and long-term results. Indications were gastroesophageal reflux in 32 patients, advanced motility disorders in eight, esophageal perforation in six, and strictures not related to reflux in seven. There were two operative deaths (3.8%). Fourteen other patients (26.4%) had 18 major complications including three graft infarcts, two graft perforations, and four anastomotic leaks, one of which required surgical treatment. Follow-up was complete in 83% of patients and averaged 5 years. Eight patients required dilations; and 15 underwent late reoperations for stricture, persistent symptoms, or anastomotic leak. Of the 20 patients who did not have pyloroplasty done at the initial resection, five (25%) required a subsequent gastric emptying procedure. Results were rated by patients (subjectively) and physicians (objectively, based on symptoms and the need for further therapy) as 1 = excellent, 2 = good, 3 = fair, and 4 = poor. The patients' ratings averaged 1.89, with 27 patients (75%) claiming good or excellent results despite symptoms of postprandial fullness in 78% and dysphagia in 42%. Objective ratings averaged 2.05, with 28 of 39 patients (72%) rating the results as excellent or good. Despite a 30% major complication rate and a 37% late reoperative rate, colon interposition for benign esophageal disease can be accomplished with low mortality and high patient acceptance and remains our preferred technique for reconstruction of benign esophageal disease.     

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。