镍钛合金组合式人工食管替代食管的实验研究

目的 观察镍钛合金组合式人工食管替代一段食管的可行性.方法 镍钛合金组合式人工食管是由柔性硅胶膜覆盖镍钛合金网状支架作管体,距两端1 cm处管体上带有涤纶连接环的组合式人工食管.以10只猪作实验动物,分为Ⅰ、Ⅱ两组（每组5只）,行手术切除一段长约7 cm的胸段食管,应用镍钛合金组合式人工食管替代建立实验动物模型,Ⅰ组用单纯镍钛合金组合式人工食管与正常食管做套入式端端全层吻合连接,Ⅱ组在Ⅰ组连接基础上,于镍钛合金组合式人工食管套入正常食管重叠处的食管外面加用涤纶条环绕固定.术后观察动物的进食及生长情况,3个月内每月做1次X线食管造影、电子纤维食管镜检查,处死3只术后66,100和123 d脱管的实验动物进行解剖,并对新生食管行病理学检查.结果两组共10只实验猪存活超过6个月以上,最长的存活已达20个月余.全组无吻合口漏发生,所有实验动物在人工食管未脱落之前都能正常进食.7只实验猪在术后2～6个月内发生脱管,Ⅰ组3只术后3个月内脱管,脱管后发生新生食管狭窄,进食出现严重梗阻;Ⅰ组1只和Ⅱ组3只术后3个月后脱管,脱管后短时间内发生轻度新生食管狭窄,随后逐渐缓解,无进食困难.Ⅰ组1只、Ⅱ组2只实验猪超过术后10个月未发生脱管,新生食管无狭窄,进食顺畅.结论 镍钛合金组合式人工食管替代猪被切除食管段,近期效果较好.     

镍钛合金组合式人工食管替代食管术后新生食管的形成与重构

目的观察镍钛合金组合式人工食管替代食管术后,新生食管的形成及重构。方法22只猪通过手术切除一段长约7 cm的胸段食管,应用镍钛合金组合式人工食管替代切除的胸段食管建立实验动物模型。对置入人工食管术后1、2、3、6个月各时段出现植入人工食管脱落移位的12只实验动物,进行X线食管造影,然后剖杀,对比观察各时段形成的新生食管的大体形态,镜下管体组织细胞结构的变化。结果12只实验动物中6只早期脱管（术后1个月内）,3只并发吻合口瘘和脓胸,另3只则出现严重吻合口狭窄;余6只脱管时间超过1个月,未发生吻合口瘘和胸腔感染,仅出现不同程度的新生食管狭窄和进食困难。镍钛合金组合式人工食管替代食管术后1个月,人工食管外壁形成一条以结缔组织膜包绕,连接正常食管两端的管道。2～3个月的新生食管管体结构,除中间狭窄部分为结缔组织外,已形成与正常食管4层组织结构相似的纤维肌性管道。3～6个月新生食管管体组织结构呈现肉芽组织增生、瘢痕组织形成的重构过程。全程未发现腺体组织。结论镍钛合金组合式人工食管作为修复材料重建食管通道置入人体后,诱导出由结缔组织包绕人工食管外壁的管道,新生食管在随后的重构过程中发生肉芽组织增生,瘢痕组织形成的转化过程,最终形成一条没有收缩功能、黏膜面覆盖复层鳞状上皮的瘢痕性管道。     

镍钛记忆合金网状内支架治疗食管狭窄

目的食管腔内放置镍钛记忆合金网状内支架，持续扩张食管、贲门部狭窄，改善患者饮食通道。方法利用内支架置放器等器械在Ｘ线下行食管狭窄扩张后放入适当长度的内支架。术后及２天、１月摄Ｘ线片对照。结果２８例均放置成功。术后定期复查，内支架膨胀、固定良好，内径最窄处平均直径１．３ｃｍ。２６例术后吞咽困难即消失。术后死亡９例，平均存活７个月。结论该术式简便、痛苦小、并发症少，解除梗阻快，有效地提高了患者生存质量，延长了存活时间     

Esophageal Intramural Pseudodiverticulosis Treated by Balloon Dilatation: Report of a Case

A 72-year-old man presented with a 17-year history of dysphagia, which had gradually become worse in recent months. A barium esophagogram showed stenosis of the upper thoracic esophagus with multiple tiny flask-shaped outpouchings along the region of stenosis. Based on this characteristic appearance, we diagnosed esophageal intramural pseudodiverticulosis. He underwent successful balloon dilatation of the stenosis and his dysphagia resolved. Dynamic esophagography showed improved passage through the esophagus. He has been well and not suffering from dysphagia for 4 years since the balloon dilatation.     

结肠代食管术的并发症及其防治

分析２６０例结肠代食管病例资料，早期１００例的并发症率为３９％，近期１６０例并发症率为‘１０．６２％。重点探讨结肠段坏死、吻合口瘘或狭窄、喉返神经损伤、肠道梗阻、胸结肠综合征及食管盲囊综合征等并发症的原因，其防治措施。作者认为，改进结肠代食管术式是降低并发症的关键。     

Macrophage Phenotype Is Associated With the Regenerative Response in Experimental Replacement of the Porcine Esophagus

A porcine model for bridging circumferential defects in the intrathoracic esophagus has been developed in order to improve the treatment of children born with long‐gap esophageal atresia. The aim of this study was to identify factors beneficial for tissue regeneration in the bridging area in this model and to describe the histological progression 20 days after replacement with a silicone‐stented Biodesign mesh. Resection of 3 cm of intrathoracic esophagus and replacement with a bridging graft was performed in six newly weaned piglets. They were fed through a gastrostomy for 10 days, and then had probe formula orally for another 10 days prior to sacrifice. Two out of six piglets had stent loss prior to sacrifice. In the four piglets with the stent in place, a tissue tube, with visible muscle in the wall, was seen at sacrifice. Histology showed that the wall of the healing area was well organized with layers of inflammatory cells, in‐growing vessels, and smooth muscle cells. CD163+ macrophages was seen toward the esophageal lumen. In the animals where the stent was lost, the bridging area was narrow, and histology showed a less organized structure in the bridging area without the presence of CD163+ macrophages. This study indicates that regenerative healing was seen in the porcine esophagus 20 days after replacement of a part of the intrathoracic esophagus with a silicone‐stented Biodesign mesh, if the bridging graft is retained. If the graft is lost, the inflammatory pattern changes with invasion of proinflammatory, M1 macrophages in the entire wall, which seems to redirect the healing process toward scar formation.     

Adenosquamous carcinoma arising in Barrett's esophagus

Primary adenocarcinoma of the esophagus is rare in Japan and, in most cases, arises from Barrett's esophagus epithelium. A 72-year-old man reporting heartburn and dysphagia and preoperatively diagnosed with adenosquamous carcinoma arising from Barrett's esophagus underwent thoracic esophagectomy and lymph node dissection in curative resection. Pathological diagnosis of the resected specimen showed adenosquamous carcinoma (coexistent adenocarcinoma and squamous cell carcinoma) invasive to the submucosal layer; metastasis was found in regional lymph nodes. Pathological staging was pT1bN1M0, stage II. Unfortunately, the man died of liver and lung metastasis 17 months postoperatively. To our knowledge, this rare case is only the fifth reported in the English literature on adenosquamous carcinoma arising from Barrett's esophagus.     

Intrathoracic esophageal replacement in the dog with the use of an artificial esophagus composed of a collagen sponge with a double-layered silicone tube.

OBJECTIVES: Intrathoracic esophageal replacement with an artificial esophagus is considered difficult. We attempted to replace the intrathoracic esophagus with an artificial esophagus composed of a collagen sponge with a double-layered silicone tube and examined the state of host tissue regeneration. METHODS: A 5-cm long gap was created in the intrathoracic esophagus in 9 dogs and repaired by interposition of our prosthesis. The dogs were fed only by intravenous hyperalimentation for 28 days. The silicone tube was removed at 29 days after the operation, and oral feeding was reintroduced. RESULTS: One dog was put to death at each of the following times: 1, 2, 3, 3, 6, 12, and 24 months after the operation. One dog is still surviving without problems after more than 26 months. One dog died of malnutrition at 10 months. In all dogs, the host regenerated tissue had replaced the resulting gap at the time of silicone tube removal. The mucosa had fully regenerated within 3 months and the glands within 12 months. The process of stenosis and shrinkage was complete within 3 months and did not advance thereafter. The lamina muscularis mucosae were observed as islets of smooth muscle within 12 months. Although the skeletal muscle regenerated close to the anastomoses, it did not extend to the middle of the regenerated esophagus even after 24 months. CONCLUSIONS: Use of a collagen sponge with a double-layered silicone tube was shown to be feasible even in the thorax and to allow the regenerated host tissue, consisting of the mucosa, glands, and lamina muscularis mucosae, to replace the esophageal gap.     

An experimental study on long term outcomes after magnetic esophageal compression anastomosis in piglets

Background/PurposePrevious studies have shown that a patent, watertight esophageal anastomosis can be accomplished safely using specially-shaped magnets in piglets. However, it is unclear whether such a magnetic esophageal compression anastomosis (MECA) remains patent in the long-term. The purpose of this study was to evaluate the long-term outcome of MECA in an experimental pig model over an observation period of 2 months.MethodsTen piglets underwent creation of an MECA with custom-made 8 mm magnets and a U-shaped esophageal bypass loop to allow peroral nutrition at eight weeks of life. Two weeks later, the bypass loop was closed surgically, requiring the pigs to swallow via the newly created magnetic compression anastomosis. The pigs were fed soft chow for 2 months. They were monitored for weight gain and signs of dysphagia. At the endpoint of two months, esophagoscopy and contrast esophagography was performed. After removal of the esophagus, the tissues were macroscopiocally and histologically assessed.ResultsSix piglets survived until the endpoint. In two pigs, closure of the bypass loop failed, these demonstrated mean weight gain of 792 gs/day [95% Confidence interval 575 to 1009 gs/day]. Weight gain in four pigs that exclusively fed via the magnetic anastomosis averaged 577 gs/day [95% confidence interval 434 to 719 gs/day (p = 0.18)]. There were no signs of dysphagia. All magnets passed with the stool within 16 days. After 2 months, a well-formed magnetic compression anastomosis was visible and easily negotiated with a 6.5 mm endoscope. Esophogram and macroscopic findings confirmed patentency of the esophageal anastomoses. Histopathology showed a circular anastomosis lined with contiguous epithelium.ConclusionMECA creates a long-term functional and patent anastomosis in pigs. This concept may facilitate minimally-invasive esophageal atresia repair by obviating a technically challenging and time-consuming hand-sewn anastomosis.     

Successful treatment of congenital esophageal web by endoscopic electrocauterization and balloon dilatation

We report a 3-year-old boy who presented with a foreign body impacted in the esophagus and had a poor tolerance of solid food since he was 5 to 6 months old. In the last 2 years, he developed progressive dysphagia, anorexia, vomiting, and poor weight gain. An esophagoscopy and barium esophagogram revealed an esophageal web in the distal third of the esophagus. Three courses of endoscopic balloon dilatation resulted in transient improvement in his dysphagia and vomiting; a follow-up barium esophagogram and esophagoscopy showed limited improvement of the esophageal stenosis. Two courses of endoscopic electrocauterization and balloon dilatation improved the clinical symptoms and esophageal stenosis.     

空肠移植重建咽食管肠咽吻合口并发症的处理

采用空肠移植重建食管治疗咽食管化学性烧伤后狭窄13例。其中4例术后发生肠咽吻合口并发症:1例因吻合口狭窄和喉部损伤严重,反复发生吸入性肺炎而于术后3周应用自体喉气管移植,成功地重建食管通道;3例吻合口高于喉上口者,发生咽下困难,均再次行吻合口成形术,术后恢复了吞咽或语言功能。     

几种少见的原发性食管运动障碍的测压观察

除最常见的原发性食管运动障碍贲门失驰症外，几种少见类型的食管运动障碍往往被忽略，因其症状无特异性。为此作者在常规食管压力测定工作中，对此种病例特别予以重视。除外冠心病引起的胸痛，全部食管良性病变和有吞咽困难、胸痛症状并疑为食管病变的病人均属检查对象，共发现１４例少见类型的原发性食管运动障碍。８例有胸痛症状，７例有吞咽困难，１例两者皆有之。据文献规定的标准，有３例弥漫性食管痉挛，４例胡桃钳食管，６例     

Iatrogenic esophageal perforation caused by endoscopic dilatation of caustic stricture: Current management and possibility of esophageal salvage

BackgroundIatrogenic esophageal perforation (EP) is an undesirable complication of endoscopic dilatation of caustic esophageal stricture. We reported our current management protocol with possibility of continuing the dilatation program.Patients and methodsFrom January 2009 to January 2020 medical records were reviewed for patients presented with iatrogenic EP. Management according to each case condition was reported.Results24 patients were enrolled, aged from 1.5 to 6 years old. Perforation was cervical in one case, abdominal in two cases, and thoracic in 21 cases. Immediate surgical repair was performed in the abdominal cases. Conservative management was chosen in 22 cases; two cases didn't respond and underwent esophageal diversion, and one of them died owing to severe sepsis. Three patients refused another trial of dilatation. Two cases failed to be redilated. 17 patients continued a dilatation program. Time passed between perforation and redilatation ranged from 35 days to 7 months. 15 patients were cured completely from dysphagia, one patient had marked improvement of his dysphagia, and one case with a resistant stricture was referred for esophageal replacement.ConclusionPreserving the native esophagus is possible after iatrogenic EP of caustic esophageal stricture. A conservative approach should be attempted with caution not to endanger patient's life.Level IV of evidence     

Surgery for scleroderma of the esophagus: a 12-year experience

Twenty patients with scleroderma of the esophagus were treated with esophageal dilation, an anti-reflux procedure, or colon interposition over a 12-year period. Antireflux procedures consisted of the following: six Belsey Mark IV, two Collis-Belsey, three Nissen, and one Collis-Nissen. Reflux esophagitis recurred in all patients at an average of 4 years postoperatively. Esophageal strictures were severe in 3 patients and necessitated partial esophagectomy and short-segment colon interposition. These patients had been on a regimen of long-standing high-dose steroid therapy, and none showed any wound healing problems or postoperative leaks. There was 1 death, which occurred fifteen days postoperatively as a result of pulmonary complications. Control of reflux and dysphagia can be achieved with antireflux procedures, but in our experience, all will ultimately fail in time. We believe esophageal replacement should be considered as the initial step in treatment of strictures of the esophagus in patients with scleroderma.     

<Emphasis Type="Italic">Candida</Emphasis> esophagitis complicated by an esophago-airway fistula: Report of a case

Candida esophagitis rarely involves life-threatening complications, such as necrosis, perforation, or fistula formation between the esophagus and the airway. We herein report a case of Candida esophagitis complicated by esophagobronchial and esophagopulmonary fistulas. The patient in our study was a 70-year-old man with a 3-month history of dysphagia. Based on endoscopy and histological findings, he was diagnosed with a coinfection of Candida spp. and herpes simplex virus. Antifungal and antiviral therapy was administered without success. The esophagopulmonary fistula formation and a lung abscess were identified 7 months later. The patient was deemed intolerable to an esophagectomy due to his poor general condition, thus necessitating a two-stage operation. A cervical esophagostomy and a tube drainage of the thoracic esophagus were followed by an esophageal bypass using the pedicled jejunum via an antethoracic route. Although the lung abscess resolved, the inflammation of the esophagus persisted. A fistula between the esophagus and the left main bronchus eventually formed postoperatively and the patient died due to respiratory failure.     

Operation for Motor Dysfunction of the Esophagus

Modern operative treatment of motor dysfunction of the esophagus began in 1949 with the recognition that anastomotic procedures that bypass or destroy the distal esophageal sphincter are associated with the development of reflux esophagitis and stricture. Thirty years later, reflux esophagitis related to esophagomyotomy or intrinsic esophageal disease remains the dominant concern and challenge.This review examines the current status of operative procedures for the management of three important primary disorders of esophageal motility: achalasia, diffuse esophageal spasm, and scleroderma. Relief of esophageal obstruction by esophagomyotomy or reconstruction is the common surgical goal. The addition of a fundoplication procedure to discourage esophageal reflux remains controversial in each disorder. Esophageal resection may become necessary when stricture persists or esophagomyotomy fails to provide lasting relief of dysphagia.     

Cervical esophagogastric anastomosis for benign disease. Functional results

Ninety-one adult patients (average age 49 years) with various benign esophageal disorders treated by total thoracic esophagectomy and a cervical esophagogastric anastomosis have been followed up with personal interviews and examinations from 6 to 104 months (average 34 months). Outpatient esophageal dilation has been used liberally for any degree of postoperative cervical dysphagia. At their latest follow-up, 39 patients (43%) eat without dysphagia; four patients (4%) have mild dysphagia necessitating no treatment; 34 patients (37%) have undergone one to three dilations during the first 6 to 12 postoperative months for intermittent dysphagia; and 14 patients (16%) have more severe dysphagia necessitating regular anastomotic dilations (two thirds of these perform home self-dilations). Mild regurgitation of gastric contents has been experienced by 27 (30%), particularly when recumbent after eating, but only four patients sleep with the head of the bed elevated to prevent nocturnal regurgitation. No patient has had pulmonary complications resulting from aspiration. Twenty patients (22%) have had varying degrees of "dumping syndrome," generally transient and well controlled with medication. Two patients have required an additional gastric drainage operation 16 months and 82 months, respectively, after the esophagectomy. At their latest evaluation, 33% of the patients weigh 3 to 83 (average 19) pounds more than they weighed preoperatively, 38% weigh 5 to 40 (average 12) pounds less, and 29% have had no change in their weight. The stomach functions well as a visceral esophageal substitute and, like the esophagus, is more thick-walled and resilient than colon. Significant gastroesophageal reflux is uncommon after a properly performed cervical esophagogastric anastomosis. Postoperative dysphagia can be minimized by attention to technique in constructing the anastomosis. These data support our belief that the stomach is the preferred organ for esophageal replacement, not only for carcinoma, but also for benign diseases as well.     

Successful surgical treatment for an aortoesophageal fistula due to a descending aortic aneurysm.

The patient was a 68-year-old man who consulted another hospital with a chief complaint of dysphagia, and was referred to our hospital based on a suspicion of esophageal submucosal tumor. However, the patient was emergently admitted due to hematemesis and hypotension, which occurred immediately after the acquisition of computed tomographic (CT) images for further examinations at the outpatient clinic. Contrast-enhanced chest CT demonstrated a thoracic aortic aneurysm measuring 45 mm in maximal diameter, in addition to pneumatization adhering to mural thrombus, which appeared to be the esophagus. Upper gastrointestinal endoscopy also demonstrated ulcerative lesions accompanied by coagulations in the middle thoracic esophagus. Therefore, emergency surgery was performed based on a diagnosis of an aortoesophageal fistula due to a descending aortic aneurysm. Graft replacement was performed under partial extracorporeal circulation, followed by total thoracic esophagectomy, esophagostomy, and gastrostomy after weaning from extracorporeal circulation. This study reports the course of a patient with an aortoesophageal fistula due to a thoracic aortic aneurysm whose life was successfully saved by emergency surgery, together with literature.     

新型可回收全覆膜镍钛合金支架治疗难治性食管良性狭窄

目的探讨自行设计的新型可回收抗反流全覆膜镍钛合金支架治疗难治性食管良性狭窄的疗效。方法2009年11月至2011年5月间中山大学肿瘤防治中心胸科采用新型支架治疗难治性食管良性狭窄患者8例。在支架置入术后第1、7、30和60天以及拔除支架术后1、2、3和6个月,进行胃镜和食管吞钡检查,评价患者吞咽功能改善及并发症发生情况。结果8例患者均成功置入新型支架．术后吞咽功能较术前明显改善（P〈0．05）。经9个月的中位随访,已拔除支架6例,其吞咽功能亦较术前明显改善（P〈0．05）：支架继续留置2例,其中1例支架置入术后已15个月,目前仍进普通饮食：另1例支架置入术后2个月吞咽功能较术前改善．但3个月后吞咽功能减退至术前水平。8例患者远期吞咽功能改善率为7／8。术后再狭窄1例：支架脱落2例：肉芽过度增生3例,其中支架覆膜破裂致肉芽向内生长2例。结论新型可回收全覆膜镍钛合金支架置入食管良性狭窄术后和拔除支架后吞咽功能明显改善．远期再狭窄发生率低：但支架脱落发生率仍较高．支架覆膜材料易破裂．仍需进一步改进。     

Achalasia developing years after surgery for reflux disease: Case reports, laparoscopic treatment, and review of achalasia syndromes following antireflux surgery

Two case reports demonstrate the paradoxical occurrence of achalasia many years after the successful surgical treatment of gastroesophageal reflux disease (GERD). These patients had remedial surgery laparoscopically. The three types of achalasia syndromes that can follow antireflux surgery are discussed. In type 1, primary achalasia is misdiagnosed as GERD and inappropriate antireflux surgeD, causes worsenhag dysphagia immediately after surgery without any symptom-free interval. In type 2, secondary iatrogenic achalasia is seen early after antireflux surgery and is characterized by the presence of stenosis and scar formation at the site of the fundic wrap. Although the motility studies resemble achalasia, the repair needs only to be taken down and refashioned when there is no response to balloon dilatation. In type 3, illustrated by the case reports, primary achalasia follows antireflux surgery after a significant symptom-free interval. There is complete absence of any stenosis or fibrosis of the esophagus and periesophageal tissues at remedial surgery. Moreover, surgical treatment of this condition needs to include esophageal myotomy.