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。     

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.     

Esophageal replacement with colon interposition in children.

During a 21-year period, 39 colon interposition operations were performed on 37 children at the UCLA Medical Center and the Childrens Hospital of Los Angeles. The average age at the time of operation was 5.8 years. The indications for operation were esophageal atresia in 23 patients and other benign strictures in 14 patients. The duration of patient follow-up ranged from 6 months to 21 years (mean: 9.7 years). The most common complications were esophagocolonic anastomotic leak (12), esophagocolonic anastomotic stricture (14), pneumonia, and pneumothorax. Fourteen of the 25 patients with retrosternal colon interposition had complications (56%), whereas 10 of 14 patients with left thoracic colon interposition had complications (71%). One patient died (mortality: 3%) after left thoracic interposition because of severe respiratory distress associated with other malformations. Each of the 18 patients with isoperistaltic colon interposition showed rapid transit and emptying, provided that obstruction or extensive dilatation did not occur; reverse colon segments were more dilated and emptied more slowly. The 25 patients with retrosternal colon segments had less colonic distension with better emptying than did the 14 patients with left thoracic interposition. Thirty-two of the 36 children increased their weight percentile after colon interposition. Within 2 years after cervical anastomotic stricture or leak, 78% of these children were asymptomatic and gaining weight. Thirty-one of the 37 patients (84%) had excellent results with colon interposition, with a mean follow-up of 9.7 years. Most of the major postoperative complications occurred within the first few weeks and were corrected during the first few months after operation. Preservation of the esophagus should be the surgeon's first priority; however, prolonged attempts to elongate the esophagus for anastomosis in certain patients with long-gap esophageal atresia have been more hazardous in our experience than has colon interposition.     

Jejunal pedicle grafts for reconstruction of the esophagus in children

Objective

Reconstruction of the esophagus in children remains a challenge. Although jejunal grafts retain peristaltic activity, large series with long-term follow up are rare. We like to present our experience in a series of 24 children.

Methods

In the period 1988 through 2005, 24 children received an orthotopic jejunal pedicle graft reconstruction of the esophagus. Nineteen had esophageal atresia (18 had no distal fistula; all but 1 had a jejunal graft as a primary procedure), 3 had an extensive caustic stricture, and 2 had a peptic stricture. All strictures had been dilated many times, and peptic strictures had been treated with antireflux surgery as well. Median age at reconstruction was 76 days in the esophageal atresia group. The technique involves a right-sided thoracotomy with preparation of the esophageal ends or resection of the diseased esophagus. At laparotomy, a small pediculated jejunal graft is prepared and placed transhiatally in an orthotopic position in the right chest.

Results

All patients survived, and none of the grafts were lost. There were 5 intrathoracic leaks, 4 in the esophageal atresia group and 1 in peptic stricture group, requiring reoperation in 1. In the esophageal atresia group, there was 1 early distal stenosis requiring reoperation. In patients in which the distal esophagus was preserved (esophageal atresia and caustic stricture group), there were always signs of distal functional subobstruction, responding to dilatation in all but 1 patient. Gastroesophageal reflux was not a problem except for 1 patient with esophageal atresia, in whom the distal esophagus was resected because of ongoing distal obstruction with dilatation of the graft. Most patients eat and grow well, and respiratory problems were rare.

Conclusion

Orthotopic jejunal pedicle graft reconstruction of the esophagus in children is a demanding operation with considerably morbidity but good long-term results.     

食管良性狭窄的治疗

目的 探讨食管良性狭窄外科治疗的效果与经验。方法 1982年2月至2001年2月，治疗食管良性狭窄45例。手术治疗42例中局限性狭窄段食管纵切横缝1例。食管部分切除食管胃吻合术5例，结肠代食管术36例，单纯扩张治疗1例，保守治疗2例，全组中胃或空肠造瘘21例，经食管镜或胃造瘘顺行或逆行扩张11例次。结果 43例痊愈，2例保守治疗者均死亡。结论 食管良性狭窄可运用机械扩张缓解，食管腐蚀性狭窄持续扩张1年以上者，应积极手术治疗，在食管重建术中以结肠代食管术为好。     

胃大部切除术后胸内横结肠间置的临床应用

目的 探讨胃大部切除术后食管下段癌和贲门癌术后局部复发的消化道重建方式。方法 从1999年3月至2001年12月，手术治疗3例胃大部切除术后食管下段癌、3例贲门癌术后吻合口局部复发、1例胃癌侵犯食管下段的患。均采用横结肠以逆蠕动方式作胸内间置，间置结肠置于食管床。食管结肠吻合均在主动脉弓下缘水平完成。结果7例患的肿瘤都得到了完全切除，无切端阳性记录。本组无结肠坏死和吻合口瘘发生。1例术后2周死于肺部感染、呼吸衰竭，2例术后早期有进食时呃逆和轻度反流，余均达到满意效果。随访9～38个月，1例9个月后死于肿瘤广泛转移；1例术后15个月至今存活；4例术后生存2年以上，其中1例至今已生存38个月。结论 对于胃大部切除术后的食管下段癌和贲门癌术后局部复发等疾病的治疗，胸内横结肠间置是一种相对简单而又安全可靠的消化道重建方法。     

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。     

食管缺损的显微外科修复与重建

目的 探索食管狭窄,闭锁或缺损的修复与重建,手术适应证,手术要点及并发症的防治。方法 采用吻合血管的带蒂空肠,游离空肠,肠瓣及前臂皮瓣移植等手术对化学灼伤或其它原因致全食管,上胸段及颈段食管狭窄或闭锁的病人进行修复与重建,结果 成功４４例,失败１例,结论吻合血管的带蒂或游离空肠及肠瓣移植修复与重建是治疗食管狭窄,闭锁,缺损的理想手术方法。经腹部多次手术的颈段食管缺损病人可采用吻合血管的皮瓣或皮管移     

Transhiatal esophageal resection for corrosive injury

OBJECTIVES: To analyze the feasibility and safety of transhiatal approach for resection of corrosively scarred esophagus. BACKGROUND SUMMARY DATA: The unrelenting corrosive strictures of esophagus merit esophageal substitution. Because of the risk of complications in the retained esophagus, such as malignancy, mucocele, gastroesophageal reflux, and bleeding, esophageal resection is deemed necessary. Transthoracic approach for esophageal resection is considered safe. The safety and feasibility of transhiatal resection of the esophagus is not established in corrosive injury of the esophagus. PATIENTS AND METHODS: Transhiatal approach was used for resection of the scarred esophagus for all patients between January 1986 and December 2001. The intraoperative complications, indications for adding thoracotomy, and postoperative outcome were studied in 51 patients. Follow-up period varied from minimum of 6 months to 15 years. RESULTS: Esophageal resection was achieved in 49 of 51 patients whereas thoracotomy was added in 2 patients. In 1 of the patients tracheal injury occurred whereas in other patient there were dense adhesions between tracheal membrane and esophagus. Gastric tube was used for esophageal substitution in 40 (78.4%) patients whereas colon was transplanted in 11 (21.6%) patients. Colon was used only when stomach was not available. One patient (1.9%) had tracheal membrane injury whereas 4 patients (7.8%) had recurrent laryngeal nerve palsy. One patient each had thoracic duct injury and intrathoracic gastric tube leak. There was no operative mortality. Anastomotic complications like leak were present in 19.6% and stricture in 58.8% patients. All the patients were able to resume their normal duties and swallow normal food within 6 months of the surgery. CONCLUSION: One-stage transhiatal esophageal resection and reconstruction could be safely used for the extirpation of scarred esophagus. Use of gastric conduit was technically simple, quicker, and offered good functional outcome. Postoperative anastomotic stricture amenable to dilatations was the commonest complication.     

Use of temporary esophageal stent in management of perforations after benign esophageal surgery

Successful conservative management in 3 patients with catastrophic postoperative esophageal leak after nonresection surgery is presented. In each case, the placement of removable stent played a significant role. First patient had persistent leak after primary repair of intrathoracic esophageal perforation. The second patient underwent a transthoracic redo Collis-Nissen repair and was subsequently found to have a perforation in the midesophagus. The last patient had a history of recurrent hiatal hernia repair with mesh reinforcement of the hiatus. A perforation resulted from mesh eroding into the esophagus. All the patients had endoscopic placement of removable silicone-covered polyester stent under fluoroscopic guidance. Stent placement was successful in all patients allowing immediate resumption of diet. After stent removal, contrast study showed no leak or stricture. Endoscopic stent therapy is an effective option in the management of postoperative esophageal perforation.     

Transhiatal esophagectomy for treatment of benign and malignant esophageal diseases

In 1978 the technique of transhiatal esophagectomy without thoracotomy was rediscovered and now it is widely used in certain, selected, cases. Between 1987 and 2003 we have performed transhiatal esophagectomy in 35 patients with intrathoracic esophageal disease: 13 (37.14%) for benign lesions of the esophagus and 22 (62.85%) for malignant lesions (22.72% upper, 9% middle and 68.18% lower third of the thoracic esophagus). The reconstruction was performed at the same operation in all but two patients. The esophageal substitute was stomach in all but one patient when left colon was used. Hospital mortality was 14.28% with one death due to uncontrollable intraoperative hemorrhage. Major complications included anastomotic leak, recurrent laryngeal nerve paralysis, atelectasis/pneumonia. The advantages of this approach over standard transthoracic esophagectomy are avoidance of a combined thoracoabdominal operation in a debilitated patient and fewer postoperative pulmonary complications and also avoidance of an intrathoracic esophagogastric anastomotic leak with high mortality due to mediastinitis.     

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。     

Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy

Chylothorax is an unusual complication after transhiatal esophagectomy (THE) and in the past 10 years has occurred in 11 of 320 patients (3%) undergoing this operation for diseases of the intrathoracic esophagus. Four patients had benign esophageal disease: scleroderma reflux esophagitis (1), caustic stricture (1), and achalasia (2), and each had undergone at least one previous esophageal operation. Seven patients had intrathoracic esophageal carcinoma--two upper-third, two middle-third, and three distal-third lesions. Excessive chest tube drainage more than 72 hours after THE was the standard presentation, and the diagnosis of chylothorax was confirmed by the administration of cream through the jejunostomy feeding tube placed routinely at operation. The character of the chest tube drainage changed from serous to opalescent. Aggressive treatment of this complication was the rule, and every patient underwent a thoracotomy between 2 to 14 days (average, 6 days) after the diagnosis was established. Cream was administered through the jejunostomy tube before operation, and in each case the thoracic duct injury was readily identified and controlled with suture ligatures. There were no deaths in this group, and there was one recurrence of the fistula that required reoperation; all patients were discharged from the hospital within 3 to 29 days (average, 10 days) after thoracic duct ligation. It is concluded that early recognition of a chylothorax after transhiatal esophagectomy with prompt transthoracic ligation of the injured duct results in a shorter overall hospitalization and lower morbidity and mortality from this complication. The traditional conservative management of chylothorax with intravenous hyperalimentation and no or low-residue enteral feedings has little place in this nutritionally depleted patient population.     

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。     

Unified approach for nonmalignant esophageal lesions using right colon and terminal ileum. A 30-year experience

Over the past 30 years, the authors reconstructed the esophagus with the right colon in 85 patients who had congenital and benign disease. The first individual operated upon in 1955 was asymptomatic. Nine patients had congenital tracheoesophageal fistula with atresia, four esophageal varices, 31 advanced obliterative esophagitis, and 23 corrosive destruction. In seven patients, severe esophagitis followed esophagogastrectomy, four had unsuccessful operations for achalasia, and seven had colon bypass following esophageal perforation. Eleven early nonfatal complications occurred. Remote nonfatal complications were seen in six patients. Three early deaths followed dehiscence of an intrathoracic esophago-colon anastomosis, and one patient died from peritonitis (4%). Four individuals died over the study period, and five patients were lost to follow-up. The late results in 72 patients show that 61 (84%) believe they have a satisfactory result, nine (13%) individuals are symptomatic, and two patients (4%) are classified as failures. Early complications have been minimized by employing preoperative intestinal angiograms and anastomotic stapling techniques, and by using the Doppler intraoperatively to prognosticate colon blood flow. Significant observations have been: Anastomosis in the neck is preferable; the transplanted colon dilates from loss of motor activity but is functionally adequate; an isoperistaltic segment is preferable, but antiperistaltic segments can be used; and colonic mucosa is relatively resistant to acid-peptic digestion.     

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     

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.     

改良反穿刺吻合技术在全腔镜Ivor Lewis食管癌根治术中消化道重建的应用体会

目的探讨反穿刺吻合技术行全腔镜Ivor Lewis食管癌根治术的可行性及近期疗效。 方法收集南京医科大学附属逸夫医院2014年2月至2018年6月期间应用改良反穿刺吻合技术行全腔镜Ivor Lewis食管癌根治术的48例中下段食管癌患者资料。手术分为三大步骤：首先用腹腔镜游离胃和腹段的食管并清扫腹腔淋巴结;其次取侧卧位,游离胸段食管,切除病变食管并清扫胸腔淋巴结;最后应用反穿刺吻合技术行胸内胃食管吻合术。 结果48例均在腔镜下完成吻合,手术过程顺利,未行胸腹部辅助切口,无中转开胸手术。手术时间(253.4±57.2)min,其中胸腔镜操作时间(175.6±64.5)min;术中出血量(107.3±87.4)ml,清扫淋巴结数目(15.2±2.5)枚。术后1例重度肥胖、糖尿病、高血压患者出现重症肺部感染及吻合口瘘,经保守治疗后治愈,吻合口瘘发生率2.1%(1/48);术后3例出现吻合口狭窄,其中1例严重,行吻合口机械扩张缓解,吻合口狭窄率6.3%(3/48)。48例中47例的术后进流食时间(7.2±1.3)d,术后住院时间10～16 d、平均11 d。 结论利用改良反穿刺吻合技术行全腔镜Ivor Lewis食管癌根治术治疗中下段食管癌是安全、可行的,是经济、有效的。     

Failure of the Nissen fundoplication to control gastroesophageal reflux in esophageal atresia patients

During the 5-year period from 1981 to 1985, Nissen fundoplication was performed on 13 esophageal atresia patients. One patient with Down's syndrome died because of cardiac malformation 2 weeks after the operation and is excluded from the analysis. Nine of the remaining 12 patients had the usual malformation with distal fistula, while three had isolated atresia. In eight patients there was a long gap between the segments, and in five Livaditis myotomy was necessary. The median age of the patients at the fundoplication was 1.3 years (range, 4.5 months to 10.6 years). The main clinical manifestations were anastomotic stricture (six patients), respiratory complications (three patients), vomiting and difficulties in feeding (two patients), and esophagitis only (one patient). Altogether nine patients had preoperative distal esophagitis. Mean follow-up time was 4.1 years (range, 2.0 to 6.4 years). All patients primarily benefited from the operation. Routine control endoscopy 3 to 8 months after the operation showed a competent fundoplication in all patients. However, in five patients the reflux later recurred, and endoscopy revealed a partially disrupted fundal wrap and esophagitis. Four patients underwent refundoplication and one is waiting for it as of this writing. Four patients had Barrett's esophagus at the last endoscopic control. There was one late death due to cardiac failure. In conclusion, although the short-term results of Nissen fundoplication in esophageal atresia patients are good, the risk for late recurrence is high. Regular long-term follow-up is therefore necessary.     

Early recognition and aggressive treatment of gastroesophageal reflux following repair of esophageal atresia

Twelve patients with gastroesophageal reflux following repair of esophageal atresia are presented. Reflux produced recurrent stricture, failure to thrive, repeated pneumonitis, and in one patient, respiratory arrest and nearly death. Treatment consists of positional therapy or fundoplication operation both of which seem less successful in this combination of lesions than with GER and a normal esophagus. There was one death as a late postoperative complication of fundoplication.