- Email: [email protected]
Esophageal reconstruction for benign disease
Esophageal reconstruction for benign disease Technical considerations During the past 3 years, 21 patients have required esophageal substitution or bypass for benign disease. The techniques and principles of esophageal replacement we have found useful in treating these patients are reviewed, with emphasis upon our preferred method of esophageal replacement—one-stage thoracic esophagectomy with interposition of a long segment of isoperistaltic left colon. Mark B. Orringer, M.D., Marvin M. Kirsh, M.D., and Herbert Sloan, M.D., Ann Arbor, Mich.
X~\.lthough there is a wide variety of benign conditions for which esophageal replacement is required, all have in common the disruption of normal swallowing with its attendant nutritional, pulmonary, and psychological implications. Satisfactory long-term function of a visceral esophageal substitute is a prerequisite of far more concern in benign disease than in esophageal carcinoma. Increasing experience with esophageal reconstruction techniques has resulted in lower operative morbidity and mortality rates and improved function of the esophageal substitutes. This discussion reviews the principles and techniques of esophageal replacement which we have found useful in treating patients with benign disease that no longer permits salvage of the esophagus as a conduit for swallowing. Clinical material The surgical indications, preoperative evaluation, and results of esophageal replacement in 21 patients with benign disease operated upon during the past 3 years have been presented.11 Esophageal substitution was accomplished with either isoperistaltic left colon (17 patients) or stomach (4 patients). Of the 17 patients in whom colon was used, 7 underwent one-stage total From the Department of Surgery, Section of Thoracic Surgery, The University of Michigan Medical Center, Ann Arbor, Mich. Presented in part at the Southern Thoracic Surgical Association, Acapulco, Mexico, Nov. 3 to 10, 1976. Received for publication Oct. 29, 1976. Accepted for publication Nov. 8, 1976. Address for reprints: Mark B. Orringer, M.D., C7175 University Hospital, Ann Arbor, Mich. 48109.
thoracic esophagectomy and long-segment colonic interposition with a cervical esophagocolonic anastomosis, 2 had distal esophagectomies and shortsegment colonic interpositions, and 8 underwent substernal colonic interpositions. Two of the 4 patients in whom stomach was used to replace the esophagus had one-stage total thoracic esophagectomies with cervical esophagogastric anastomoses, one had resection of a distal esophagogastric anastomosis and a new intrathoracic esophagogastrostomy, and one underwent substernal bypass of the esophagus with a reversed gastric tube. Techniques For substernal esophageal bypass, the abdominal incision is varied with the planned visceral esophageal substitute: upper midline for stomach, low left subcostal for colon. The cervical incision is 6 to 8 cm. long and parallels the anterior border of the sternocleidomastoid muscle, curving downward from the suprasternal notch onto the manubrium for 2 to 3 cm. Whether stomach or colon is used, the posterior prominence of the clavicular head and adjacent manubrium are removed routinely to widen the anterior opening into the superior mediastinum and thus avoid compression of the esophageal substitute at this point.12 In addition, mobilization of the cervical esophagus medial to the carotid sheath is facilitated by the greater exposure of the superior mediastinum provided by prior resection of the clavicle and manubrium. Resection of the clavicle on the side opposite the dominant hand minimizes postoperative discomfort. The cervical esophagus is divided with the GIA surgical stapler and the distal end is oversewn with a running 4-0 Prolene Lembert stitch. 807
8 0 8 Orringer, Kirsh, Sloan
The Journal of Thoracic and Cardiovascular Surgery
Fig. 1. The thoracic esophagus is mobilized above, below, and medial to the aortic arch and then well into the neck from within the chest. Inset shows positioning of patient with the left arm draped into thefield.This posture allows a thoracoabdominal incision in the sixth intercostal space (A) as well as access to the neck (B). An isoperistaltic segment of transverse and left colon based on the ascending branch of the left colic artery, as described by Belsey1 (see Fig. 2), is generally used for substernal bypass, although transposition of the stomach to a substernal location also provides an excellent means of esophageal bypass.11 In adults, a retrosternal tunnel which admits the surgeon's hand and forearm is created. Injury to the pericardium or pleura and undue pressure against the heart are avoided. An adequate retrosternal opening for the graft in the diaphragm must be provided to prevent subsequent local stenosis at this point. The mobilized colonic graft and its vascular pedicle are passed behind the stomach through the gastrohepatic omentum, and the cologastric anastomosis is performed on the anterior gastric wall at the junction of the upper and middle thirds. A gastric drainage procedure, usually a pyloromyotomy, is performed. The abdominal portion of the operation is completed and the incision is closed prior to beginning the cervical anastomosis to avoid contamination of the abdomen by intraoral bacteria encountered upon opening the esophagus in the neck. When resection of the thoracic esophagus is indicated, esophagectomy and reconstruction with either stomach or colon is achieved through left thoracoabdominal and cervical incisions (to be discussed later). This is our preferred approach, except in cases of megaesophagus, in which division of extensive rightsided pleural attachments may result in bleeding that is difficult to control from the left side of the chest. When
resection for reflux esophagitis is required, we do not hesitate to remove the entire intrathoracic esophagus if mucosal and submucosal disease is found more proximally than predicted by preoperative barium and esophagoscopic studies. It is unwise to hazard an anastomosis to such diseased tissue or to struggle with a high anastomosis beneath the aortic arch. A cervical anastomosis avoids the catastrophe of an intrathoracic anastomotic disruption and provides no less ability to swallow than when the proximal third or half of the intrathoracic esophagus remains. For one-stage esophagectomy and reconstruction with either stomach or colon, the patient is positioned on the right side with the hips rotated 45 degrees posteriorly and the left arm draped into the field. This posture allows access to the left side of the chest, left upper quadrant of the abdomen, and neck without repositioning the patient (Fig. 1). With the patient's left arm extended forward, most of the operation is performed through a lateral thoracotomy in the left sixth intercostal space. The incision is extended anteriorly through the costal arch to the lateral border of the left rectus sheath. The diaphragm is opened peripherally, posterior to the costal arch, to avoid injury to the phrenic nerve and its branches. This incision provides excellent exposure of the upper abdomen, particularly the stomach, transverse colon, and left colon. When total thoracic eosphagectomy is planned, the entire esophagus is mobilized from within the chest above and below the aortic arch and well into the neck (Fig.
Volume 73 Number 5 May, 1977
Esophageal reconstruction
Fig. 2. The mobilized colon graft and its vascular pedicle are passed behind the stomach, through the gastrohepatic omentum, and the proximal end of the colon graft is delivered into the chest through the diaphragmatic hiatus. Note the divided distal esophagus within the chest, the oversewn gastric cardia, the completed pyloromyotomy, and the colocolostomy. Inset shows the length of colon and its blood supply for short-segment (A to B) grafts to replace the distal esophagus and long-segment (Ax to B) grafts to replace the entire esophagus. L.C., Left colic artery. M.C., Middle colic artery.
Fig. 3. The proximal end of the colon graft is sutured to the end of the divided and mobilized esophagus. The cologastric anastomosis is completed on the posterior gastric wall, as shown in main illustration and inset. The tip of the spleen, which is easily injured, is shown.
8 09
8 1 0 Orringer, Kirsh, Sloan
The Journal of Thoracic and Cardiovascular Surgery
Fig. 4. Positioning the esophageal substitute medial to the aortic arch in the original esophageal bed within the posterior mediastinum. 1). Much of the dissection medial to the aortic arch can be achieved bluntly, but an occasional esophageal branch from the aorta or from a bronchial artery may require separate ligation. For colonic interposition, either a long or short isoperistaltic segment of left colon is mobilized, based on the ascending branch of the left colic artery, as described by Belsey1 (Fig. 2). After the cardia has been divided and oversewn, the mobilized segment of left colon and its vascular pedicle are passed behind the stomach through the gastrohepatic omentum to minimize tension on the blood supply. The divided colon is reapproximated and the defect in the mesocolon closed. A gastric drainage procedure, usually a pyloromyotomy, is done. The proximal end of the colon graft is brought through the diaphragmatic esophageal hiatus and is sutured to the distal end of the mobilized and divided thoracic esophagus, which is subsequently used for traction (Fig. 3). The cologastric anastomosis is performed on the posterior aspect of the stomach at the junction of the upper and middle thirds to ensure an adequate length of intra-abdominal distal colonic graft upon which positive intra-abdominal pressure can be exerted to prevent gastroesophageal reflux. The left arm is then lowered to the patient's side. Through a 4 to 6 cm. oblique incision along the anterior border of the left sternomastoid muscle, with the carotid sheath retracted laterally and care taken to avoid injury to
the recurrent laryngeal nerve, the cervical esophagus is mobilized and encircled. The clavicle and manubrium are not resected when the esophageal substitute is brought through the posterior mediastinum to the neck. With gentle traction on the cervical esophagus and guidance from within the chest, the proximal end of the colonic graft is passed beneath the aortic arch and into the neck, where the esophagocolonic anastomosis will be performed (Fig. 4). In this way, the aortic arch helps to maintain the position of the graft within the posterior mediastinum. Through the same incision, the stomach may be used for esophageal replacement, with the fundus being mobilized into the cervical wound. Passage of the stomach beneath the aortic arch effectively keeps it within the posterior mediastinum. In older individuals with benign strictures, esophagogastrostomy is the simplest, most efficient, and therefore preferable method for esophageal reconstruction. Whenever this technique is utilized, however, careful attention to the details of anastomotic construction is essential to prevent subsequent esophagitis and aspiration pneumonia from gastroesophageal reflux. In the thorax, a fundoplication around the anastomosis may effectively control reflux.13 In the neck, we12 suspend the gastric fundus from the prevertebral fascia and anastomose the cervical esophagus several centimeters below on the anterior aspect of the stomach wall. The acute angle of entry of the esophagus onto the stomach and dilatation
Volume 73 Number 5 May, 1977
of the retroesophageal portion of the stomach create a flap valve mechanism preventing gastroesophageal reflux. The edge of the diaphragmatic hiatus is carefully sutured to the colonic or gastric substitute to prevent subsequent herniation of intra-abdominal contents through the hiatus into the chest. The abdominal and thoracic wounds are always closed prior to performing the cervical anastomosis to minimize bacterial contamination which occurs once the cervical esophagus is opened. For colonic interposition, gastric decompression is achieved through a gastrostomy tube. No tube is left within the colonic graft. For cervical esophagogastrostomy, a tube pharyngostomy provides both gastric decompression and a means of providing nutrition should an anastomotic leak occur. Oral intake is generally begun after bowel sounds appear on the second or third postoperative day. Results Complications following esophageal reconstruction generally have been related to the age and nutrition of the patients and to the degree of difficulty encountered in operating upon tissues scarred by previous esophageal procedures, peptic esophagitis, or caustic injury. Among our 21 patients, there were three postoperative deaths, two following cerebral vascular accidents in older patients and one from sepsis resulting from an unrecognized fistula between a substernal reversed gastric tube and the pericardium. Additional complications included anastomotic leak (3 patients), small bowel obstruction (3 patients), wound infection (2 patients), cecal dilation requiring cecostomy (one patient), stricture of gastric anastomosis following resection for caustic injury (one patient), and intrathoracic hemorrhage (one patient). One elderly woman died 6 months postoperatively of heart disease and renal failure, but she was able to swallow normally up to the time of her death. In the remaining 17 patients, after an average follow-up of 17 months, the visceral esophageal substitutes have functioned well and have allowed ingestion of regular diets and maintenance of normal nutritional status. Comments Esophageal reconstruction involves decisions regarding (1) the route to be used to connect the esophagus with the stomach, (2) the organ to be used as the visceral esophageal substitute, and (3) the desirability or necessity of removing the patient's esophagus. The esophagus may be replaced or bypassed by means of
Esophageal reconstruction
81 1
the antethoracic subcutaneous, posterior mediastinal, or substernal routes. The subcutaneous position for an esophageal substitute is cosmetically unappealing and functionally less satisfactory than the other two positions, since subcutaneous fibrosis may result in obstruction of the graft. The posterior mediastinal route is the most direct and natural compartment between the mouth and the stomach. However, when the esophagus is congenitally absent or when esophagectomy or esophageal exclusion for trauma or control of a chronic fistula has been necessary, the substernal route, which avoids the need for thoracotomy, is quite satisfactory. Although there may be some increased risk of malignant degeneration within the scarred esophagus, 8,9 it is not great enough per se to warrant esophagectomy.2,10 However, in the patient with pain or bleeding from the esophagus, relief of dysphagia alone by bypassing the obstruction will not suffice, and esophagectomy must be performed. In our experience, distortion of the esophagogastric junction from fibrosis after severe caustic esophageal injury has been common. Thus, when one elects not to resect the esophagus in such patients, the risk of future bleeding from reflux esophagitis is of some concern. Although jejunal interposition is an effective method of distal esophageal replacement,4 we have not used this technique because of its disadvantages of having the most delicate blood supply and length limitations of all visceral esophageal substitutes. Through either the substernal or posterior mediastinal route, the stomach can be adequately mobilized, preserving its dual blood supply, the right gastric and gastroepiploic vessels, which thus surpasses that of all other visceral esophageal substitutes.12 These factors and the simplicity of standard esophagogastrostomy make this operation our reconstructive procedure of choice in elderly patients. However, because of the morbidity associated with esophagogastrostomy and loss of a gastric reservoir, namely reflux esophagitis, pulmonary complications of reflux, early satiety, and dumping symptoms,6, 14 this method of esophageal reconstruction is not recommended in young patients with benign disease who have a long life expectancy. Techniques for minimizing gastroesophageal reflux following intrathoracic or cervical esophagogastric anastomoses have been described and should be utilized whenever possible. 1,2 " 13 Bypass of the esophagus with a reversed gastric tube is facilitated greatly by the use of surgical stapling devices but requires the construction and healing of a long gastric suture line. The gastric tube-pericardial fistula which occurred in one of our patients resulted in his
The Journal of Thoracic and Cardiovascular Surgery
8 1 2 Orringer, Kirsh, Sloan
death. Also of concern with this technique is the T formed at the junction of the esophagus and gastric tube, which is responsible for a high incidence of anastomotic disruption and subsequent stricture formation,3' 5 and the added morbidity of the recommended routine splenectomy.7 For these reasons, despite the favorable results reported with the reversed gastric tube bypass as an esophageal substitute,3' 5 we avoid this method for benign disease in which there is a reasonable life expectancy, unless other methods of reconstruction have failed. We believe that colonic interposition with isoperistaltic left colon based on the ascending branch of the left colic artery as described by Belsey,1 is currently the best method of esophageal reconstruction for benign disease in relatively healthy patients in the first four to five decades of life. The relative size, length, constancy of blood supply, and ease of mobilization of the left colon and transverse colon through a left thoracoabdominal incision make this segment of bowel ideal for either one-stage esophagectomy and reconstruction or for substernal bypass. Mesenteric arterosclerosis, diabetes melitus with accompanying small vessel disease, collagen vascular disease, inflammatory large bowel disease, or the finding of a thickened, fatty mesocolon which makes identification and preservation of blood supply to the colon extremely difficult, are relative contraindications to colonic interposition. REFERENCES 1 Belsey, R.: Reconstruction of Esophagus With Left Colon, J. THORAC. CARDIOVASC. SURG. 49: 33, 1965. 2 Carver, C M., Sealy, W. C , and Dillon, J. J.: Management of Alkali Burns of the Esophagus, J. A. M. A. 160: 447, 1956.
3 Cohen, D. H., Middleton, A. W., and Fletcher, J.: Gastric Tube Esophagoplasty, J. Pediatr. Surg. 9: 451, 1974. 4 Dave, K. S., Wooler, G. H., Holden, M. P., et al: Esophageal Replacement With Jejunum For Nonmalignant Lesions: 26 Years' Experience. Surgery 72: 466, 1972. 5 Gavriliu, D.: Aspects of Esophageal Surgery: Current Problems in Surgery, Chicago, 1975, Year Book Medical Publishers, Inc. 6 Hanna, F. A., Harrison, A. W., and Derrick, J. R.: Long-Term Results of Visceral Esophageal Substitutes, Ann. Thorac. Surg. 3: 111, 1967. 7 Heimlich, J. H.: Esophagitis: Complications Treated by Total Bypass Without Esophageal Resection, Ann. Thorac. Surg. 10: 203, 1970. 8 Joske, R. A., and Benedict, E. B.: The Role of Benign Esophageal Obstruction in the Development of Carcinoma of the Esophagus, Gastroenterology 36: 749, 1959. 9 Kiviranta, N. K.: Corrosive Carcinoma of the Esophagus, Acta Otolaryngol. 42: 82, 1952. 10 Marchand, P.: Caustic Strictures of the Esophagus, Thorax 10: 171, 1956. 11 Orringer, M. B., Kirsh, M. M., and Sloan, H.: New Trends in Esophageal Replacement for Benign Disease. Ann. Thorac. Surg. 23: 409, 1977. 12 Orringer, M. B., Sloan, H.: Substernal Gastric Bypass of the Excluded Thoracic Esophagus for Palliation of Esophageal Carcinoma, J. THORAC. CARDIOVASC. SURG. 70: 836, 1975. 13 Pearson, F. G., Henderson, R. D., and Parrish, R. M.: An Operative Technique for the Control of Reflux Following Esophagogastrostomy, J. THORAC. CARDIOVASC. SURG. 58: 668,
1969.
14 Raptis, S., and Mearns-Milne, D.: A Review of the Management of 100 Cases of Benign Strictures of the Esophagus, Thorax 27: 599, 1972.
X~\.lthough there is a wide variety of benign conditions for which esophageal replacement is required, all have in common the disruption of normal swallowing with its attendant nutritional, pulmonary, and psychological implications. Satisfactory long-term function of a visceral esophageal substitute is a prerequisite of far more concern in benign disease than in esophageal carcinoma. Increasing experience with esophageal reconstruction techniques has resulted in lower operative morbidity and mortality rates and improved function of the esophageal substitutes. This discussion reviews the principles and techniques of esophageal replacement which we have found useful in treating patients with benign disease that no longer permits salvage of the esophagus as a conduit for swallowing. Clinical material The surgical indications, preoperative evaluation, and results of esophageal replacement in 21 patients with benign disease operated upon during the past 3 years have been presented.11 Esophageal substitution was accomplished with either isoperistaltic left colon (17 patients) or stomach (4 patients). Of the 17 patients in whom colon was used, 7 underwent one-stage total From the Department of Surgery, Section of Thoracic Surgery, The University of Michigan Medical Center, Ann Arbor, Mich. Presented in part at the Southern Thoracic Surgical Association, Acapulco, Mexico, Nov. 3 to 10, 1976. Received for publication Oct. 29, 1976. Accepted for publication Nov. 8, 1976. Address for reprints: Mark B. Orringer, M.D., C7175 University Hospital, Ann Arbor, Mich. 48109.
thoracic esophagectomy and long-segment colonic interposition with a cervical esophagocolonic anastomosis, 2 had distal esophagectomies and shortsegment colonic interpositions, and 8 underwent substernal colonic interpositions. Two of the 4 patients in whom stomach was used to replace the esophagus had one-stage total thoracic esophagectomies with cervical esophagogastric anastomoses, one had resection of a distal esophagogastric anastomosis and a new intrathoracic esophagogastrostomy, and one underwent substernal bypass of the esophagus with a reversed gastric tube. Techniques For substernal esophageal bypass, the abdominal incision is varied with the planned visceral esophageal substitute: upper midline for stomach, low left subcostal for colon. The cervical incision is 6 to 8 cm. long and parallels the anterior border of the sternocleidomastoid muscle, curving downward from the suprasternal notch onto the manubrium for 2 to 3 cm. Whether stomach or colon is used, the posterior prominence of the clavicular head and adjacent manubrium are removed routinely to widen the anterior opening into the superior mediastinum and thus avoid compression of the esophageal substitute at this point.12 In addition, mobilization of the cervical esophagus medial to the carotid sheath is facilitated by the greater exposure of the superior mediastinum provided by prior resection of the clavicle and manubrium. Resection of the clavicle on the side opposite the dominant hand minimizes postoperative discomfort. The cervical esophagus is divided with the GIA surgical stapler and the distal end is oversewn with a running 4-0 Prolene Lembert stitch. 807
8 0 8 Orringer, Kirsh, Sloan
The Journal of Thoracic and Cardiovascular Surgery
Fig. 1. The thoracic esophagus is mobilized above, below, and medial to the aortic arch and then well into the neck from within the chest. Inset shows positioning of patient with the left arm draped into thefield.This posture allows a thoracoabdominal incision in the sixth intercostal space (A) as well as access to the neck (B). An isoperistaltic segment of transverse and left colon based on the ascending branch of the left colic artery, as described by Belsey1 (see Fig. 2), is generally used for substernal bypass, although transposition of the stomach to a substernal location also provides an excellent means of esophageal bypass.11 In adults, a retrosternal tunnel which admits the surgeon's hand and forearm is created. Injury to the pericardium or pleura and undue pressure against the heart are avoided. An adequate retrosternal opening for the graft in the diaphragm must be provided to prevent subsequent local stenosis at this point. The mobilized colonic graft and its vascular pedicle are passed behind the stomach through the gastrohepatic omentum, and the cologastric anastomosis is performed on the anterior gastric wall at the junction of the upper and middle thirds. A gastric drainage procedure, usually a pyloromyotomy, is performed. The abdominal portion of the operation is completed and the incision is closed prior to beginning the cervical anastomosis to avoid contamination of the abdomen by intraoral bacteria encountered upon opening the esophagus in the neck. When resection of the thoracic esophagus is indicated, esophagectomy and reconstruction with either stomach or colon is achieved through left thoracoabdominal and cervical incisions (to be discussed later). This is our preferred approach, except in cases of megaesophagus, in which division of extensive rightsided pleural attachments may result in bleeding that is difficult to control from the left side of the chest. When
resection for reflux esophagitis is required, we do not hesitate to remove the entire intrathoracic esophagus if mucosal and submucosal disease is found more proximally than predicted by preoperative barium and esophagoscopic studies. It is unwise to hazard an anastomosis to such diseased tissue or to struggle with a high anastomosis beneath the aortic arch. A cervical anastomosis avoids the catastrophe of an intrathoracic anastomotic disruption and provides no less ability to swallow than when the proximal third or half of the intrathoracic esophagus remains. For one-stage esophagectomy and reconstruction with either stomach or colon, the patient is positioned on the right side with the hips rotated 45 degrees posteriorly and the left arm draped into the field. This posture allows access to the left side of the chest, left upper quadrant of the abdomen, and neck without repositioning the patient (Fig. 1). With the patient's left arm extended forward, most of the operation is performed through a lateral thoracotomy in the left sixth intercostal space. The incision is extended anteriorly through the costal arch to the lateral border of the left rectus sheath. The diaphragm is opened peripherally, posterior to the costal arch, to avoid injury to the phrenic nerve and its branches. This incision provides excellent exposure of the upper abdomen, particularly the stomach, transverse colon, and left colon. When total thoracic eosphagectomy is planned, the entire esophagus is mobilized from within the chest above and below the aortic arch and well into the neck (Fig.
Volume 73 Number 5 May, 1977
Esophageal reconstruction
Fig. 2. The mobilized colon graft and its vascular pedicle are passed behind the stomach, through the gastrohepatic omentum, and the proximal end of the colon graft is delivered into the chest through the diaphragmatic hiatus. Note the divided distal esophagus within the chest, the oversewn gastric cardia, the completed pyloromyotomy, and the colocolostomy. Inset shows the length of colon and its blood supply for short-segment (A to B) grafts to replace the distal esophagus and long-segment (Ax to B) grafts to replace the entire esophagus. L.C., Left colic artery. M.C., Middle colic artery.
Fig. 3. The proximal end of the colon graft is sutured to the end of the divided and mobilized esophagus. The cologastric anastomosis is completed on the posterior gastric wall, as shown in main illustration and inset. The tip of the spleen, which is easily injured, is shown.
8 09
8 1 0 Orringer, Kirsh, Sloan
The Journal of Thoracic and Cardiovascular Surgery
Fig. 4. Positioning the esophageal substitute medial to the aortic arch in the original esophageal bed within the posterior mediastinum. 1). Much of the dissection medial to the aortic arch can be achieved bluntly, but an occasional esophageal branch from the aorta or from a bronchial artery may require separate ligation. For colonic interposition, either a long or short isoperistaltic segment of left colon is mobilized, based on the ascending branch of the left colic artery, as described by Belsey1 (Fig. 2). After the cardia has been divided and oversewn, the mobilized segment of left colon and its vascular pedicle are passed behind the stomach through the gastrohepatic omentum to minimize tension on the blood supply. The divided colon is reapproximated and the defect in the mesocolon closed. A gastric drainage procedure, usually a pyloromyotomy, is done. The proximal end of the colon graft is brought through the diaphragmatic esophageal hiatus and is sutured to the distal end of the mobilized and divided thoracic esophagus, which is subsequently used for traction (Fig. 3). The cologastric anastomosis is performed on the posterior aspect of the stomach at the junction of the upper and middle thirds to ensure an adequate length of intra-abdominal distal colonic graft upon which positive intra-abdominal pressure can be exerted to prevent gastroesophageal reflux. The left arm is then lowered to the patient's side. Through a 4 to 6 cm. oblique incision along the anterior border of the left sternomastoid muscle, with the carotid sheath retracted laterally and care taken to avoid injury to
the recurrent laryngeal nerve, the cervical esophagus is mobilized and encircled. The clavicle and manubrium are not resected when the esophageal substitute is brought through the posterior mediastinum to the neck. With gentle traction on the cervical esophagus and guidance from within the chest, the proximal end of the colonic graft is passed beneath the aortic arch and into the neck, where the esophagocolonic anastomosis will be performed (Fig. 4). In this way, the aortic arch helps to maintain the position of the graft within the posterior mediastinum. Through the same incision, the stomach may be used for esophageal replacement, with the fundus being mobilized into the cervical wound. Passage of the stomach beneath the aortic arch effectively keeps it within the posterior mediastinum. In older individuals with benign strictures, esophagogastrostomy is the simplest, most efficient, and therefore preferable method for esophageal reconstruction. Whenever this technique is utilized, however, careful attention to the details of anastomotic construction is essential to prevent subsequent esophagitis and aspiration pneumonia from gastroesophageal reflux. In the thorax, a fundoplication around the anastomosis may effectively control reflux.13 In the neck, we12 suspend the gastric fundus from the prevertebral fascia and anastomose the cervical esophagus several centimeters below on the anterior aspect of the stomach wall. The acute angle of entry of the esophagus onto the stomach and dilatation
Volume 73 Number 5 May, 1977
of the retroesophageal portion of the stomach create a flap valve mechanism preventing gastroesophageal reflux. The edge of the diaphragmatic hiatus is carefully sutured to the colonic or gastric substitute to prevent subsequent herniation of intra-abdominal contents through the hiatus into the chest. The abdominal and thoracic wounds are always closed prior to performing the cervical anastomosis to minimize bacterial contamination which occurs once the cervical esophagus is opened. For colonic interposition, gastric decompression is achieved through a gastrostomy tube. No tube is left within the colonic graft. For cervical esophagogastrostomy, a tube pharyngostomy provides both gastric decompression and a means of providing nutrition should an anastomotic leak occur. Oral intake is generally begun after bowel sounds appear on the second or third postoperative day. Results Complications following esophageal reconstruction generally have been related to the age and nutrition of the patients and to the degree of difficulty encountered in operating upon tissues scarred by previous esophageal procedures, peptic esophagitis, or caustic injury. Among our 21 patients, there were three postoperative deaths, two following cerebral vascular accidents in older patients and one from sepsis resulting from an unrecognized fistula between a substernal reversed gastric tube and the pericardium. Additional complications included anastomotic leak (3 patients), small bowel obstruction (3 patients), wound infection (2 patients), cecal dilation requiring cecostomy (one patient), stricture of gastric anastomosis following resection for caustic injury (one patient), and intrathoracic hemorrhage (one patient). One elderly woman died 6 months postoperatively of heart disease and renal failure, but she was able to swallow normally up to the time of her death. In the remaining 17 patients, after an average follow-up of 17 months, the visceral esophageal substitutes have functioned well and have allowed ingestion of regular diets and maintenance of normal nutritional status. Comments Esophageal reconstruction involves decisions regarding (1) the route to be used to connect the esophagus with the stomach, (2) the organ to be used as the visceral esophageal substitute, and (3) the desirability or necessity of removing the patient's esophagus. The esophagus may be replaced or bypassed by means of
Esophageal reconstruction
81 1
the antethoracic subcutaneous, posterior mediastinal, or substernal routes. The subcutaneous position for an esophageal substitute is cosmetically unappealing and functionally less satisfactory than the other two positions, since subcutaneous fibrosis may result in obstruction of the graft. The posterior mediastinal route is the most direct and natural compartment between the mouth and the stomach. However, when the esophagus is congenitally absent or when esophagectomy or esophageal exclusion for trauma or control of a chronic fistula has been necessary, the substernal route, which avoids the need for thoracotomy, is quite satisfactory. Although there may be some increased risk of malignant degeneration within the scarred esophagus, 8,9 it is not great enough per se to warrant esophagectomy.2,10 However, in the patient with pain or bleeding from the esophagus, relief of dysphagia alone by bypassing the obstruction will not suffice, and esophagectomy must be performed. In our experience, distortion of the esophagogastric junction from fibrosis after severe caustic esophageal injury has been common. Thus, when one elects not to resect the esophagus in such patients, the risk of future bleeding from reflux esophagitis is of some concern. Although jejunal interposition is an effective method of distal esophageal replacement,4 we have not used this technique because of its disadvantages of having the most delicate blood supply and length limitations of all visceral esophageal substitutes. Through either the substernal or posterior mediastinal route, the stomach can be adequately mobilized, preserving its dual blood supply, the right gastric and gastroepiploic vessels, which thus surpasses that of all other visceral esophageal substitutes.12 These factors and the simplicity of standard esophagogastrostomy make this operation our reconstructive procedure of choice in elderly patients. However, because of the morbidity associated with esophagogastrostomy and loss of a gastric reservoir, namely reflux esophagitis, pulmonary complications of reflux, early satiety, and dumping symptoms,6, 14 this method of esophageal reconstruction is not recommended in young patients with benign disease who have a long life expectancy. Techniques for minimizing gastroesophageal reflux following intrathoracic or cervical esophagogastric anastomoses have been described and should be utilized whenever possible. 1,2 " 13 Bypass of the esophagus with a reversed gastric tube is facilitated greatly by the use of surgical stapling devices but requires the construction and healing of a long gastric suture line. The gastric tube-pericardial fistula which occurred in one of our patients resulted in his
The Journal of Thoracic and Cardiovascular Surgery
8 1 2 Orringer, Kirsh, Sloan
death. Also of concern with this technique is the T formed at the junction of the esophagus and gastric tube, which is responsible for a high incidence of anastomotic disruption and subsequent stricture formation,3' 5 and the added morbidity of the recommended routine splenectomy.7 For these reasons, despite the favorable results reported with the reversed gastric tube bypass as an esophageal substitute,3' 5 we avoid this method for benign disease in which there is a reasonable life expectancy, unless other methods of reconstruction have failed. We believe that colonic interposition with isoperistaltic left colon based on the ascending branch of the left colic artery as described by Belsey,1 is currently the best method of esophageal reconstruction for benign disease in relatively healthy patients in the first four to five decades of life. The relative size, length, constancy of blood supply, and ease of mobilization of the left colon and transverse colon through a left thoracoabdominal incision make this segment of bowel ideal for either one-stage esophagectomy and reconstruction or for substernal bypass. Mesenteric arterosclerosis, diabetes melitus with accompanying small vessel disease, collagen vascular disease, inflammatory large bowel disease, or the finding of a thickened, fatty mesocolon which makes identification and preservation of blood supply to the colon extremely difficult, are relative contraindications to colonic interposition. REFERENCES 1 Belsey, R.: Reconstruction of Esophagus With Left Colon, J. THORAC. CARDIOVASC. SURG. 49: 33, 1965. 2 Carver, C M., Sealy, W. C , and Dillon, J. J.: Management of Alkali Burns of the Esophagus, J. A. M. A. 160: 447, 1956.
3 Cohen, D. H., Middleton, A. W., and Fletcher, J.: Gastric Tube Esophagoplasty, J. Pediatr. Surg. 9: 451, 1974. 4 Dave, K. S., Wooler, G. H., Holden, M. P., et al: Esophageal Replacement With Jejunum For Nonmalignant Lesions: 26 Years' Experience. Surgery 72: 466, 1972. 5 Gavriliu, D.: Aspects of Esophageal Surgery: Current Problems in Surgery, Chicago, 1975, Year Book Medical Publishers, Inc. 6 Hanna, F. A., Harrison, A. W., and Derrick, J. R.: Long-Term Results of Visceral Esophageal Substitutes, Ann. Thorac. Surg. 3: 111, 1967. 7 Heimlich, J. H.: Esophagitis: Complications Treated by Total Bypass Without Esophageal Resection, Ann. Thorac. Surg. 10: 203, 1970. 8 Joske, R. A., and Benedict, E. B.: The Role of Benign Esophageal Obstruction in the Development of Carcinoma of the Esophagus, Gastroenterology 36: 749, 1959. 9 Kiviranta, N. K.: Corrosive Carcinoma of the Esophagus, Acta Otolaryngol. 42: 82, 1952. 10 Marchand, P.: Caustic Strictures of the Esophagus, Thorax 10: 171, 1956. 11 Orringer, M. B., Kirsh, M. M., and Sloan, H.: New Trends in Esophageal Replacement for Benign Disease. Ann. Thorac. Surg. 23: 409, 1977. 12 Orringer, M. B., Sloan, H.: Substernal Gastric Bypass of the Excluded Thoracic Esophagus for Palliation of Esophageal Carcinoma, J. THORAC. CARDIOVASC. SURG. 70: 836, 1975. 13 Pearson, F. G., Henderson, R. D., and Parrish, R. M.: An Operative Technique for the Control of Reflux Following Esophagogastrostomy, J. THORAC. CARDIOVASC. SURG. 58: 668,
1969.
14 Raptis, S., and Mearns-Milne, D.: A Review of the Management of 100 Cases of Benign Strictures of the Esophagus, Thorax 27: 599, 1972.