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Esophageal reconstruction for complex benign esophageal disease
J THORAC
CARDIOVASC SURG
1990;99:192-9
Original Communications
Esophageal reconstruction for complex benign esophageal disease We report the cases of 35 patients with complex benign esophageal disease who required radical surgical reconstruction. These patients had undergone 63 previous esophageal operations. Twenty-seven patients required esophagogastrectomy, four had esophageal exclusion before colon interposition, two had cardioplasty, and two without stricture did not require resection. Reconstruction was achieved by esophagogastrostomy in six patients, colon interposition in eight, and acid suppression and alkaline diversion in 21. One patient died of pneumonia 2 weeks after esophagogastrostomy. The overall rate of postoperative improvement was 70 %, but the condition of 86 % of patients was improved after the acid-suppression and alkaline-diversion procedure, which is the reconstructive procedure we prefer in properly selected patients with complex benign esophageal disease.
F. Henry Ellis, Jr., MD, phD,a,b and S. Peter Gibb, MD e (by invitation),
Burlington and Boston, Mass.
he
surgical management of complex benign esophageal disease is challenging and has no easy solution. Many patients with this condition have undergone a previous operation, which makes simple straightforward repair and reconstruction techniques inappropriate. The results of our experience with reoperation for failed fundoplication 1 and for failed esophagomyotomy/ have been less good than when these procedures were performed as primary operations. Furthermore, our results after gastroplasty-fundoplication' for complex gastroesophageal reflux disease (GERD) leave much to be desired. These experiences suggest that a more radical approach may be required for patients with selected From the Departments of Thoracic and Cardiovascular Surgery" and Gastroenterology," LaheyClinicMedicalCenter, Burlington,Mass., and the Division of Thoracic and Cardiovascular Surgery," New England Deaconess Hospital, Boston, Mass. Read at the Sixty-ninth Annual Meetingof The American Association for Thoracic Surgery, Boston, Mass., May 8-10, 1989. Address for reprints: F. Henry Ellis, Jr., MD, PhD, Department of Thoracic and Cardiovascular Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805. o
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complex benign esophageal disorders. In this paper, we review our experience with such operations to determine the proper indications for a radical approach and to identify the operative procedure that can be expected to give the best results.
Methods Patients. From January 1970 to January 19&9, 35 patients underwent reconstructive operative procedures for complex benign esophageal disease, which represented 6.7% of the 516 operations for benign disorders of the body and lower part of the esophagus performed during that period. These 35 patients had undergone a total of63 previous operations, an average of nearly two per patient. One patient had undergone six previous operations on the distal esophagus, upper stomach, or both. One patient had undergone five previous operations; two patients, four operations; six patients, three operations; and six patients, two operations. Fourteen patients had undergone only one previous operation. Only three patients had not been operated on before. A carcinoma was suspected preoperatively in one of these patients, and scleroderma was present in the other two patients. The esophageal procedures performed before the reconstructive operations that form the basis of this report are listed in Table I. Nine of the 63 procedures had been performed by us; four were esophageal exclusion procedures performed in anticipation of subsequent reconstruction. The two commonest previous operations were fundoplication, usually of the Nissen type, and
Volume 99 Number 2
Table I. Complex benign esophageal disease: Previous
Table II. Complex benign esophageal disease
operation
No. No.
Fundoplication Nissen Collis-Nissen Collis-Belsey Belsey ThaI-Nissen Hill Esophagomyotomy Diaphragmatic hernia repair Esophageal exploration and/or repair Esophageal exclusion Cardiectomy Diverticulectomy Miscellaneous Total
19 3
Complex benign esophageal disease
February 1990
31 17 7 2 2 2
1 11
5 4
4 3 2
3 63
esophagomyotomy, eight of which were modifications of the Heller procedure. The other three esophagomyotomies were long myotomies, although diffuse esophageal spasm (DES) could be proved in only one of these patients. There were 20 men and I 5 women, their ages ranging from 26 to 75 years.with an average age of 55213 years. Pertinent associated disorders were achalasia in 13 patients, Barrett's esophagus in three patients, one of whom also had scleroderma, and scleroderma, corrosive injury, DES, and giant esophageal leiomyoma (previously reported on") in one patient each. The indication for a reconstructive esophageal operation was severe GERD in 30 patients, 21 of whom had an esophageal stricture. Esophageal perforation was the indication in five patients, four of whom had mediastinitis and sepsis. The cause of the perforation was iatrogenic, Boerhaave's syndrome, incarcerated paraesophageal hernia, corrosive injury with tracheoesophageal fistula, and infarcted gastroplasty tube in one patient each. The esophagus was defunctionalized in four of these five patients before reconstruction by colon interposition. The fifth patient underwent esophagogastrectomy with esophagogastrostomy. Surgical technique. Twenty-seven patients required resection of variable amounts of esophagus (Table II). Two patients underwent cardioplasty, and six required no resection or plastic revision. Four of these six patients underwent colon bypass after an esophageal exclusion. The other two patients had G ERD without stricture. The reconstructive techniques included esophagogastrectomy with esophagogastrostomy in six patients; in two of these patients, the anastomosis was wrapped with adjacent redundant gastric fundus in the fashion of an "inkwell" procedure.! Colon interposition was performed in eight patients, in fiveof whom the colon was placed substernally. In the other three, a limited esophageal resection with intrathoracic colon interposition between the stomach and residual esophagus was performed. The remaining 21 patients had an acid-suppression and alkaline-diversion operation, a procedure whose evolution has been described previously (Fig. 1).6-8 Briefly, this operation consists of eliminating the cephalic phase of gastric secretion by bilateral vagotomy and the gastric phase by antrectomy. The left gastric artery is preserved, and
Operation Esophagectomy Esophageal exclusion Cardioplasty No resection Total Reconstruction Acid-suppression and alkaline-diversion Colon interposition Substernal Intrathoracic Esophagogastrostomy Inkwell End-to-side Transhiatal Total
27
4 2 2
35 21
8 5
3 6 3 2
I
35
cardiectomy is performed in patients with a nondilatable stricture. In this series, cardiectomy was required in 17 patients. In two patients, only cardioplasty was needed. No stricture was present in the other two patients. Continuity is reestablished by esophagogastrostomy and Roux-en-Y gastrojejunostomy to divert alkaline secretions at least 18 inches beyond the gastrojejunostomy.
Results One hospital death occurred, for a hospital mortality rate of 2.7%. This patient died of septicemia that resulted from pneumonia and respiratory failure 2 weeks after esophagogastrectomy and esophagogastrostomy with fundoplication for a nondilatable stricture resulting from GERD. There were nine postoperative complications (25.7%). Two patients had respiratory complications as a result of retained secretions. Other complications that occurred in one patient each were duodenal stump leakage, cervical anastomotic leakage, wound infection, empyema, enteritis, and gastric volvulus. In one patient with scleroderma, severe vascular insufficiency of the lower extremities developed. The patient with gastric volvulus required surgical derotation of the stomach after transhiatal resection for persistent pain occurring after a long myotomy for DES. Clinical evaluation after hospital discharge was possible in all but one patient who underwent colon interposition and was lost to follow-up. Follow-up information was obtained by either direct examination or a letter from the patient, his or her physician, or both within the past year, with the exception of three patients who died of unrelated causes during the follow-up period but whose condition was known at the time of death. Clinical results were classified as excellent if the patient was virtually free of symptoms, good if occasional symptoms persisted, and
The Journal of
I 94
Thoracic and Cardiovascular
Ellis and Gibb
Surgery
3
ESOPHAGOGASTROSTOMY
:::::;;::r
COLON INTERPOSITION
3 Surgical procedures
/is
LAHEY
CUNIC 01989
ACIO SUPPRESSION ALKALINE DIVERSION
Fig. 1. Complex benign esophageal disease. Diagrammatic depiction of the three reconstructive procedures referred to in the text. (Printed by permission of the Lahey Clinic.)
fair if symptoms were persistent but considerably less severe than before operation. If the patient's condition was unchanged or made worse by the operation, the results were considered poor (Table III). Five patients treated by esophagogastrectomy were evaluated at follow-up of 4 months to 6% years, with a 'median follow-up of 3lf2 years. Only two of these patients were classified as having good results. Three patients had
poor results caused by esophageal stricture. One of these patients required colon interposition. Esophagitis and bleeding developed in another patient, and in the third patient, Roux-en- Y gastroenterostomy was performed elsewhere because of poor gastric emptying. Seven of the eight patients who underwent colon interposition were available for follow-up from I to 14V3 years after operation, with a median follow-up of 4 years. The
Volume 99 Number 2
Complex benign esophageal disease
February 1990
19 5
Table III. Results of operation for complex benign esophageal disease Results No. improved Procedure
No.
Esophagogastrostomy
5
Colon interposition
7
Acid-suppression and alkaline-diversion Total
21
Follow-up (yr)
Excellent
Good
Fair
Percent improved
No. unimproved (poor)
Percent unimproved
'/3-634 (median, 3\12) 1-14Y3 (median, 4)
0
2
0
40
3
60
0
43
4
57
\4-16Y4
6
8
4
86
3
14
8
II
4
70
10
30
2
(median, 334) 33
Y3-16\4 (median.Bts)
condition of only three of these seven patients was improved. Four patients had poor results; in three patients, this was due to anastomotic stricture, and in the fourth patient, severe bile reflux developed, necessitating Roux-en- Y gastrojejunostomy. All 21 patients who underwent the acid-suppression and alkaline-diversion procedure were available for follOW-Up from 3 months to 161/4 years postoperatively, with a median follow-up of 3% years. Eighteen of these patients (86%) were considered to be in improved condition. Three patients had poor results; two patients had recurrent dysphagia, and a third patient had troublesome nausea and vomiting with inability to maintain normal weight. The overall rate of improvement, however, was only 70% because of the relatively poor results after esophagogastrostomy and colon interposition.
Discussion The complex nature of the patient with benign esophageal disease requiring reoperation makes analysis and comparison of the results of different operative and reconstructive procedures almost impossible. The findings we report herein are no exception, for no two patients had precisely the same clinical and anatomic problems. Thus, each patient should be considered as presenting a unique set of circumstances, which requires that the surgical approach be individualized. Even so, it is helpful to formulate a reasonably sound surgical approach for these patients. Historically, complex esophageal problems, particularly those resulting from GERD with stricture, were almost uniformly treated by resection of the stricture. Pearson and associates9, ]0 significantly altered the thrust of surgical treatment for such problems by introducing the more conservative gastroplasty-fundoplication concept combined with intraoperative dilation of the stricture. This approach or modifications thereof was rapidly
adopted, particularly in the United States.' 1-14 However, in recent years, there has been a slow but recognizable return in selected patients to a more radical approach that includes resection. Waters and associates] 5 have adopted such a philosophy and prefer a transhiatal esophagogastrectomy in selected patients, an approach supported strongly by Orringer and Stirling.l'' Polk]7 and Wright and Cuschieri18 have preferred to use jejunal interposition in patients with complicated esophageal disease necessitating esophageal resection. The use of interposed colon is preferred by others, notably DeMeester and associates,19 who reported 92 such operations, 50 ofwhich were performed for benign disease even though graft necrosis occurred and subsequent operation was required in a high percentage of patients. Little and associates.I" who never supported the gastroplasty-fundoplication procedure, have likewise favored colon interposition in patients with undilatable stricture, Barrett's ulcer, or mucosal dysplasia and have had excellent or good results in 71 % of patients. Use of the reversed gastric tube has also been supported, although this operation is used less widely than those mentioned previously." More than 30 years ago, one of us (F.H.E.)22 described a physiologic operation developed in the experimental laboratory for the management of G ERD in patients with a severely shortened esophagus and stricture, which involved vagotomy, cardiectomy, and antrectomy. Although the early results of this procedure were satisfactory.s-? longer follow-up revealed the need to divert alkaline secretions by means of Roux-en-Y gastrojejunostomy instead of gastroduodenostomy.f a modification that one of us (F.H.E.) has used in subsequent years in selected patients and that is described in this paper. This procedure, with some exceptions,23-25 has not been used widely in the United States but has received considerable support in England,26-29 Scandinavia." and Europe." Payne and associates''? reviewed the reported results of
The Journal of
1 96
Ellis and Gibb
this procedure, including their own, and found that 89% of patients had excellent or good results. Poor results, although few in number, seem to be related to dumping and diarrhea or respiratory aspiration because reflux continues, although the bland nature of the regurgitant material rarely induces esophageal injury. The comparatively small numbers of reconstructive procedures in our report reflect our early enthusiasm for the gastroplasty-fundoplication procedure.F which after a longer period offollow-up was successful in only 76% of patients.' This experience, coupled with less satisfactory results in patients with achalasia and in patients with recalcitrant GERD who undergo reoperation as compared with the results of primary surgery, has influenced us to adopt a more radical approach to certain selected patients with complex benign esophageal disease. Our results after esophagogastrectomy and esophagogastrostomy, even when fundoplication (inkwell procedure) was added, have been relatively poor and not surprisingly so, for others have pointed out the dangers of persistent reflux and recurrent stricture under such circumstances':' even though some may claim a place for the operation." The colon interposition procedure is a more complicated undertaking and in our experience fails too frequently because of anastomotic stricture. Other reported complications of the operation, including necrosis, anastomotic leakage, and the need for reoperation, 19,35 now restrict its use to patients with esophageal carcinoma in whom inadequate stomach remains for esophagogastrectomy or for those few patients with esophageal perforation and mediastinitis requiring an esophageal exclusion procedure and subsequent reconstruction. Most of the patients in our report underwent the acidsuppression and alkaline-diversion procedure; therefore, a meaningful comparison with the results of esophagogastrostomy and colon interposition is not possible. All the same, we prefer the acid-suppression and alkaline-diversion procedure when we perform reconstruction on the patient undergoing reoperation with complex benign esophageal disease. We have had no deaths. Complications have been few, and although the follow-up interval of 33;4 years is short, the improvement rate of 86% of the treated patients is indeed encouraging, considering the complicated nature of their diseases. Two of three poor results were due to persistent dysphagia caused by motility disorders rather than stenosis resulting from reflux esophagitis. The reason for the third poor result is unclear. This patient, whose preoperative dysphagia was relieved, was troubled by nausea and vomiting and an inability to maintain weight. Dumping, diarrhea, and respiratory as-piration were not encountered. Proper selection of the patient for complex reconstructive operations is difficult and certainly controversial but
Thoracic and Cardiovascular Surgery
clearly includes the following: (1) the "undilatable" stricture, (2) certain cases of megaesophagus, and (3) an unsuccessful antireflux operation. Most of our patients had an esophageal stricture, and this complication of GERD predominates among the various indications for operation. The "undilatable" stricture, when identifiable, is a clear indication without prior conservative surgical efforts. Many scleroderma strictures might qualify, as others have noted," and this was true in two of our patients. The patient with megaesophagus who does not respond to one esophagomyotomy, in our opinion, requires a radical operation. We prefer an acid-suppression and alkaline-diversion procedure to total esophagectomy, which has been advocated by Orringer and Stirling." The role of segmental esophagectomy, elliptical esophagectomy, or both versus esophagoplication in such patients remains to be defined. Other patients with achalasia and lesser degrees of esophageal dilatation may still respond to a second myotomy if recurrent symptoms are not due to GERD. A more radical operation should be considered if the patient's condition does not improve after two Heller procedures. Failure of an antireflux operation in patients with GERD can later be reversed by proper performance of one or even two more fundoplication procedures of the Nissen type before a more radical approach is used. A failed gastroplasty-fundoplication operation clearly necessitates a radical surgical approach. As just indicated, each patient with complex benign esophageal disease must be individualized. It is difficult, if not impossible, to establish hard and fast rules as to which patient will require a radical approach. Our indications for such a surgical procedure are expanding, however, and our early success with acid-suppression and alkaline-diversion procedures has influenc.ed us to continue its use in properly selected patients.
REFERENCES I. EllisFH Jr, CrozierRE. Reflux controlby fundoplication: a clinical and manometric assessment of the Nissen operation. Ann Thorac Surg 1984;38:387-92. 2. Ellis FH Jr, Crozier RE, Watkins E Jr. Operation for esophageal achalasia: resultsof esophagomyotomy without an antireflux operation. J THORAC CARDIOVASC SURG 1984;88:344-51. 3. Thayer JO Jr, Gibb SP, EllisFH Jr. Gastroplasty and fun-
doplication for severe gastroesophageal reflux with esophageal shortening. Dis Esophagus 1988; I: 153-8. 4. Kramer MD, Gibb SP, Ellis FH Jr. Giant leiomyoma of esophagus. J Surg Oneal 1986;33:166-9. 5. Procter DSC. The "ink-well" anastomosis in oesophageal reconstruction. S Afr Moo J 1967;41:187-91.
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6. Ellis FH Jr, Andersen HA, Clagett OT. Surgical management of complications of reflux esophagitis. Arch Surg 1956;73:578-89. 7. Ellis FH Jr. Physiologic operation for ulceration and stricture of terminal esophagus. Mayo Clin Proc 1956;31: 615-9. 8. Payne WS, Andersen HA, Ellis FH Jr. Reappraisal of esophagogastrectomy and antral excision in the treatment of short esophagus. Surgery 1964;55:344-8. 9. Pearson FG, Langer B, Henderson RD. Gastroplasty and Belsey hiatus hernia repair: an operation for the management of peptic stricture with acquired short esophagus. J THORAC CARDIOVASC SURG 1971;61:50-63. 10. Pearson FG, Cooper 1D, Patterson GA, Ramirez J, Todd TR. Gastroplasty and fundoplication for complex reflux problems: long-term results. Ann Surg 1987;206:473-81. 11. Henderson RD. Reflux control following gastroplasty. Ann Thorac Surg 1977;24:206-14. 12. Ellis FH Jr, Leonardi HK, Dabuzhsky L, Crozier RE. Surgery for short esophagus with stricture: an experimental and clinical manometric study. Ann Surg 1978;188: 341-50. 13. Orringer MB, Sloan H. Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 1978;25:16-21. 14. Stirling MC, Orringer MB. Continued assessment of the combined Collis-Nissen operation. Ann Thorac Surg 1989; 47:224-30. 15. Waters PF, Pearson FG, Todd TR, et al. Esophagectomy for complex benign esophageal disease. J THORAC CARDIOVASC SURG 1988;95:378-81. 16. Orringer MB, Stirling MC. Cervical esophagogastric anastomosis for benign disease: functional results. J THORAC CARDIOVASC SURG 1988;96:887-93. 17. Polk HC Jr. Jejunal interposition for reflux esophagitis and esophageal stricture unresponsive to valvuloplasty. World J Surg 1980;4:731-6. 18. Wright C, Cuschieri A. Jejunal interposition for benign esophageal disease: technical considerations and long-term results. Ann Surg 1987;205:54-60. 19. DeMeester TR, Johansson K-E, Franze I, etal. Indications, surgical technique, and long-term functional results of colon interposition or bypass. Ann Surg 1988;208:460-74. 20. Little AG, Naunheim KS, Ferguson MK, Skinner DB. Surgical management of esophageal strictures. Ann Thorac Surg 1988;45:144-7. 21. O'Connor TW. A historical review of reversed gastric tube esophagoplasty. Surg Gynecol Obstet 1983;156:371-4. 22. Ellis FH Jr. Experimental aspects of surgical treatment of refluxesophagitis and esophageal stricture. Ann Surg 1956; 143:465-70. 23. Holt CJ, Large AM. Surgical management of reflux esophagitis. Ann Surg 1961;153:55-62. 24. Payne WS. Surgical treatment of reflux esophagitis and stricture associated with permanent incompetence of the cardia. Mayo Clin Proc 1970;45:553-62. 25. Herrington JL Jr, Mody B. Total duodenal diversion for
26. 27.
28.
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30.
31.
32.
33.
34.
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36.
37.
treatment of reflux esophagitis uncontrolled by repeated antireflux procedures. Ann Surg 1976;183:636-44. Wells C, Johnston JH. Hiatus hernia: surgical relief of reflux oesophagitis. Lancet 1955;1:937-40. Royston CM, Dowling BL, Spencer J. Antrectomy with Roux-en-Y anastomosis in the treatment of peptic oesophagitis with stricture. Br J Surg 1975;62:605-7. Washer GF, Gear MW, Dowling BL, Gillison EW, Royston CM, Spencer J. Randomized prospective trial of Rouxen-Y duodenal diversion versus fundoplication for severe reflux oesophagitis. Br J Surg 1984;71:181-4. Washer GF, Gear MW, Dowling BL, Gillison EW, Royston CM, Spencer J. Duodenal diversion with vagotomy and antrectomy for severe or recurrent reflux oesophagitis and stricture: an alternative to operation at the hiatus. Ann R Coli Surg Engl 1986;68:222-6. Matikainen M. Antrectomy: Roux-en- Y reconstruction and vagotomy for recurrent reflux oesophagitis. Acta Chir Scand 1984;150:643-5. de Miguel J. Tratamiento de ciertas estrecheces peticas del esofago mediante vagatornia, gastrectomia parcial y anastomosis gastroyeyunal en 'V' de Roux. Rev Esp Enferm Apar Dig 1985;67:511-6 (Eng. Abstr.) Payne WS, Thompson GB, Trastek VF, Piehler JM, Pairolero Pc. Gastric secretion suppression and duodenal diversion: the Roux-en-Y principle in the management of complex reflux problems. In: DeMeester TR, Matthews HR, eds. Benign esophageal disease. Vol. 3. International trends in general thoracic surgery. St. Louis: CV Mosby, 1987:162-71. Bender EM, Walbaum PRo Esophagogastrectomy for benign esophageal stricture: fate of the esophagogastric anastomosis. Ann Surg 1987;205:385-8. AI-JilaihawiA, Forrester-Wood CP, IacovouJ. Oesophago gastric resection for peptic stricture of the oesophagus: long-term results with special reference to the incidence of restricture. Presented at the annual meeting of The Society of Thoracic and Cardiovascular Surgeons of Great Britain and Ireland, September 27, 1984. McGovern E, Burke P, Shaw KM. Colon interposition for oesophageal stricture: a review of 42 cases. Presented at the annual meeting of The Society of Thoracic and Cardiovascular Surgeons of Great Britain and Ireland, September 27, 1984. Mansour KA, Malone CEo Surgery for scleroderma of the esophagus: a 12-year experience. Ann Thorac Surg 1988; 46:513-4. Orringer MB, Stirling MC. Esophageal resection for achalasia: indications and results. Ann Thorac Surg 1989; 47:340-5.
Discussion
s.c;
Dr. Blair A. Keagy (Chapel Hill. Dr. Washer and his associates have described patients with complex gastroesophageal disease who were treated with antrectomy, vagotomy, duodenal diversion, and dilatation when necessary. They did not disturb the esophageal hiatus. Perhaps at the conclusion of my
198
Ellis and Gibb
discussion Dr. Ellis will comment on when he would recommend this approach. In 1964, Dr. Ellis, you reported on a group of patients who had an operation similar to the one described here, except that they did not have alkaline diversion. There were no significant differences in the number of excellent and good results between that group and the patients described in this paper. Have you objectively documented--such as with esophageal biopsy-that the addition of the alkaline-diversion procedure improves longterm results compared with your earlier series? Dr. Pearson, who recently reported experience with 430 patients managed by Collis gastroplasty and partial fundoplication, states that the number of unsatisfactory results tripled after reoperation after failed antireflux operations and, when stricture was associated with a primary motor disorder, only half the patients had a good result. Should the Collis-Nissen or Collis-Belsey combination still be used as the initial treatment of severe reflux-induced stricture associated with a shortened esophagus, or should a more radical procedure sometimes be considered initially? At the University of North Carolina we have also advocated resection of the distal esophagus and proximal stomach in the case of recurrent complex esophageal disease. Our reconstructive efforts have been with a short segment of colon. Our shortterm results have been good. Rather than stricture, our main long-term problem has been redundancy, which has sometimes required a second operation several years later. What technical maneuvers would you suggest to prevent this occurrence? Dr. Wright reported in the Annals of Surgery that good long-term results were obtained in 95% of patients with complicated benign esophageal disease with the use of an isoperistaltic jejunal interposition. Are these excellent results due to the fact that the jejunum is more immune to the effects of both acid and alkaline reflux? Is the problem with redundancy and late stricture less than in the case of a colon interposition, and would you ever advocate this technique? Dr. Orringer and others have suggested a cervical esophagogastric anastomosis as a good alternative in patients with severe esophageal disease. When a severe motor disorder or marked dilatation of the entire esophagus exists, such as in the late stages of achalasia, would you prefer their approach to your diversion procedure, which would leave some diseased esophagus in the chest? Finally, your technique involves preservation of the left gastric artery. Are there ever situations in which your resection coupled with scarring from previous operations makes length a difficulty when performing the esophagogastric anastomosis? Dr. Ellis. Thank you very much, Dr. Keagy, for your comments. I will do my best to answer your questions. You wondered about the need for disturbing the esophageal hiatus. It is true that Dr. Washer, as well as others, have used the antrectomy duodenal diversion procedure in many cases without including cardiectomy. We have found that, in our patient population, resection of the strictured area is often necessary because by the time they need a major reconstruction procedure they have usually had several previous operations and the stricture is no longer easily dilatable. In our original report, in which the alkaline-diversion procedure was not used, the early results were encouraging, but a later paper by Dr. Payne and me documented the fact that the favorable results decreased from 96% to 79% after further follow-up. The decline in good results, in our opinion, being the result of alkaline esophageal reflux suggested to us the need to change the operation to include the alkaline-diversion concept.
The Journal of Thoracic and Cardiovascular Surgery
I still think that the Collis-Belsey and Collis-Nissen procedures play an important role in the treatment of certain selected patients, although we are somewhat less enthusiastic regarding the results of their use than are others. When one of these operations has been used as a primary procedure for a complicated esophageal problem, our improvement rate has been in the neighborhood of 70% to 80%. However, a more radical approach is required when the Collis-Nissen or Collis-Belsey operation fails. An exception might be certain cases of scleroderma with stricture, for in my opinion some of these patients may initially be candidates for the acid-suppression alkaline-diversion procedure coupled with cardiectomy, because scleroderma strictures are often panmural and difficult to dilate. Interposition procedures with the jejunum or colon are widely used by other surgeons and not without success. For short interposition procedures, the jejunum is satisfactory. We have had anastomotic problems when using the colon, and even those skilled in its use report a worrisome incidence of graft necrosis and need for reoperation. We also have encountered the redundant colon segment syndrome, even though, when originally positioned, the colon seemed if anything to be on the short side. We have made it a point to stretch the colon before completing the anastomosis, hoping to avoid later redundancy. If redundancy does occur and causes obstruction, I have on one or two occasions actually resected the redundant segment at a second operation. The transhiatal esophagectomy with cervical esophagogastrostomy is preferred by Dr. Orringer and his associates for all complex esophageal diseases necessitating reconstruction. He has recently advocated its use in patients with "megaesophagus," but we prefer a more limited operation, which works extremely well despite the theoretical disadvantages of removing some normal stomach and leaving some abnormal esophagus in place. Dr. Victor F. Trastek (Rochester, Minn.). The treatment of these patients with complex esophageal problems is difficult. Procedures that are available to salvage these patients vary widely and need to be individualized, as we have heard. Dr. Ellis's excellent review provides perspective and guidance in how to deal with these patients. More important, it provides data on a large group of patients having one particular approach, in essence, the acid-suppression alkaline-diversion procedure. This approach yielded a functional gastrointestinal tract, significant improvement in symptoms, no mortality.and low morbidity. We have had a similar experience with this procedure and strongly support its use as a tertiary salvage procedure in selected patients. It should be included in the armamentarium of all thoracic surgeons who deal with these complex esophageal problems. I would just like to reiterate one technical point that was well outlined in Dr. Ellis's paper and one that we believe contributes to the success of this procedure. When the Roux -en-Y is being formed, the jejunum should be divided 9 inches distal to the ligament of Treitz to prevent angulation of the short limb, and the long limb should be 18 inches long to provide an adequate alkaline reflux barrier. I have one question for Dr. Ellis: In our experience with this procedure, we found that those patients with less than optimal results have problems with regurgitation and aspiration, as well as postgastrectomy sequelae. If one of your patients had reflux, regurgitation, and aspiration preoperatively, would you still recommend this procedure for that patient? Dr. Ellis. Thank you, Dr. Trastek, for your kind comments.
Volume 99 Number 2 February 1990
It is gratifying to know that thoracic surgery is alive and well at the Mayo Clinic under the triumvirate of Drs. Payne, Pairolero, and Trastek. Dr. Payne, of course, has written frequently about the advantages of the acid-suppression alkaline-diversion procedure, in the development of which he participated, and the technical points elucidated by Dr. Trastek are certainly important in the performance of the Roux-en- Y gastrojejunostomy. We, too, have followed Dr. Payne's recommendations, which Dr. Trastek has illustrated. For some reason, we have not run into the problems of
Complex benign esophageal disease 1 9 9
dumping, diarrhea, and nocturnal aspiration that Dr. Trastek and Dr. Payne have reported and that others have encountered as well. We have emphasized to our patients postoperatively that they must continue antireflux measures, particularly elevation of the head ofthe bed on 6- to 8-inch blocks at night and avoidance of food and liquids for a few hours before retiring, recommendations that may minimize the risk of nocturnal aspiration. Whether or not the use of a small gastrojejunostomy stoma minimizes the risk of dumping and diarrhea is conjectural but may be helpful in minimizing postgastrectomy symptoms.
CARDIOVASC SURG
1990;99:192-9
Original Communications
Esophageal reconstruction for complex benign esophageal disease We report the cases of 35 patients with complex benign esophageal disease who required radical surgical reconstruction. These patients had undergone 63 previous esophageal operations. Twenty-seven patients required esophagogastrectomy, four had esophageal exclusion before colon interposition, two had cardioplasty, and two without stricture did not require resection. Reconstruction was achieved by esophagogastrostomy in six patients, colon interposition in eight, and acid suppression and alkaline diversion in 21. One patient died of pneumonia 2 weeks after esophagogastrostomy. The overall rate of postoperative improvement was 70 %, but the condition of 86 % of patients was improved after the acid-suppression and alkaline-diversion procedure, which is the reconstructive procedure we prefer in properly selected patients with complex benign esophageal disease.
F. Henry Ellis, Jr., MD, phD,a,b and S. Peter Gibb, MD e (by invitation),
Burlington and Boston, Mass.
he
surgical management of complex benign esophageal disease is challenging and has no easy solution. Many patients with this condition have undergone a previous operation, which makes simple straightforward repair and reconstruction techniques inappropriate. The results of our experience with reoperation for failed fundoplication 1 and for failed esophagomyotomy/ have been less good than when these procedures were performed as primary operations. Furthermore, our results after gastroplasty-fundoplication' for complex gastroesophageal reflux disease (GERD) leave much to be desired. These experiences suggest that a more radical approach may be required for patients with selected From the Departments of Thoracic and Cardiovascular Surgery" and Gastroenterology," LaheyClinicMedicalCenter, Burlington,Mass., and the Division of Thoracic and Cardiovascular Surgery," New England Deaconess Hospital, Boston, Mass. Read at the Sixty-ninth Annual Meetingof The American Association for Thoracic Surgery, Boston, Mass., May 8-10, 1989. Address for reprints: F. Henry Ellis, Jr., MD, PhD, Department of Thoracic and Cardiovascular Surgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805. o
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complex benign esophageal disorders. In this paper, we review our experience with such operations to determine the proper indications for a radical approach and to identify the operative procedure that can be expected to give the best results.
Methods Patients. From January 1970 to January 19&9, 35 patients underwent reconstructive operative procedures for complex benign esophageal disease, which represented 6.7% of the 516 operations for benign disorders of the body and lower part of the esophagus performed during that period. These 35 patients had undergone a total of63 previous operations, an average of nearly two per patient. One patient had undergone six previous operations on the distal esophagus, upper stomach, or both. One patient had undergone five previous operations; two patients, four operations; six patients, three operations; and six patients, two operations. Fourteen patients had undergone only one previous operation. Only three patients had not been operated on before. A carcinoma was suspected preoperatively in one of these patients, and scleroderma was present in the other two patients. The esophageal procedures performed before the reconstructive operations that form the basis of this report are listed in Table I. Nine of the 63 procedures had been performed by us; four were esophageal exclusion procedures performed in anticipation of subsequent reconstruction. The two commonest previous operations were fundoplication, usually of the Nissen type, and
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Table I. Complex benign esophageal disease: Previous
Table II. Complex benign esophageal disease
operation
No. No.
Fundoplication Nissen Collis-Nissen Collis-Belsey Belsey ThaI-Nissen Hill Esophagomyotomy Diaphragmatic hernia repair Esophageal exploration and/or repair Esophageal exclusion Cardiectomy Diverticulectomy Miscellaneous Total
19 3
Complex benign esophageal disease
February 1990
31 17 7 2 2 2
1 11
5 4
4 3 2
3 63
esophagomyotomy, eight of which were modifications of the Heller procedure. The other three esophagomyotomies were long myotomies, although diffuse esophageal spasm (DES) could be proved in only one of these patients. There were 20 men and I 5 women, their ages ranging from 26 to 75 years.with an average age of 55213 years. Pertinent associated disorders were achalasia in 13 patients, Barrett's esophagus in three patients, one of whom also had scleroderma, and scleroderma, corrosive injury, DES, and giant esophageal leiomyoma (previously reported on") in one patient each. The indication for a reconstructive esophageal operation was severe GERD in 30 patients, 21 of whom had an esophageal stricture. Esophageal perforation was the indication in five patients, four of whom had mediastinitis and sepsis. The cause of the perforation was iatrogenic, Boerhaave's syndrome, incarcerated paraesophageal hernia, corrosive injury with tracheoesophageal fistula, and infarcted gastroplasty tube in one patient each. The esophagus was defunctionalized in four of these five patients before reconstruction by colon interposition. The fifth patient underwent esophagogastrectomy with esophagogastrostomy. Surgical technique. Twenty-seven patients required resection of variable amounts of esophagus (Table II). Two patients underwent cardioplasty, and six required no resection or plastic revision. Four of these six patients underwent colon bypass after an esophageal exclusion. The other two patients had G ERD without stricture. The reconstructive techniques included esophagogastrectomy with esophagogastrostomy in six patients; in two of these patients, the anastomosis was wrapped with adjacent redundant gastric fundus in the fashion of an "inkwell" procedure.! Colon interposition was performed in eight patients, in fiveof whom the colon was placed substernally. In the other three, a limited esophageal resection with intrathoracic colon interposition between the stomach and residual esophagus was performed. The remaining 21 patients had an acid-suppression and alkaline-diversion operation, a procedure whose evolution has been described previously (Fig. 1).6-8 Briefly, this operation consists of eliminating the cephalic phase of gastric secretion by bilateral vagotomy and the gastric phase by antrectomy. The left gastric artery is preserved, and
Operation Esophagectomy Esophageal exclusion Cardioplasty No resection Total Reconstruction Acid-suppression and alkaline-diversion Colon interposition Substernal Intrathoracic Esophagogastrostomy Inkwell End-to-side Transhiatal Total
27
4 2 2
35 21
8 5
3 6 3 2
I
35
cardiectomy is performed in patients with a nondilatable stricture. In this series, cardiectomy was required in 17 patients. In two patients, only cardioplasty was needed. No stricture was present in the other two patients. Continuity is reestablished by esophagogastrostomy and Roux-en-Y gastrojejunostomy to divert alkaline secretions at least 18 inches beyond the gastrojejunostomy.
Results One hospital death occurred, for a hospital mortality rate of 2.7%. This patient died of septicemia that resulted from pneumonia and respiratory failure 2 weeks after esophagogastrectomy and esophagogastrostomy with fundoplication for a nondilatable stricture resulting from GERD. There were nine postoperative complications (25.7%). Two patients had respiratory complications as a result of retained secretions. Other complications that occurred in one patient each were duodenal stump leakage, cervical anastomotic leakage, wound infection, empyema, enteritis, and gastric volvulus. In one patient with scleroderma, severe vascular insufficiency of the lower extremities developed. The patient with gastric volvulus required surgical derotation of the stomach after transhiatal resection for persistent pain occurring after a long myotomy for DES. Clinical evaluation after hospital discharge was possible in all but one patient who underwent colon interposition and was lost to follow-up. Follow-up information was obtained by either direct examination or a letter from the patient, his or her physician, or both within the past year, with the exception of three patients who died of unrelated causes during the follow-up period but whose condition was known at the time of death. Clinical results were classified as excellent if the patient was virtually free of symptoms, good if occasional symptoms persisted, and
The Journal of
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Thoracic and Cardiovascular
Ellis and Gibb
Surgery
3
ESOPHAGOGASTROSTOMY
:::::;;::r
COLON INTERPOSITION
3 Surgical procedures
/is
LAHEY
CUNIC 01989
ACIO SUPPRESSION ALKALINE DIVERSION
Fig. 1. Complex benign esophageal disease. Diagrammatic depiction of the three reconstructive procedures referred to in the text. (Printed by permission of the Lahey Clinic.)
fair if symptoms were persistent but considerably less severe than before operation. If the patient's condition was unchanged or made worse by the operation, the results were considered poor (Table III). Five patients treated by esophagogastrectomy were evaluated at follow-up of 4 months to 6% years, with a 'median follow-up of 3lf2 years. Only two of these patients were classified as having good results. Three patients had
poor results caused by esophageal stricture. One of these patients required colon interposition. Esophagitis and bleeding developed in another patient, and in the third patient, Roux-en- Y gastroenterostomy was performed elsewhere because of poor gastric emptying. Seven of the eight patients who underwent colon interposition were available for follow-up from I to 14V3 years after operation, with a median follow-up of 4 years. The
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Complex benign esophageal disease
February 1990
19 5
Table III. Results of operation for complex benign esophageal disease Results No. improved Procedure
No.
Esophagogastrostomy
5
Colon interposition
7
Acid-suppression and alkaline-diversion Total
21
Follow-up (yr)
Excellent
Good
Fair
Percent improved
No. unimproved (poor)
Percent unimproved
'/3-634 (median, 3\12) 1-14Y3 (median, 4)
0
2
0
40
3
60
0
43
4
57
\4-16Y4
6
8
4
86
3
14
8
II
4
70
10
30
2
(median, 334) 33
Y3-16\4 (median.Bts)
condition of only three of these seven patients was improved. Four patients had poor results; in three patients, this was due to anastomotic stricture, and in the fourth patient, severe bile reflux developed, necessitating Roux-en- Y gastrojejunostomy. All 21 patients who underwent the acid-suppression and alkaline-diversion procedure were available for follOW-Up from 3 months to 161/4 years postoperatively, with a median follow-up of 3% years. Eighteen of these patients (86%) were considered to be in improved condition. Three patients had poor results; two patients had recurrent dysphagia, and a third patient had troublesome nausea and vomiting with inability to maintain normal weight. The overall rate of improvement, however, was only 70% because of the relatively poor results after esophagogastrostomy and colon interposition.
Discussion The complex nature of the patient with benign esophageal disease requiring reoperation makes analysis and comparison of the results of different operative and reconstructive procedures almost impossible. The findings we report herein are no exception, for no two patients had precisely the same clinical and anatomic problems. Thus, each patient should be considered as presenting a unique set of circumstances, which requires that the surgical approach be individualized. Even so, it is helpful to formulate a reasonably sound surgical approach for these patients. Historically, complex esophageal problems, particularly those resulting from GERD with stricture, were almost uniformly treated by resection of the stricture. Pearson and associates9, ]0 significantly altered the thrust of surgical treatment for such problems by introducing the more conservative gastroplasty-fundoplication concept combined with intraoperative dilation of the stricture. This approach or modifications thereof was rapidly
adopted, particularly in the United States.' 1-14 However, in recent years, there has been a slow but recognizable return in selected patients to a more radical approach that includes resection. Waters and associates] 5 have adopted such a philosophy and prefer a transhiatal esophagogastrectomy in selected patients, an approach supported strongly by Orringer and Stirling.l'' Polk]7 and Wright and Cuschieri18 have preferred to use jejunal interposition in patients with complicated esophageal disease necessitating esophageal resection. The use of interposed colon is preferred by others, notably DeMeester and associates,19 who reported 92 such operations, 50 ofwhich were performed for benign disease even though graft necrosis occurred and subsequent operation was required in a high percentage of patients. Little and associates.I" who never supported the gastroplasty-fundoplication procedure, have likewise favored colon interposition in patients with undilatable stricture, Barrett's ulcer, or mucosal dysplasia and have had excellent or good results in 71 % of patients. Use of the reversed gastric tube has also been supported, although this operation is used less widely than those mentioned previously." More than 30 years ago, one of us (F.H.E.)22 described a physiologic operation developed in the experimental laboratory for the management of G ERD in patients with a severely shortened esophagus and stricture, which involved vagotomy, cardiectomy, and antrectomy. Although the early results of this procedure were satisfactory.s-? longer follow-up revealed the need to divert alkaline secretions by means of Roux-en-Y gastrojejunostomy instead of gastroduodenostomy.f a modification that one of us (F.H.E.) has used in subsequent years in selected patients and that is described in this paper. This procedure, with some exceptions,23-25 has not been used widely in the United States but has received considerable support in England,26-29 Scandinavia." and Europe." Payne and associates''? reviewed the reported results of
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Ellis and Gibb
this procedure, including their own, and found that 89% of patients had excellent or good results. Poor results, although few in number, seem to be related to dumping and diarrhea or respiratory aspiration because reflux continues, although the bland nature of the regurgitant material rarely induces esophageal injury. The comparatively small numbers of reconstructive procedures in our report reflect our early enthusiasm for the gastroplasty-fundoplication procedure.F which after a longer period offollow-up was successful in only 76% of patients.' This experience, coupled with less satisfactory results in patients with achalasia and in patients with recalcitrant GERD who undergo reoperation as compared with the results of primary surgery, has influenced us to adopt a more radical approach to certain selected patients with complex benign esophageal disease. Our results after esophagogastrectomy and esophagogastrostomy, even when fundoplication (inkwell procedure) was added, have been relatively poor and not surprisingly so, for others have pointed out the dangers of persistent reflux and recurrent stricture under such circumstances':' even though some may claim a place for the operation." The colon interposition procedure is a more complicated undertaking and in our experience fails too frequently because of anastomotic stricture. Other reported complications of the operation, including necrosis, anastomotic leakage, and the need for reoperation, 19,35 now restrict its use to patients with esophageal carcinoma in whom inadequate stomach remains for esophagogastrectomy or for those few patients with esophageal perforation and mediastinitis requiring an esophageal exclusion procedure and subsequent reconstruction. Most of the patients in our report underwent the acidsuppression and alkaline-diversion procedure; therefore, a meaningful comparison with the results of esophagogastrostomy and colon interposition is not possible. All the same, we prefer the acid-suppression and alkaline-diversion procedure when we perform reconstruction on the patient undergoing reoperation with complex benign esophageal disease. We have had no deaths. Complications have been few, and although the follow-up interval of 33;4 years is short, the improvement rate of 86% of the treated patients is indeed encouraging, considering the complicated nature of their diseases. Two of three poor results were due to persistent dysphagia caused by motility disorders rather than stenosis resulting from reflux esophagitis. The reason for the third poor result is unclear. This patient, whose preoperative dysphagia was relieved, was troubled by nausea and vomiting and an inability to maintain weight. Dumping, diarrhea, and respiratory as-piration were not encountered. Proper selection of the patient for complex reconstructive operations is difficult and certainly controversial but
Thoracic and Cardiovascular Surgery
clearly includes the following: (1) the "undilatable" stricture, (2) certain cases of megaesophagus, and (3) an unsuccessful antireflux operation. Most of our patients had an esophageal stricture, and this complication of GERD predominates among the various indications for operation. The "undilatable" stricture, when identifiable, is a clear indication without prior conservative surgical efforts. Many scleroderma strictures might qualify, as others have noted," and this was true in two of our patients. The patient with megaesophagus who does not respond to one esophagomyotomy, in our opinion, requires a radical operation. We prefer an acid-suppression and alkaline-diversion procedure to total esophagectomy, which has been advocated by Orringer and Stirling." The role of segmental esophagectomy, elliptical esophagectomy, or both versus esophagoplication in such patients remains to be defined. Other patients with achalasia and lesser degrees of esophageal dilatation may still respond to a second myotomy if recurrent symptoms are not due to GERD. A more radical operation should be considered if the patient's condition does not improve after two Heller procedures. Failure of an antireflux operation in patients with GERD can later be reversed by proper performance of one or even two more fundoplication procedures of the Nissen type before a more radical approach is used. A failed gastroplasty-fundoplication operation clearly necessitates a radical surgical approach. As just indicated, each patient with complex benign esophageal disease must be individualized. It is difficult, if not impossible, to establish hard and fast rules as to which patient will require a radical approach. Our indications for such a surgical procedure are expanding, however, and our early success with acid-suppression and alkaline-diversion procedures has influenc.ed us to continue its use in properly selected patients.
REFERENCES I. EllisFH Jr, CrozierRE. Reflux controlby fundoplication: a clinical and manometric assessment of the Nissen operation. Ann Thorac Surg 1984;38:387-92. 2. Ellis FH Jr, Crozier RE, Watkins E Jr. Operation for esophageal achalasia: resultsof esophagomyotomy without an antireflux operation. J THORAC CARDIOVASC SURG 1984;88:344-51. 3. Thayer JO Jr, Gibb SP, EllisFH Jr. Gastroplasty and fun-
doplication for severe gastroesophageal reflux with esophageal shortening. Dis Esophagus 1988; I: 153-8. 4. Kramer MD, Gibb SP, Ellis FH Jr. Giant leiomyoma of esophagus. J Surg Oneal 1986;33:166-9. 5. Procter DSC. The "ink-well" anastomosis in oesophageal reconstruction. S Afr Moo J 1967;41:187-91.
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6. Ellis FH Jr, Andersen HA, Clagett OT. Surgical management of complications of reflux esophagitis. Arch Surg 1956;73:578-89. 7. Ellis FH Jr. Physiologic operation for ulceration and stricture of terminal esophagus. Mayo Clin Proc 1956;31: 615-9. 8. Payne WS, Andersen HA, Ellis FH Jr. Reappraisal of esophagogastrectomy and antral excision in the treatment of short esophagus. Surgery 1964;55:344-8. 9. Pearson FG, Langer B, Henderson RD. Gastroplasty and Belsey hiatus hernia repair: an operation for the management of peptic stricture with acquired short esophagus. J THORAC CARDIOVASC SURG 1971;61:50-63. 10. Pearson FG, Cooper 1D, Patterson GA, Ramirez J, Todd TR. Gastroplasty and fundoplication for complex reflux problems: long-term results. Ann Surg 1987;206:473-81. 11. Henderson RD. Reflux control following gastroplasty. Ann Thorac Surg 1977;24:206-14. 12. Ellis FH Jr, Leonardi HK, Dabuzhsky L, Crozier RE. Surgery for short esophagus with stricture: an experimental and clinical manometric study. Ann Surg 1978;188: 341-50. 13. Orringer MB, Sloan H. Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 1978;25:16-21. 14. Stirling MC, Orringer MB. Continued assessment of the combined Collis-Nissen operation. Ann Thorac Surg 1989; 47:224-30. 15. Waters PF, Pearson FG, Todd TR, et al. Esophagectomy for complex benign esophageal disease. J THORAC CARDIOVASC SURG 1988;95:378-81. 16. Orringer MB, Stirling MC. Cervical esophagogastric anastomosis for benign disease: functional results. J THORAC CARDIOVASC SURG 1988;96:887-93. 17. Polk HC Jr. Jejunal interposition for reflux esophagitis and esophageal stricture unresponsive to valvuloplasty. World J Surg 1980;4:731-6. 18. Wright C, Cuschieri A. Jejunal interposition for benign esophageal disease: technical considerations and long-term results. Ann Surg 1987;205:54-60. 19. DeMeester TR, Johansson K-E, Franze I, etal. Indications, surgical technique, and long-term functional results of colon interposition or bypass. Ann Surg 1988;208:460-74. 20. Little AG, Naunheim KS, Ferguson MK, Skinner DB. Surgical management of esophageal strictures. Ann Thorac Surg 1988;45:144-7. 21. O'Connor TW. A historical review of reversed gastric tube esophagoplasty. Surg Gynecol Obstet 1983;156:371-4. 22. Ellis FH Jr. Experimental aspects of surgical treatment of refluxesophagitis and esophageal stricture. Ann Surg 1956; 143:465-70. 23. Holt CJ, Large AM. Surgical management of reflux esophagitis. Ann Surg 1961;153:55-62. 24. Payne WS. Surgical treatment of reflux esophagitis and stricture associated with permanent incompetence of the cardia. Mayo Clin Proc 1970;45:553-62. 25. Herrington JL Jr, Mody B. Total duodenal diversion for
26. 27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
treatment of reflux esophagitis uncontrolled by repeated antireflux procedures. Ann Surg 1976;183:636-44. Wells C, Johnston JH. Hiatus hernia: surgical relief of reflux oesophagitis. Lancet 1955;1:937-40. Royston CM, Dowling BL, Spencer J. Antrectomy with Roux-en-Y anastomosis in the treatment of peptic oesophagitis with stricture. Br J Surg 1975;62:605-7. Washer GF, Gear MW, Dowling BL, Gillison EW, Royston CM, Spencer J. Randomized prospective trial of Rouxen-Y duodenal diversion versus fundoplication for severe reflux oesophagitis. Br J Surg 1984;71:181-4. Washer GF, Gear MW, Dowling BL, Gillison EW, Royston CM, Spencer J. Duodenal diversion with vagotomy and antrectomy for severe or recurrent reflux oesophagitis and stricture: an alternative to operation at the hiatus. Ann R Coli Surg Engl 1986;68:222-6. Matikainen M. Antrectomy: Roux-en- Y reconstruction and vagotomy for recurrent reflux oesophagitis. Acta Chir Scand 1984;150:643-5. de Miguel J. Tratamiento de ciertas estrecheces peticas del esofago mediante vagatornia, gastrectomia parcial y anastomosis gastroyeyunal en 'V' de Roux. Rev Esp Enferm Apar Dig 1985;67:511-6 (Eng. Abstr.) Payne WS, Thompson GB, Trastek VF, Piehler JM, Pairolero Pc. Gastric secretion suppression and duodenal diversion: the Roux-en-Y principle in the management of complex reflux problems. In: DeMeester TR, Matthews HR, eds. Benign esophageal disease. Vol. 3. International trends in general thoracic surgery. St. Louis: CV Mosby, 1987:162-71. Bender EM, Walbaum PRo Esophagogastrectomy for benign esophageal stricture: fate of the esophagogastric anastomosis. Ann Surg 1987;205:385-8. AI-JilaihawiA, Forrester-Wood CP, IacovouJ. Oesophago gastric resection for peptic stricture of the oesophagus: long-term results with special reference to the incidence of restricture. Presented at the annual meeting of The Society of Thoracic and Cardiovascular Surgeons of Great Britain and Ireland, September 27, 1984. McGovern E, Burke P, Shaw KM. Colon interposition for oesophageal stricture: a review of 42 cases. Presented at the annual meeting of The Society of Thoracic and Cardiovascular Surgeons of Great Britain and Ireland, September 27, 1984. Mansour KA, Malone CEo Surgery for scleroderma of the esophagus: a 12-year experience. Ann Thorac Surg 1988; 46:513-4. Orringer MB, Stirling MC. Esophageal resection for achalasia: indications and results. Ann Thorac Surg 1989; 47:340-5.
Discussion
s.c;
Dr. Blair A. Keagy (Chapel Hill. Dr. Washer and his associates have described patients with complex gastroesophageal disease who were treated with antrectomy, vagotomy, duodenal diversion, and dilatation when necessary. They did not disturb the esophageal hiatus. Perhaps at the conclusion of my
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Ellis and Gibb
discussion Dr. Ellis will comment on when he would recommend this approach. In 1964, Dr. Ellis, you reported on a group of patients who had an operation similar to the one described here, except that they did not have alkaline diversion. There were no significant differences in the number of excellent and good results between that group and the patients described in this paper. Have you objectively documented--such as with esophageal biopsy-that the addition of the alkaline-diversion procedure improves longterm results compared with your earlier series? Dr. Pearson, who recently reported experience with 430 patients managed by Collis gastroplasty and partial fundoplication, states that the number of unsatisfactory results tripled after reoperation after failed antireflux operations and, when stricture was associated with a primary motor disorder, only half the patients had a good result. Should the Collis-Nissen or Collis-Belsey combination still be used as the initial treatment of severe reflux-induced stricture associated with a shortened esophagus, or should a more radical procedure sometimes be considered initially? At the University of North Carolina we have also advocated resection of the distal esophagus and proximal stomach in the case of recurrent complex esophageal disease. Our reconstructive efforts have been with a short segment of colon. Our shortterm results have been good. Rather than stricture, our main long-term problem has been redundancy, which has sometimes required a second operation several years later. What technical maneuvers would you suggest to prevent this occurrence? Dr. Wright reported in the Annals of Surgery that good long-term results were obtained in 95% of patients with complicated benign esophageal disease with the use of an isoperistaltic jejunal interposition. Are these excellent results due to the fact that the jejunum is more immune to the effects of both acid and alkaline reflux? Is the problem with redundancy and late stricture less than in the case of a colon interposition, and would you ever advocate this technique? Dr. Orringer and others have suggested a cervical esophagogastric anastomosis as a good alternative in patients with severe esophageal disease. When a severe motor disorder or marked dilatation of the entire esophagus exists, such as in the late stages of achalasia, would you prefer their approach to your diversion procedure, which would leave some diseased esophagus in the chest? Finally, your technique involves preservation of the left gastric artery. Are there ever situations in which your resection coupled with scarring from previous operations makes length a difficulty when performing the esophagogastric anastomosis? Dr. Ellis. Thank you very much, Dr. Keagy, for your comments. I will do my best to answer your questions. You wondered about the need for disturbing the esophageal hiatus. It is true that Dr. Washer, as well as others, have used the antrectomy duodenal diversion procedure in many cases without including cardiectomy. We have found that, in our patient population, resection of the strictured area is often necessary because by the time they need a major reconstruction procedure they have usually had several previous operations and the stricture is no longer easily dilatable. In our original report, in which the alkaline-diversion procedure was not used, the early results were encouraging, but a later paper by Dr. Payne and me documented the fact that the favorable results decreased from 96% to 79% after further follow-up. The decline in good results, in our opinion, being the result of alkaline esophageal reflux suggested to us the need to change the operation to include the alkaline-diversion concept.
The Journal of Thoracic and Cardiovascular Surgery
I still think that the Collis-Belsey and Collis-Nissen procedures play an important role in the treatment of certain selected patients, although we are somewhat less enthusiastic regarding the results of their use than are others. When one of these operations has been used as a primary procedure for a complicated esophageal problem, our improvement rate has been in the neighborhood of 70% to 80%. However, a more radical approach is required when the Collis-Nissen or Collis-Belsey operation fails. An exception might be certain cases of scleroderma with stricture, for in my opinion some of these patients may initially be candidates for the acid-suppression alkaline-diversion procedure coupled with cardiectomy, because scleroderma strictures are often panmural and difficult to dilate. Interposition procedures with the jejunum or colon are widely used by other surgeons and not without success. For short interposition procedures, the jejunum is satisfactory. We have had anastomotic problems when using the colon, and even those skilled in its use report a worrisome incidence of graft necrosis and need for reoperation. We also have encountered the redundant colon segment syndrome, even though, when originally positioned, the colon seemed if anything to be on the short side. We have made it a point to stretch the colon before completing the anastomosis, hoping to avoid later redundancy. If redundancy does occur and causes obstruction, I have on one or two occasions actually resected the redundant segment at a second operation. The transhiatal esophagectomy with cervical esophagogastrostomy is preferred by Dr. Orringer and his associates for all complex esophageal diseases necessitating reconstruction. He has recently advocated its use in patients with "megaesophagus," but we prefer a more limited operation, which works extremely well despite the theoretical disadvantages of removing some normal stomach and leaving some abnormal esophagus in place. Dr. Victor F. Trastek (Rochester, Minn.). The treatment of these patients with complex esophageal problems is difficult. Procedures that are available to salvage these patients vary widely and need to be individualized, as we have heard. Dr. Ellis's excellent review provides perspective and guidance in how to deal with these patients. More important, it provides data on a large group of patients having one particular approach, in essence, the acid-suppression alkaline-diversion procedure. This approach yielded a functional gastrointestinal tract, significant improvement in symptoms, no mortality.and low morbidity. We have had a similar experience with this procedure and strongly support its use as a tertiary salvage procedure in selected patients. It should be included in the armamentarium of all thoracic surgeons who deal with these complex esophageal problems. I would just like to reiterate one technical point that was well outlined in Dr. Ellis's paper and one that we believe contributes to the success of this procedure. When the Roux -en-Y is being formed, the jejunum should be divided 9 inches distal to the ligament of Treitz to prevent angulation of the short limb, and the long limb should be 18 inches long to provide an adequate alkaline reflux barrier. I have one question for Dr. Ellis: In our experience with this procedure, we found that those patients with less than optimal results have problems with regurgitation and aspiration, as well as postgastrectomy sequelae. If one of your patients had reflux, regurgitation, and aspiration preoperatively, would you still recommend this procedure for that patient? Dr. Ellis. Thank you, Dr. Trastek, for your kind comments.
Volume 99 Number 2 February 1990
It is gratifying to know that thoracic surgery is alive and well at the Mayo Clinic under the triumvirate of Drs. Payne, Pairolero, and Trastek. Dr. Payne, of course, has written frequently about the advantages of the acid-suppression alkaline-diversion procedure, in the development of which he participated, and the technical points elucidated by Dr. Trastek are certainly important in the performance of the Roux-en- Y gastrojejunostomy. We, too, have followed Dr. Payne's recommendations, which Dr. Trastek has illustrated. For some reason, we have not run into the problems of
Complex benign esophageal disease 1 9 9
dumping, diarrhea, and nocturnal aspiration that Dr. Trastek and Dr. Payne have reported and that others have encountered as well. We have emphasized to our patients postoperatively that they must continue antireflux measures, particularly elevation of the head ofthe bed on 6- to 8-inch blocks at night and avoidance of food and liquids for a few hours before retiring, recommendations that may minimize the risk of nocturnal aspiration. Whether or not the use of a small gastrojejunostomy stoma minimizes the risk of dumping and diarrhea is conjectural but may be helpful in minimizing postgastrectomy symptoms.