Lateral esophagostomy: an alternative in the initial management of long gap esophageal atresia without fistula

The authors report an alternative method of cervical esophagostomy that was used in a child with type A esophageal atresia. This method involved performing a lateral esophagostomy in the proximal pouch, preserving its distal end, allowing the child to swallow normally, without choking, while stimulating the spontaneous growth of the proximal esophagus. As a result, the infant could be discharged home on G-tube feedings while waiting for spontaneous growth of the proximal pouch to occur. There were no episodes of aspiration during this period, and definitive reconstruction through end-to-end esophageal anastomosis was accomplished successfully at the age of 18 months. The authors consider that this alternative might increase the possibility of a definitive correction through delayed primary anastomosis of the infant's own esophagus in children with this type of malformation.     

食管腐蚀性瘢痕狭窄的外科治疗

１９６１年至１９９２年间我科共收治１０３例食管腐蚀性烧伤。５６例因严重狭窄行食管重建术，其中３４例采用了石炭酸烧灼狭窄下食管粘膜、颈段食管与胃行侧一侧吻合，较理想地解决了残存食管双端盲囊问题，并简化了手术操作，从而减少并发症发生。本文观察到２例因长期服用中药酒致食管瘢痕狭窄应注意防止。     

The prevention and treatment of the incompetence of esophageal anastomoses]

The main cause of lethal outcomes after operations on the oesophagus and cardia remains failure of esophageal anastomosis. The lack of substantial positive changes in prophylaxis and especially in treatment of this complication is explained by etiological approach to this problem. Pathogenesis of the failure is determined by the only trigger--penetration of infection into the tissues of anastomotic area. The authors have developed and introduced into practice the method and the device to influence the basic link of the pathogenesis. The application of the method of permanent irrigation and sealing of the esophageal anastomosis line in treatment of 917 patients made it possible to cut down lethal outcomes from insufficiency of esophageal anastomosis to 0.1%.     

胸胃对食管癌围术期呼吸功能的影响

目的 探讨胸胃对食管癌围术期呼吸功能的影响。方法 自１９９７年至１９９８年４月,连续选择食管癌病人３６例,其中行食食管癌切除食管胃主动脉弓上吻合１８例,弓下吻合１８例。动态监测围术期肺功能及血气分析主要指标变化。结果 弓上吻合较弓下吻合对ＰａＯ２的影响差异始终有显著性（Ｐ〈０．０５）,手术第１０ｄ以后对ＶＣ％、ＦＶＣ％、ＭＶＶ％的影响差异显著（Ｐ〈０．０５）,对ＦＥＶ１．０％的影响差异始终无显著性     

Cervical esophago-visceral anastomosis with an endoscopic linear stapler. Note on a surgical technique

The incidence of anastomotic fistula in the neck after esophagectomy and esophagogastroplasty may be as high as 30%; the incidence of anastomotic stenosis may be as high as 10%. To avoid these potential and sometimes serious complications, the authors describe a partially mechanical esophago-visceral anastomosis. The esophageal stump is brought near the anterior wall of the transposed stomach. A small gastrotomy is performed. An endoscopic linear stapler is then inserted in the esophageal and gastric lumen, and fired. The anterior wall of the anastomosis is fashioned with a running suture.     

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%.     

食管癌切除附加抗反流术后残余食管黏膜上环氧化酶-2的表达

目的探讨食管癌切除附加改良Nissen折叠术后残余食管黏膜上环氧化酶-2(COX-2)表达的意义。 方法对2013年12月—2015年7月徐州医科大学附属徐州市立医院胸外科收治的50例食管中下段癌患者按照随机对照试验原则分为抗反流吻合组和常规吻合组。常规吻合组实施食管癌切除食管胃常规吻合术,抗反流吻合组在实施常规吻合基础上附加改良Nissen折叠术,术后42例患者参加随访,并以10名无反流症状的健康志愿者为对照组。行胃镜检查观察残余食管黏膜形态学改变和黏膜活检,采用real-time PCR检测残余食管黏膜上COX-2基因的表达。 结果抗反流吻合组反流性食管炎的发生率为45%,常规吻合组为68.2%,两组间反流性食管炎的发生率无明显差别(P＝1.313),而抗反流组反流性食管炎评分明显低于常规吻合组(P＝0.038)。正常对照组食管黏膜上COX-2呈现低水平表达,两组在胃镜下检查残余食管黏膜是否发生反流性食管炎的COX-2相对表达量均高于正常对照组(P＝0.031,P＝0.016),而两组间无明显差别(P＝0.137)。常规吻合组和抗反流吻合组残余食管黏膜上COX-2的相对表达量均高于对照组(P＝0.002,P＝0.047),而抗反流吻合组残余食管黏膜上COX-2表达明显低于常规吻合组(P＝0.036)。 结论食管癌切除附加改良Nissen折叠术具有抗反流的效果,检测残余食管黏膜上COX-2的表达变化是反应食管癌术后胃食管反流的灵敏指标,也可能是一种评估抗反流吻合效果的新方法。     

Duodenal closure and esophagojejunostomy experience with mechanical stapling devices in total gastrectomy for cancer

Two hundred fifty patients with cancer underwent gastrectomy over a ten-year period. In 225 the duodenum was closed by stapler and only one disruption occurred (0.45%). The first 89 esophagojejunostomies were hand sewn, and thereafter 161 were stapled with an end-to-end anastomosis device. Overall mortality was 27% and 10%, respectively. Death due to surgical causes occurred in 19% of the cases in the first group and 6.8% in the second. No statistical difference was observed in the esophageal anastomosis leakage rate, but the mortality due to such fistula was significantly higher in the group of hand-sewn anastomoses. Surprisingly, esophageal end invasion (at the anastomotic site) was 14% in the manual group vs 3.9% in the stapled one. The operator's experience had no effect on the incidence of esophageal fistula when the stapler was used. Thus, staplers are safe and useful when total gastrectomy is undertaken, provided that sound experience has been acquired.     

New procedure for purse-string suture in thoracoscopic esophagectomy with intrathoracic anastomosis

Background In endoscopic surgery, one of the greatest problems is the difficulty with the reconstructive procedure. This problem frequently makes operating times longer. The authors have performed thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis for reconstruction using a circular stapler for the esophageal cancer. Although the circular stapler is a useful device for gastrointestinal anastomosis, it was difficult to place a purse-string suture and to fixate the anvil into the proximal esophagus endoscopically.Methods The authors devised a new procedure for the placement of the purse-string suture by using an Endo-Stitch device along with a new method to incise the esophageal wall and thereby facilitate fixation of the anvil.Results The authors attempted this procedure for five patients. The anastomoses were performed successfully.Conclusions The new procedure can make endoscopic intrathoracic anastomosis feasible and safe. In addition, this procedure can be applied widely to other endoscopic reconstructions.     

机械吻合在食管外科中的应用：1605例经验总结

１９８０年８月至１９９４年２月应用机械方法对１６０５例食管癌和贲门癌切除后进行吻合。男１２８１例，女３２４例。年龄２８～８１岁，其中５０～６９岁１１８４例（７３．８％）。食管癌１０４４例，贲门癌５６１例。食管胃颈部吻合３５例；超胸顶吻合５８例；弓上吻合８３５例；弓下吻合６７７例。术后发生吻合口瘘１６例（ｌ％），其中颈部吻合口瘘发生率１４．３％（５／３５）；胸内吻合口瘘发生率０．７％（１１／１５７０），前６年胸内吻合口瘘发生率１．４％（８／５７５），近８年胸内吻合口瘘发生率０．３％（３／９９５）。术后发生吻合口狭窄１６例（１％），狭窄明显者经扩张后均恢复正常饮食。作者认为：机械吻合是减少胸内吻合口瘘的有效方法之一。     

41例Ⅲ型先天性食管闭锁Ⅰ期手术治疗

目的 探讨先天性食管闭锁Ⅰ期根治手术治疗的效果.方法 1994年11月至2008年6月收治先天性食管闭锁113例,其中接受Ⅰ期根治术41例,均为Ⅲ型,其中B型38例,A型3例.手术治疗率36.28%(41/113例).手术先行胃造瘘术,后行食管闭锁根治术.结果 术后近、远期死亡6例,死亡率14.63%(6/41例).长期生存35例.2007年以后手术12例全部生存.术后常见并发症包括吻合口狭窄、吻合口瘘.吻合口狭窄行食管扩张术治愈.吻合口瘘5例,放弃治疗死亡2例,再次手术2例,保守治愈1例.结论 手术治疗先天性食管闭锁疗效肯定,吻合口瘘是死亡高风险因子,但不是决定因素.提高手术疗效的关键在于早诊早冶,加强围术期监护.     

Resection of esophageal and gastric cardiac cancer and esophagogastrostomy by planting esophagus into the stomach: a report of cases

105 cases of esophageal cancer and 46 cases of gastric cardia carcinoma were resected and the continuity of alimentary canal was resumed by planting esophagus into the stomach. This procedure had been designed by authors. There is neither anastomotic leakage nor stricture. Only 1 case died perioperatively. The anastomosis start by suturing the whole thickness of esophageal wall to the mucous membrane of stomach. Then the esophageal stump was telescoped into the stomach by suturing the secomuscular layer of stomach to the outer layer of esophageal muscles, with a distance of about 3 cm from the inner anastomatic line. When the anastomasis was finished, esophageal mucous membrane everted slightly, and prolapsed a little as food bolus passes. We suggest these are the mechanisms preventing the anastomosis from leaking or narrowing. Reflex of gastric content may be prevented too.     

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。     

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。     

Endoscopic interventions in cicatricial strictures of esophageal anastomoses]

Endoscopic balloon hydrodilation was conducted in 39 patients with cicatricial stenoses of esophageal anastomoses, in 12 patients it was combined with electrodissection of the esophageal anastomosis, in 3 with bougienage, and in 10 with temporary endoprosthetics. The anastomosis was dilated adequately (to 2.0-2.5 cm) in 38 patients. In one case endoscopic treatment was ineffective; another surgical intervention was performed. In another case endoprosthetics was complicated by decubitus of the cervical esophagus (favorable outcome). In late-term period of 2 months to 4 years restenosis occurred in 6 of 38 patients; the course of dilation was repeated in 4 patients, 2 patients underwent a reconstructive operation. The authors believe that in development of cicatricial stenosis of the esophageal anastomosis modern methods of therapeutic endoscopy should be resorted to in the first place, and only if they prove ineffective should the question of repeated surgical intervention be discussed. Balloon hydrodilation is the principal method of operative endoscopy in cicatricial stenoses of esophageal anastomoses, which in some cases should be combined with other endoscopic interventions (electroincision and temporary endoprosthetics).     

Polarographic evaluation of oxygen metabolism in the transplant after esophagogastroplasty

Oxygen metabolism of a tube graft formed from the greater curvature of the stomach in esophagoplasty for carcinoma of the thoracic esophagus was studied by polarography. The study was conducted during the stages of treatment: in the early postoperative period and before the formation of a postponed extracavitary esophagogastric anastomosis. Oxygen tension (pO2) and the rate of oxygen consumption (ROC) by the graft tissue were studied. The pO2 for the isoperistaltic grafts was 65.3 +/- 2.31 mm Hg in the zone of the nutrient vessel and 51.68 +/- 11.6 mm Hg in the zone of the mechanical suture. A favourable postoperative period corresponded with a ROC of 0.1-0.2 units. The results of the study coincided with the clinical result in 86.3% of cases.     

Temporary distance shunting of the anastomosis with a probe shunt

The authors present results of using temporary shunting of intestinal anastomosis in combination with selective lavage of the suture line with a curative antiseptic mixture in experiment in 12 dogs and in clinic in 36 patients with a probe of the authors' original construction. The probe consists of a polychlorvenyl tube with the inner diameter 0.8-1.0 cm, having two inflatable rubber cuffs mounted on the distal end at a distance of 15 cm from each other. After inflation of the cuffs a closed isolated cavity is formed in the zone of intestinal sutures, into which the distal end of the tube is opened for the decompression and selective intraluminal lavage of the anastomosis. The using of the temporary shunting of intestinal anastomosis in combination with selective intraluminal lavage with a mixture of broad-spectrum antibiotics and antioxidant 1.5% Reamberin accelerates the process of the intestinal suture healing, results in favorable course of the postoperative period, prevents complications.     

Clinical, endoscopic and morphological criteria for assessing function of esophageal anastomosis

Clinical and endoscopic data on 115 patients after surgery with creation of esophageal anastomosis was analyzed. Functional status of esophageal anastomosis was studied with x-ray, endoscopic, morphological, and US-assisted endoscopic METHODS: The findings provided information for development of functionally effective esophageal anastomosis criteria. Potential of US-assisted endoscopy was demonstrated. Objective and early diagnosis of the depth and intensity of inflammatory infiltration in early postoperative period allowed conduction of adequate treatment. The study of tissue structure in the zone of esophageal anastomosis in a late postoperative period discovers the cause of functional insufficiency of esophageal anastomosis.     

Esophageal substitution or esophageal elongation procedures in patients with complicated esophageal atresia? Results of a comparative study

BackgroundIn newborns with complex esophageal atresia, there are situations in which a primary anastomosis cannot be safely performed. The alternative is performing a late anastomosis after the esophageal ends have gone through a period of spontaneous growth or after elongations of the distant ends of the esophagus and create an anastomosis under tension which causes risks of morbidity. An alternative to the elongation procedures is to perform a cervical esophagostomy with a gastrostomy for nutritional support and later on an esophageal replacement. The purposes of this retrospective chart review study are to report on our experience with esophageal substitution procedures in such cases, address the quality of life of a group of patients, and compare our results with those of patients who underwent esophageal elongation procedures as reported in the literature.MethodsPatients with esophageal atresia underwent esophageal replacement procedures and quality of life was assessed in a group of esophagocoloplasty patients.ResultsFrom February 1978 to July 2019, 276 children (232 colonic interpositions and 44 total gastric transpositions) were studied; the most frequent complication was cervical anastomosis leakage [70 (30.2%) esophagocoloplasty patients and 7 (15.9%) gastric transposition patients], which sealed spontaneously in all but 4 patients. The quality of life was considered excellent or good in approximately 90% of the studied 70 out of the 276 patients; the comparison with the esophageal elongation procedures showed that esophageal substitution procedures promoted excellent long-term results with normal deglutition function (98.2% of patients, versus 33.3%, 36.5%, and 62.5%, respectively from the elongation series, P < 0.0001 for all comparisons).ConclusionEsophagocoloplasty or total gastric transposition is a good alternative to treat patients with complex esophageal atresia.Type of studyRetrospective study.Level of evidenceLevel III.     

Robotically assisted esophago-esophagostomy in newborn pigs

Purpose

Repair of esophageal atresia and tracheoesophageal fistula (TEF) in the newborn is challenging when done as an open procedure but only a few surgeons have attempted this with minimally invasive surgery (MIS). Surgical robots that hold MIS instruments have wrists and provide tremor filtration and motion scaling, which might be expected to facilitate complex procedures in small spaces such as an esophageal anastomosis in a newborn.

Methods

Seven newborn pigs weighing 2 to 3 kg were used as a model. The authors performed an esophageal resection and end-to-end anastomosis using the Zeus Microwrist Robotic Surgical System. The authors monitored the following data-Zeus robotic set-up time, operating time, esophageal dissection time, and anastomosis time. After 1 month, the animals were anesthetized to perform esophagram and than were killed.

Results

In these very small animals the space available for performing an anastomosis is very limited, approximately 2 cm³. Two pigs each died 18 days postoperatively. One animal could not eat and died during esophageal dilation. The second pig died of unrelated enteritis. Neither had evidence of anastomotic leak at autopsy. The esophagram of the 5 pigs that survived for 30 days showed no narrowing or proximal dilation in 2. In 3 there was some stenosis requiring dilation. Histopathology was done on each operated animal. Two of the anastomoses were well healed, and 5 showed only focal small ulceration.

Conclusions

Robotic assistance facilitates an MIS approach to the upper esophagus even in the limited space of the infant chest.