颈椎前路内固定术后中远期食管并发症

 目的 探讨颈椎前路内固定术后中远期食管并发症的发生率及其诊疗策略。方法 对2001年1月至2011年12月2316例行颈椎前路内固定手术患者发生的中远期食管并发症情况进行回顾性分析。食管中远期并发症包括术后2周以上发生的食管穿孔、食管气管瘘、食管皮下瘘、食管憩室、食管胸膜瘘及食管狭窄等。结果 共4例患者发生中远期食管并发症,发生率为0.17%(４/２３1６),其中食管穿孔发生率为0.09%(2例)。病例1为31岁男性患者,自体髂骨移植融合加钢板内固定(C5)术后7年发现食管憩室合并食管穿孔。手术取出内固定,清创后切除憩室,胸骨舌骨肌及肩胛舌骨肌肌瓣修补食管。病例2为46岁男性患者,自体髂骨移植融合加钢板内固定(C5)术后3年发现食管憩室。手术取出内固定,切除食管憩室,胸骨舌骨肌及肩胛舌骨肌肌瓣修补食管。病例3为58岁女性患者,自体髂骨移植融合加钢板内固定(C6)术后5年出现食管憩室。手术取出内固定,切除食管憩室,胸锁乳突肌肌瓣修补食管。病例4为56岁女性患者,钛网植骨融合加钢板内固定(C6)术后3年出现食管穿孔。手术取出内固定,清创后胸锁乳突肌肌瓣修补食管。4例患者术后食管并发症均获得成功治疗,恢复良好。结论 颈椎前路内固定术后中远期食管并发症的发生率较低,X线片、消化道造影及消化道内镜检查是主要的诊断方法,手术是其主要的治疗手段。     

不开胸食管剥脱术在颈段食管癌中的治疗价值

目的探讨不开胸食管剥脱术治疗颈段食管癌的效果。方法自1995年7月至2004年12月对21例颈段食管癌患者行不开胸食管剥脱术并Ⅰ期行胃咽吻合或胃食管端侧吻合术。结果本组病人的手术切除率100%。手术后发生各类并发症8例,其中吻合口瘘3例,肺部感染3例,伤口裂开1例,气胸1例。18例患者术后有不同程度的胃液反流。1例住院期间因胃大出血死亡。除2例失访外其余患者获得随访27个月～12年,13例存活超过1年,6例存活超过3年,3例存活超过5年。结论不开胸食管剥脱术手术简单,效果满意,适用于颈段食管癌。食管剥脱术后行胃代食管者胃液反流严重,手术方式有待进一步改善。     

Repairing esophageal perforations with a transverse cervical musculofascial flap

OBJECTIVES/HYPOTHESIS: Although rare, perforations of the esophagus following spinal surgery via an anterior approach are serious life-threatening problems. Complications include abscess formation, mediastinitis, sepsis, and fistula that can carry a mortality rate of 20%-50%. Early diagnosis and treatment are imperative. A common method of repair is isolation and primary repair of the defect in the esophagus, with interpositional muscle coverage. A transverse cervical myofascial artery flap is described here as a potential reconstructive option. STUDY DESIGN/METHODS: Retrospective review was performed on 3 patients who had repair of esophageal perforations following spinal surgery with an anterior approach. RESULTS: In all 3 cases, hardware was found to be eroding through the esophagus. The hardware was removed at the time of repair and flap coverage in 2 patients, and each went on to an oral diet within 10 days without complication, with follow-up exceeding 6 months. A third patient with recurrent erosions could not have the hardware removed and subsequently suffered with another erosion through the muscle flap. A secondary surgery with pectoralis flap coverage was successful but required revision surgeries for flap debulking. No patients had limitation of shoulder movement after flap reconstruction, and all went on to a normal diet without dysphagia. CONCLUSIONS: The transverse cervical artery musculofascial flap can be an ideal method for repair of small cervical esophageal perforations, although spinal hardware should be removed if felt to be the etiology of the perforation.     

Esophageal reconstruction with intraoperative dilatation of the hypopharynx for the management of chronic corrosive esophageal strictures.: A technical tip

Chronic corrosive strictures of the upper cervical esophagus and hypopharynx resulting from ingestion of caustic substances are a challenging surgical entity when repeated endoscopic dilatations fail to yield satisfactory results. Restoring the continuity of the upper digestive tract by esophageal substitution at healthy tissue margins not only compromises the integrity of the swallowing mechanism, but also often requires the performance of a tracheostomy in order to ensure avoidance of recurrent aspirations. We describe three cases of corrosive upper cervical esophageal strictures treated with intraoperative dilatation of the proximal hypopharyngeal stump and concurrent ‘stenting’ of the pharyngeal anastomosis with the conduit replacing the esophagus. All patients tolerated the procedure well. Avoidance of both impairment of deglutition and respiratory complications, as well as restoration of normal esophageal function, was successfully accomplished.     

Curatively resected primary malignant melanoma of the esophagus: Report of a case

We report herein a rare case of primary esophageal malignant melanoma in a 49-year-old Japanese woman who presented with a 3-week history of dysphagia. Esophagogram and esophagoscopy demonstrated a polypoid tumor in the upper to mid-thoracic portion of the esophagus, and a radical subtotal esophagectomy was performed through a right thoracotomy. Histological and immunohistochemical studies proved this tumor to be a primary esophageal malignant melanoma. She received no postoperative adjuvant therapy and no signs of recurrence have been clinically observed for the 22 months since her operation.     

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     

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.     

Self-expanding esophageal prosthesis

Whether to palliate dysphagia in patients with inoperable cancer of the cervical esophagus is a debatable issue. We report herein a patient who underwent definitive chemoradiotherapy for cancer of the cervical esophagus, with early recurrence of dysphagia 1 month after the end of the treatment. No salvage surgery was attempted due to the poor general conditions and to the residual effects of the radiotherapy in the neck. Endoscopically, the upper esophageal sphincter (UES) was located 17 cm from the incisors, and the cranial margin of an infiltrating stricture was just 1 cm below the sphincter. After endoscopic dilatation, a self-expanding esophageal prosthesis (Ultraflex, Microvasive, USA) was placed under endoscopic and radiologic control with the cranial margin at the level of the UES. The patient promptly resumed oral feeding and 2 months later he is still on unrestricted diet.     

Contact invasion by a polypoid pseudosarcomatous carcinoma of the esophageal wall: Report of a case

We present herein the interesting case of a 43-year-old man in whom a rapidly growing polypoid tumor of the esophagus was histologically proven to be pseudosarcomatous carcinoma. Of particular interest was the unusual type of invasion displayed by this tumor, whereby the head of the polyp came into contact with and directly invaded the esophageal wall at the distal end of the pedicle to the submucosal layer, while invasion near the stalk was restricted to the mucosa. This style of invasion is considered to be caused by the mechanical pressure produced by the rapid growth of the tumor in the narrow esophageal lumen.     

Primary esophageal diffuse large B-cell lymphoma: Report of a case

Primary esophageal lymphoma is very rare, with fewer than 25 cases documented in the English-language literature. We report a case of primary diffuse large B-cell lymphoma of the esophagus in a 42-year-old woman. Barium esophagogram revealed almost complete esophageal obstruction at the level of the cervical esophagus, and flexible endoscopy showed a circumferential submucosal tumor covered with intact mucosa. Neck magnetic resonance imaging (MRI) showed a wide cervical mass circumferentially encompassing the lumen of the cervical esophagus. Biopsies taken with multiple forceps during flexible and rigid esophagoscopy were nondiagnostic. Finally, external esophageal wall biopsies taken during neck exploration provided information that helped us establish the diagnosis. Pathohistological findings confirmed non-Hodgkin's lymphoma of the diffuse large B-cell type. The patient was treated with combined immunochemotherapy, consisting of rituximab plus cyclophosphamide, vincristine, adriablastin, and prednisone (CHOP), followed by irradiation. A complete response was achieved, and 3 years after diagnosis and treatment the patient was disease-free.     

Repair of cervical esophageal perforation using longus colli muscle flap: a case report of a patient with cervical spinal cord injury

BACKGROUND CONTEXT: Perforation of the esophagus after anterior cervical spine surgery is a rare, but well-recognized complication. The management of esophageal perforation is controversial, and either nonoperative or operative treatment can be selected. PURPOSE: Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with an esophageal perforation. STUDY DESIGN: Case report. PATIENT SAMPLE: A 20-year-old man sustained cervical spinal cord injury, on diving and hitting his head against the bottom of a pool. A C6 burst fracture was observed with posterior displacement of a bone fragment into the spinal canal. The patient exhibited complete paralysis below the C8 spinal segment level. METHODS: The patient underwent subtotal corpectomy of the sixth cervical vertebra with the iliac bone graft and augmented posterior spinal fixation (C5-7) with pedicle screws. After the primary operation, the patient showed signs of infection such as throat pain, a high fever, and osteolytic change of the grafted bone by cervical radiograph. A second operation was performed to replace the graft bone using fibula. On the day after the operation, food residue was confirmed in the suction drainage tube, suggesting esophagus perforation. A third operation was immediately performed to confirm and treat esophagus perforation, although apparent esophageal perforation could not be detected at the second operation. Because the erosion around the perforation of the esophageal posterior wall was extensive, a longus colli muscle flap transposition was accordingly performed into the interspace between the esophageal posterior wall and the grafted bone in addition to simple suturing of the perforation. RESULTS: Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery. CONCLUSIONS: To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for esophageal perforation after anterior cervical spine surgery.     

Management of esophageal perforations: the value of aggressive surgical treatment

BACKGROUND: The treatment of esophageal perforation remains controversial, particularly in terms of the type of operative therapy. This report analyzed results of an aggressive treatment protocol. METHODS: Patients with esophageal perforations in a normal esophagus or those with a motor disorder were treated by operative closure. All defects were buttressed or closed by either muscle or pleura. Sternocleidomastoid muscle was used to buttress or primarily close the defects in the neck, and a flap of diaphragm was often used for thoracic perforation. Patients with perforated cancer or severe underlying disease had an esophagectomy. RESULTS: Sixty-four patients had operation: 50 underwent preservation of the esophagus after closure of the perforation and 14 underwent resection. The leak rate was 17%, but all healed. One patient treated with primary closure died (1.5% mortality); only 1 patient required subsequent esophagectomy. Thirteen of 14 patients treated with esophagectomy had an excellent result. CONCLUSION: The aggressive approach to esophageal perforations with attempt at uniform closure or resection of severe disease produced excellent results with reduced morbidity and low mortality.     

Use of the radial forearm fasciocutaneous free flap and montgomery salivary bypass tube for pharyngoesophageal reconstruction

BACKGROUND: Head and neck reconstructive surgeons involved in pharyngoesophageal reconstruction have several options available to repair the defect after partial or total laryngopharyngectomy. There is no uniform agreement among head and neck surgeons as to which of the most frequently used techniques offers the best results. METHODS: A retrospective study was performed on 20 consecutive patients who had undergone reconstruction of the hypopharynx and cervical esophagus using a radial forearm free flap with Montgomery salivary bypass tube at the Massachusetts Eye and Ear Infirmary in Boston, Massachusetts, and St. Louis University, Department of Otolaryngology-Head and Neck Surgery between 1992 and 1996. This reconstruction was used for primary reconstruction after total or partial laryngopharyngectomy with cervical esophagectomy, partial pharyngectomy sparing the larynx, and for reconstruction of the stenotic neopharynx after laryngectomy. RESULTS: The overall rate of pharyngocutaneous fistula was 20%, and the rate of postoperative stricture was 10%. Of patients reconstructed with this technique, 85% were able to resume oral alimentation, whereas 15% remained G-tube dependent. Of the 18 patients who did not have their larynges remain intact, 6 were able to develop useful tracheoesophageal speech. CONCLUSIONS: The results of this study show that the radial forearm fasciocutaneous free flap in combination with the Montgomery salivary bypass tube is extremely useful for reconstruction of partial and circumferential defects of the hypopharynx and cervical esophagus.     

Osteocutaneous radial forearm flap for hand reconstruction.

We treated 5 patients (4 men and 1 woman) with bone and soft tissue defects or total thumb loss using an osteocutaneous radial forearm flap. Their ages at the time of surgery ranged from 27 to 65 years (mean, 53 years). Preoperative conditions were traumatic loss of the thumb in 3 cases and severe injuries with soft tissue and bone defects in 2. The length of the donated radius ranged from 2 to 7 cm (mean, 4.7 cm). In 4 patients the radial forearm flap was transposed, including the lateral antebrachial cutaneous nerve as a sensory flap. Simultaneous iliac bone grafting to the donor site was also performed in 4 of the cases. The follow-up period ranged from 44 to 87 months (mean, 64 months). All flaps survived over their full extent. Radiographic bone union was attained after 2 to 3 months (mean, 2.5 months). Two-point discrimination over the 4 sensory flaps ranged from 8 to 15 mm (mean, 10.8 mm). No radius fractures occurred. No patients showed signs of vascular insufficiency from sacrifice of the radial artery. The radial forearm flap provides thin skin of good texture together with bone for a 1-stage reconstruction. For patients with skin and bone defects of the hand, a radial forearm osteocutaneous flap is recommended. This flap is also recommended for patients with traumatic thumb loss, if the dorsalis pedis artery is absent, or if the patient declines using tissue from the foot.     

颈段食管癌的外科治疗

目的总结外科治疗颈段食管癌的经验体会。方法综合分析1993年12月至2005年12月在河南省肿瘤医院胸外科和头颈外科接受外科治疗的82例颈段食管癌患者的临床资料。结果本组患者1997年以前以单纯手术治疗为主（27例）；1997年后，除5例早期癌患者外，50例常规采用半量放疗后再手术的综合治疗模式。非开胸食管切除73例．开胸食管切除9例；同期行单侧或双侧区域性颈淋巴结清扫14例；联合脏器切除12例。单纯手术组和综合治疗组保喉率分别为81．3％和95．8％，差异无统计学意义（P〉0．05）。无术中或术后大出血、气管和（或）支气管撕裂及围手术期死亡者；并发症发生率为19．5％；术后病理证实上切缘阳性5例，均为单纯手术组；淋巴结转移14例（17．1％）。全组5年总生存率43％：其中综合治疗组50．2％，高于单纯手术组的33．9％（Χ^2=7．17；P=0．007）；开胸食管切除者、同期行单侧或双侧区域性颈淋巴结清扫者和联合脏器切除者的5年生存率分别为36．5％、45．8％和33．3％。结论颈段食管癌患者半量放疗后再手术．可明显减少肿瘤上切缘阳性的发生率，提高保喉率和5年生存率。手术方式以非开胸游离食管为首选，联合脏器切除或双侧颈部淋巴结清扫应非常谨慎。     

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps is described. The delto-pectoral cutaneous flap, latissimus dorsi or pectoris major musculocutaneous flap, free forearm cutaneous flap, and free rectus abdominis musculocutaneous flap are generally used for reconstruction of the cervical esophagus. Although free jejunal transfer with microsurgery is now common for reconstruction of the cervical esophagus, cutaneous or musculocutaneous flaps remain useful in high-risk patients or patients in whom free jejunal transfer or gastrointestinal reconstruction would prove incompetency due to a history of abdominal surgery or other reasons. Cutaneous or musculocutaneous flaps are also used in patients with failure of free jejunal transfer or incurable fistula after reconstruction using the stomach or colon for thoracic esophageal cancer.     

Reconstruction of the hypopharynx and cervical esophagus

Hypopharynx and cervical esophageal defects are challenging problems for the reconstructive surgeon. Prior surgery and radiation therapy contribute to the difficulty in managing these patients. The surgeon must possess a reconstructive algorithm that varies depending on the defect, available donor sites, and his or her experience. The free jejunal flap is the flap used for most of these defects. The radial forearm flap is reserved for partial defects measuring less than 50% of the circumference of the pharynx. The gastric pull-up is used when an intrathoracic esophagectomy is necessary. The pectoralis flap is reserved for situations when external coverage is necessary in addition to hypopharyngeal reconstruction or when a free-tissue transfer is not appropriate. Reconstruction can offer most patients successful swallowing while minimizing complications.     

Use of the Rhomboid Major Muscle Flap for Esophageal Repair

A 16-year-old boy sustained vehicular blunt trauma with delayed esophageal rupture that resulted in empyema and an esophagopleurocutaneous fistula. Diverting esophagostomy, gastrostomy, and transpyloric jejunostomy were performed, and these procedures permitted satisfactory nutritional support of the patient.Staged direct closure of the esophagus buttressed by a rhomboid muscle flap preserved normal esophageal function. Both clinical application and cadaver dissections have demonstrated that the rhomboid flap has an excellent blood supply and that it can be used to repair lesions on either side in the upper half of the esophagus. Because this flap is extrathoracic, it is not usually distorted by intrathoracic sepsis or previous thoracic incisions. The rhomboid major muscle flap is an excellent alternative to conventional autogenous grafts for esophageal repair.     

Laparoscopic excision of esophageal leiomyoma

Esophageal leiomyoma is the most common benign tumor of the esophagus. The lower and middle thirds of the esophagus are the most frequent locations of these tumors and in about one-third of the patients they occur at the level of the gastroesophageal junction. They are less than 5 cm in size in 50% of the patients. A left thoracotomy, thoracoscopy or a laparoscopic approach can be used for lesions in the lower third of the esophagus. Esophageal leiomyomas should be considered for resection when symptomatic. Preoperative evaluation allows precise characterization of the diagnosis and location. Minimally invasive surgery is considered today the treatment of choice with the laparoscopic approach used for distal tumors. We present the case of a 63-year-old woman with an esophageal leiomyoma located above the gastroesophageal junction who underwent a successful laparoscopic excision of the tumor.     

Enucleation for a giant esophageal leiomyoma; report of a case

A 32-year-old man was referred to our hospital because of a mediastinal tumor with mild dysphagia. Computed tomography (CT) showed that the tumor was located in the neck and the posterior mediastinum. An esophagogram demonstrated severe distortion of the esophageal lumen and an endoscopic examination disclosed a submucosal bulge covered by normal mucosa with no erosion and no ulceration. A CT-guided needle biopsy for neck lesion of the tumor was performed and the histopathological diagnosis was an esophageal leiomyoma. Complete enucleation via a left anteroaxillary thoracotomy for the tumor was performed without perforation of esophageal mucosa. The resected tumor was 12 cm in size. The final diagnosis of the resected tumor located in the cervical, upper, middle and intramural esophagus was a rare giant esophageal leiomyoma. Postoperative course was uneventful. We suggested that enucleation with an operative procedure selected carefully for a giant esophageal leiomyoma was attempted for preservation of esophageal function.