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Esophagoplasty with an autogenous tubed gastric flap
Esophagoplasty With an Autogenous Tubed Gastric Flap
Tsuneaki Yamato, MD, Osaka, Japan Yoshiro Hamanaka, MD, Osaka, Japan Sanae Hirata, MD, Osaka, Japan Katsuji Sakai, MD, Osaka, Japan
Various procedures have been used for esophageal reconstruction after total thoracic esophagectomy, according to the location of the lesion, the method of thoracotomy, the organ to be used as an esophageal substitute, and the elevating route. The stomach is most often used as an esophageal substitute because it has many vessels and is easily accessible anatomically [I-4]. As an elevating route, many surgeons prefer an antesternal subcutaneous tunnel to prevent serious consequences from anastomotic insufficiency [I+]. The authors initially used a residual stomach, which was elevated through an antesternal subcutaneous tunnel and anastomosed with the cervical esophagus in the ieft supraclavicular fossa. However, anastomotic breakdown occurred in 9 of 17 patients who underwent this procedure, and the incidence of sinus formation after an antesternal esophagogastrostomy is reported to be 40 to 70 per cent. [I-3,5,7]. Although anastomotic leakage in the neck is not life-threatening, the anastomosis is difficult to close and tends to resuit in stenosis even after its spontaneous closure [S,S] . One of the main causes of anastomotic breakdown after an esophagogastrostomy is impaired local blood supply of the lifted stomach wall. Therefore, we attempted to study the blood supply to the stomach wall. Material and Methods Anatomic variations of the gastroepiploic were examined in 420 patients undergoing
artery (GEA) celiac arteri-
From the 2nd Division, Department of Surgery, Osaka City University Hospital, Asahi-machi, Abenu-ku, Osaka 545, Japan. Reprint requests should be addressed to Tsuneaki Yamato, MD, 2nd Division, Department of Surgery, Osaka City University Hospital, Asahi-machi, Abeno-ku, Osaka 545, Japan.
Volume 137, May 1979
ography. For the purpose of this study, 137 celiac angiograms from these patients were useful. We also examined 32 stomach-omentum-spleen specimens removed en block by total gastrectomy for stomach cancer. These specimens did not include cases with scirrhous carcinoma or macroscopic invasion of the carcinoma into the serosa along the greater curvature. The greater omentum was carefully dissected off the transverse colon in total gastrectomy, meticulously preventing trauma to the GEA’s. Immediately after removal of a specimen, the right GEA was perfused from its origin with a 100 ml saline solution containing 1,000 units of heparin Na (Novo Co., Ltd.) to wash out the blood in the gastric wall. The right GEA of a specimen was demonstrated on X-ray films by injecting a 20 ml contrast medium (Micropark). Among the patients with esophageal cancer admitted to the our division at the Osaka City University Hospital from October 1974 to March 1978,50 patients who underwent either resection or bypass operation were subjected to reconstructive surgery using a tubed gastric flap. The tubed gastric flap was made by the following procedures. The greater omentum was excised, leaving the right GEA untraumatized. A long curvilinear incision was made parallel to the greater curvature to obtain a long gastric flap, and the pedicle of the flap was attached to the gastric antrum (Figure 1). A narrow long gastric tube was then made from the flap and the anterior and posterior walls were sutured with interrupted O-O-Osilk. The remaining stomach wall was removed. The gastric tube thus constructed was fed with the right GEA (Figure 2). A retrosternal tunnel was used to elevate the tubed flap. A Heinecke-Mickulicz pyloroplasty was routinely performed to prevent gastric stasis (Figure 3). An esophagogastrostomy was performed in two layers with interrupted O-O-Opolyglycolic acid sutures (Dexon) in an inverted fashion. The length of the tubed gastric flap was determined to be within 4.0 cm from the terminal branch of the right GEA. If a tension was present in the anastomosis, the duodenum was mobilized by Kocher’s maneuver.
597
Yamato et al
Figure 1. A long curvlllnear incision was made parallel fo the greafer curvature obtain to a iong tubed gastric fiap staiked to the antrum.
Results
The authors evaluated the localization and communication of the left and right GEA’s demonstrated in 137 clinical cases and 32 stomach-omentum-spleen specimens and classified them into the following four types (Figure 4): Type I: Distinct extramural communication was proved between the left and right GEA’s along the greater curvature. Type II: Bilateral GEA’s were clearly visualized, but no definite evidence of extramural anastomosis existed. Some cases of this type had a definite intramural anastomosis of both arteries. Type III: The right GEA ran up to the middle part of the gastric body along the greater curvature, whereas the left GEA from the splenic artery ran downward a short distance along the greater curvature. The distance between the terminal branches of the right and left GEA’s was relatively long. No direct extramural or intramural anastomosis between both arteries was seen on the X-ray films. Type IV: Indirect anastomosis was noted between the right and left GEA’s by way of the left epiploic artery. The 137 arteriograms were classified as follows: Type I, 47 cases (34.4 per cent) (Figure 5); Type II, 21 cases (15.3 per cent) (Figure 6); Type III, 61 cases (44.5 per cent) (Figure 7); Type IV, 8 cases (5.8 per
598
Figure 2. Top, the tubed gastric fiap was closed aiong the cut line in fwo iayers with interrupted 0-g-U silk sutures. Bottom, a completed tubed gastric fiap. i?f. g.e.a. = right gastroepipioic arfery.
Figure 3. Retrosternai elevate to tunnel a gastric tubed fiap. The fubed fiap was broughf up refrosfernaiiy and anasfomosed with the cervical esophageal stump in the left ( /t. ) supracia vicuiar fossa.
cent) (Figure 8). The 32 arteriograms obtained from the operative specimens were classified as follows: Type I, 10 cases (31.3 per cent) (Figure 9); Type II, 4 cases (12.5 per cent) (Figure 10); Type III, 12 cases (37.5 per cent) (Figure 11); Type IV, 6 cases (18.7 per cent) (Figure 12). Therefore, no complete extramural
The American Journal of Surgery
Autogenous Tubed Gastric Flap
Arterlographlc
anatomy
of
right
& left
gastro-eptploic
aa.
Figure 5. Arteriogram of Type I, showing direct extramural communication is between bilateral GEA ‘s.
Type[v
Rr g e a c.omm~n,c
wth
It
ep~plo~c a
Figure 4. Arteriographic variations in communication ;;emam)u$z,) of the right and left gastroepiploic arteries S . . . . = atfery; Lt. = /eft; Rt. = rtght.
Figure 7. Arteriogram of Type Ill. The right GEA runs up to the middle part of the gastric body along the greater curvature, and the left GEA from the splenic artery runs downward a short distance along the greater curvature.
Figure 6. Ark&gram of type II, showing no direct extramural communication between bilateral GEA’s.
anastomosis was found between the bilateral GEA’s in approximately two-thirds of the human stomachs studied. In clinical cases the tubed gastric flap used for esophageal reconstruction was 27.0 cm in length on average, and the Heinecke-Mickulicz pyloroplasty
Volume 137, May 1979
resulted in a 1.4 cm shortening on average. The esophagogastrostomy was easily performed in 32 cases using a tubed gastric flap greater than 26 cm in length. In contrast, 18 cases with tubed flaps less than 26 cm in length had slight tension at the site of esophagogastrostomy. The duodenum was mobilized by Kocher’s maneuver, resulting in release of the tension at the anastomotic line in 15 cases. The remaining three cases with a short gastric flap 23.5 cm in length retained a slight tension at the site of esophagogastrostomy even after duodenal mobilization, causing a breakdown on the 8th postoperative day. The fistula spontaneously closed in an average of 24 days
599
Yamato et al
with no additional operative procedure, whereas the fistulas made with a traditional antesternal esophagogastrostomy usually lasted longer [8]. Comments
Anastomotic insufficiency of the antesternal esonhagogastrostomv after esdphagectomv is induced
600
layer in the esophagus to support an anastomotic line, swallowing and respiratory movements that cause tension in the anastomotic line, and compromised blood circulation to the lifted stomach wall due to compression by the overlying skin and clavicula. Because the lifted stomach is primarily fed through
The American Journal of Surgery
Autogenous Tubed Gastric Flap
the right GEA, one of the important causes of anastomotic failure is thought to be impaired circulation in the lifted gastric wall. The following methods are available today to maintain or improve local circulation in the esophogastrostomy. The first method provides communication between the vascular stalk of tubed flap and the small cervical vessels to prevent postoperative ischemia [5]. This method is accomplished by dissecting and anastomosing vessels. However, such vascular anastomosis is often complicated later by thrombosis. The second method is to reinforce the site of an anastomosis with the greater omentum [I] or free peritoneal patch [9,10]. However, this method has not been widely used because of postoperative stenosis. The third method attempts to obtain an autogenous long gastric tube and maintain its local perfusion. The authors tried this method and reviewed arteriograms of clinical cases and of stomach-omentum-spleen specimens obtained by surgery, concentrating on studies of blood supply of the gastric wall along the greater curvature, especially of the right GEA. The results revealed extramural anastomosis between the left and right GEA’s in only approximately one-third of the cases. The blood circulation was not maintained sufficiently in many cases in the region along the greater curvature of the lifted gastric flap using various methods reported previously [1,5,6], indicating that the anatomy of the right GEA is important in preventing breakdown of the suture line. It is necessary to prepare a gastric tube long enough to reach the cervical esophagus so that local circulation will not be compromised and no tension will be exerted on the esophagogastrostomy. A reversed gastric tube has been used as an esophageal substitute for more than 20 years [2,11,12]. The gastric tube made with this procedure is perfused by the left GEA. However, our study revealed that the left GEA is sometimes not well developed enough to perfuse the antral end of the tube because of insufficient communication with the right GEA. The tubed gastric flap described in this study is fed by the right GEA and pedicled to the antrum. A long gastric tube, usually 38 cm in length, can be constructed using interrupted two layer sutures without metallic staples; this tube can be 25 per cent longer than a tube made of a lifted gastric remnant. In clinical cases with a tubed gastric flap longer than 26 cm in length, the lower end of the remaining esophagus can be reached to assure a safe esophagogastrostomy without tension. In 18 cases with a tubed gastric flap less than 26 cm in length, tension on the anastomotic line was relieved by mobilizing
Volume137,May1979
Figure 12. Arteriogram of a Type IV specimen, showing anastomosis between the rtght and left epiptoic arteries.
the duodenum using Kocher’s maneuver. Only three cases with a tubed flap 23.5 cm in length retained a slight tension at the anastomotic site after duodenal mobilization, resulting in its postoperative breakdown. From these results, we conclude that a safe esophagogastrostomy can be carried out when a tubed gastric flap longer than 26 cm in length is constructed after the completion of pyloroplasty. A retrosternal tunnel to elevate a tubed gastric flap can save some distance in reaching the cervical esophagus and can prevent compression on the flap exerted by the overlying skin and clavicula. Using our procedures we have never encountered compromised local circulation evidenced by venous congestion, dilatation, or discoloration. A retrosternal tunnel was used in our study to elevate tubed gastric flaps. With antesternal subcutaneous tunnel, the lifted tubed gastric flap is compressed by overlying skin and local circulation is compromised, particularly at the site of esophagogastrostomy, thus leading to anastomotic insufficiency. With the retrosternal tunnel, food stuffs in a traditional lifted stomach compress the adjacent organs. However, a narrow tubed flap does not compress the adjacent organs. Summary
As an esophageal substitute, a tubed gastric flap 2.5 cm in inner diameter and 38 cm in length, was constructed from the gastric wall along the greater curvature; a pedicle was attached to the gastric antrum, and its oral stump was brought up into the left supraclavicular fossa through a retrosternal tunnel to perform an esophagogastrostomy. Anastomotic
601
Yamato et al
breakdown occurred which this procedure
in only three was used.
of fifty cases in
References 1. Hanyu F, Sakakibara H, Kobayashi S: Radical operation for the carcinoma of mid-thoracic esophagus. R&ho Geka (Japan) 26: 731, 1971. 2. Heimlich HJ: Esophagoplasty with reversed gastric tube. Am J Surg 123: 80, 1972. 3. Huguier M, Gordin F, Maillard JN, Lortat-Jacob JL: Results of 117 esophageal replacements. Surg Gynecol Obstet 130: 1054,197o. 4. Parker EF, Gregorie HB, Arrants JE, Ravenei JM: Carcinoma of the esophagus. Ann Surg 171: 746, 1970. 5. lnokuchi K, Nakamura T: The breakdown of the suture line in the surgery of the esophageal cancer. Rinsho Geka (Japan) 20: 593, 1965.
602
6. Nakayama K, Hanyu F, Endo M: Complications following antethoracic esophagogastrostomy. Geka Shinryo (Japan) 13: 391.1971. 7. Katsura S, Abo S: Leakage following operation for the carcinoma of the esophagus. C/in Surg (Japan) 20: 583, 1965. 8. Yamato T: Experimental and clinical studies on reconstruction of esophagus with special reference to formation of autogenous gastric tubed flap and its usefulness following a subtotal esophagectomy. Osaka City Med J 24: 709, 1975. 9. lnokuchi K, Nakamura T, Sugimachi K, Hirano M: Our procedures for esophageal reconstruction. Rinsho Geka (Japan) 29: 753, 1974. 10. Kurachi M: Experimental studies on intrathoracic reconstruction of the esophagus. J Juzen Med Sot 80: 595,197l. 11. Heimlich l-N, Winefield JM: The use of a gastric tube to replace or by-pass the esophagus. Surg 37: 549, 1955. 12. Uchiyama, H, Kajasa T: The breakdown of the suture line in the surgery of the esophageal cancer. Rinsho Geka (Japan) 20: 587, 1965.
The American Journal of Surgery
Tsuneaki Yamato, MD, Osaka, Japan Yoshiro Hamanaka, MD, Osaka, Japan Sanae Hirata, MD, Osaka, Japan Katsuji Sakai, MD, Osaka, Japan
Various procedures have been used for esophageal reconstruction after total thoracic esophagectomy, according to the location of the lesion, the method of thoracotomy, the organ to be used as an esophageal substitute, and the elevating route. The stomach is most often used as an esophageal substitute because it has many vessels and is easily accessible anatomically [I-4]. As an elevating route, many surgeons prefer an antesternal subcutaneous tunnel to prevent serious consequences from anastomotic insufficiency [I+]. The authors initially used a residual stomach, which was elevated through an antesternal subcutaneous tunnel and anastomosed with the cervical esophagus in the ieft supraclavicular fossa. However, anastomotic breakdown occurred in 9 of 17 patients who underwent this procedure, and the incidence of sinus formation after an antesternal esophagogastrostomy is reported to be 40 to 70 per cent. [I-3,5,7]. Although anastomotic leakage in the neck is not life-threatening, the anastomosis is difficult to close and tends to resuit in stenosis even after its spontaneous closure [S,S] . One of the main causes of anastomotic breakdown after an esophagogastrostomy is impaired local blood supply of the lifted stomach wall. Therefore, we attempted to study the blood supply to the stomach wall. Material and Methods Anatomic variations of the gastroepiploic were examined in 420 patients undergoing
artery (GEA) celiac arteri-
From the 2nd Division, Department of Surgery, Osaka City University Hospital, Asahi-machi, Abenu-ku, Osaka 545, Japan. Reprint requests should be addressed to Tsuneaki Yamato, MD, 2nd Division, Department of Surgery, Osaka City University Hospital, Asahi-machi, Abeno-ku, Osaka 545, Japan.
Volume 137, May 1979
ography. For the purpose of this study, 137 celiac angiograms from these patients were useful. We also examined 32 stomach-omentum-spleen specimens removed en block by total gastrectomy for stomach cancer. These specimens did not include cases with scirrhous carcinoma or macroscopic invasion of the carcinoma into the serosa along the greater curvature. The greater omentum was carefully dissected off the transverse colon in total gastrectomy, meticulously preventing trauma to the GEA’s. Immediately after removal of a specimen, the right GEA was perfused from its origin with a 100 ml saline solution containing 1,000 units of heparin Na (Novo Co., Ltd.) to wash out the blood in the gastric wall. The right GEA of a specimen was demonstrated on X-ray films by injecting a 20 ml contrast medium (Micropark). Among the patients with esophageal cancer admitted to the our division at the Osaka City University Hospital from October 1974 to March 1978,50 patients who underwent either resection or bypass operation were subjected to reconstructive surgery using a tubed gastric flap. The tubed gastric flap was made by the following procedures. The greater omentum was excised, leaving the right GEA untraumatized. A long curvilinear incision was made parallel to the greater curvature to obtain a long gastric flap, and the pedicle of the flap was attached to the gastric antrum (Figure 1). A narrow long gastric tube was then made from the flap and the anterior and posterior walls were sutured with interrupted O-O-Osilk. The remaining stomach wall was removed. The gastric tube thus constructed was fed with the right GEA (Figure 2). A retrosternal tunnel was used to elevate the tubed flap. A Heinecke-Mickulicz pyloroplasty was routinely performed to prevent gastric stasis (Figure 3). An esophagogastrostomy was performed in two layers with interrupted O-O-Opolyglycolic acid sutures (Dexon) in an inverted fashion. The length of the tubed gastric flap was determined to be within 4.0 cm from the terminal branch of the right GEA. If a tension was present in the anastomosis, the duodenum was mobilized by Kocher’s maneuver.
597
Yamato et al
Figure 1. A long curvlllnear incision was made parallel fo the greafer curvature obtain to a iong tubed gastric fiap staiked to the antrum.
Results
The authors evaluated the localization and communication of the left and right GEA’s demonstrated in 137 clinical cases and 32 stomach-omentum-spleen specimens and classified them into the following four types (Figure 4): Type I: Distinct extramural communication was proved between the left and right GEA’s along the greater curvature. Type II: Bilateral GEA’s were clearly visualized, but no definite evidence of extramural anastomosis existed. Some cases of this type had a definite intramural anastomosis of both arteries. Type III: The right GEA ran up to the middle part of the gastric body along the greater curvature, whereas the left GEA from the splenic artery ran downward a short distance along the greater curvature. The distance between the terminal branches of the right and left GEA’s was relatively long. No direct extramural or intramural anastomosis between both arteries was seen on the X-ray films. Type IV: Indirect anastomosis was noted between the right and left GEA’s by way of the left epiploic artery. The 137 arteriograms were classified as follows: Type I, 47 cases (34.4 per cent) (Figure 5); Type II, 21 cases (15.3 per cent) (Figure 6); Type III, 61 cases (44.5 per cent) (Figure 7); Type IV, 8 cases (5.8 per
598
Figure 2. Top, the tubed gastric fiap was closed aiong the cut line in fwo iayers with interrupted 0-g-U silk sutures. Bottom, a completed tubed gastric fiap. i?f. g.e.a. = right gastroepipioic arfery.
Figure 3. Retrosternai elevate to tunnel a gastric tubed fiap. The fubed fiap was broughf up refrosfernaiiy and anasfomosed with the cervical esophageal stump in the left ( /t. ) supracia vicuiar fossa.
cent) (Figure 8). The 32 arteriograms obtained from the operative specimens were classified as follows: Type I, 10 cases (31.3 per cent) (Figure 9); Type II, 4 cases (12.5 per cent) (Figure 10); Type III, 12 cases (37.5 per cent) (Figure 11); Type IV, 6 cases (18.7 per cent) (Figure 12). Therefore, no complete extramural
The American Journal of Surgery
Autogenous Tubed Gastric Flap
Arterlographlc
anatomy
of
right
& left
gastro-eptploic
aa.
Figure 5. Arteriogram of Type I, showing direct extramural communication is between bilateral GEA ‘s.
Type[v
Rr g e a c.omm~n,c
wth
It
ep~plo~c a
Figure 4. Arteriographic variations in communication ;;emam)u$z,) of the right and left gastroepiploic arteries S . . . . = atfery; Lt. = /eft; Rt. = rtght.
Figure 7. Arteriogram of Type Ill. The right GEA runs up to the middle part of the gastric body along the greater curvature, and the left GEA from the splenic artery runs downward a short distance along the greater curvature.
Figure 6. Ark&gram of type II, showing no direct extramural communication between bilateral GEA’s.
anastomosis was found between the bilateral GEA’s in approximately two-thirds of the human stomachs studied. In clinical cases the tubed gastric flap used for esophageal reconstruction was 27.0 cm in length on average, and the Heinecke-Mickulicz pyloroplasty
Volume 137, May 1979
resulted in a 1.4 cm shortening on average. The esophagogastrostomy was easily performed in 32 cases using a tubed gastric flap greater than 26 cm in length. In contrast, 18 cases with tubed flaps less than 26 cm in length had slight tension at the site of esophagogastrostomy. The duodenum was mobilized by Kocher’s maneuver, resulting in release of the tension at the anastomotic line in 15 cases. The remaining three cases with a short gastric flap 23.5 cm in length retained a slight tension at the site of esophagogastrostomy even after duodenal mobilization, causing a breakdown on the 8th postoperative day. The fistula spontaneously closed in an average of 24 days
599
Yamato et al
with no additional operative procedure, whereas the fistulas made with a traditional antesternal esophagogastrostomy usually lasted longer [8]. Comments
Anastomotic insufficiency of the antesternal esonhagogastrostomv after esdphagectomv is induced
600
layer in the esophagus to support an anastomotic line, swallowing and respiratory movements that cause tension in the anastomotic line, and compromised blood circulation to the lifted stomach wall due to compression by the overlying skin and clavicula. Because the lifted stomach is primarily fed through
The American Journal of Surgery
Autogenous Tubed Gastric Flap
the right GEA, one of the important causes of anastomotic failure is thought to be impaired circulation in the lifted gastric wall. The following methods are available today to maintain or improve local circulation in the esophogastrostomy. The first method provides communication between the vascular stalk of tubed flap and the small cervical vessels to prevent postoperative ischemia [5]. This method is accomplished by dissecting and anastomosing vessels. However, such vascular anastomosis is often complicated later by thrombosis. The second method is to reinforce the site of an anastomosis with the greater omentum [I] or free peritoneal patch [9,10]. However, this method has not been widely used because of postoperative stenosis. The third method attempts to obtain an autogenous long gastric tube and maintain its local perfusion. The authors tried this method and reviewed arteriograms of clinical cases and of stomach-omentum-spleen specimens obtained by surgery, concentrating on studies of blood supply of the gastric wall along the greater curvature, especially of the right GEA. The results revealed extramural anastomosis between the left and right GEA’s in only approximately one-third of the cases. The blood circulation was not maintained sufficiently in many cases in the region along the greater curvature of the lifted gastric flap using various methods reported previously [1,5,6], indicating that the anatomy of the right GEA is important in preventing breakdown of the suture line. It is necessary to prepare a gastric tube long enough to reach the cervical esophagus so that local circulation will not be compromised and no tension will be exerted on the esophagogastrostomy. A reversed gastric tube has been used as an esophageal substitute for more than 20 years [2,11,12]. The gastric tube made with this procedure is perfused by the left GEA. However, our study revealed that the left GEA is sometimes not well developed enough to perfuse the antral end of the tube because of insufficient communication with the right GEA. The tubed gastric flap described in this study is fed by the right GEA and pedicled to the antrum. A long gastric tube, usually 38 cm in length, can be constructed using interrupted two layer sutures without metallic staples; this tube can be 25 per cent longer than a tube made of a lifted gastric remnant. In clinical cases with a tubed gastric flap longer than 26 cm in length, the lower end of the remaining esophagus can be reached to assure a safe esophagogastrostomy without tension. In 18 cases with a tubed gastric flap less than 26 cm in length, tension on the anastomotic line was relieved by mobilizing
Volume137,May1979
Figure 12. Arteriogram of a Type IV specimen, showing anastomosis between the rtght and left epiptoic arteries.
the duodenum using Kocher’s maneuver. Only three cases with a tubed flap 23.5 cm in length retained a slight tension at the anastomotic site after duodenal mobilization, resulting in its postoperative breakdown. From these results, we conclude that a safe esophagogastrostomy can be carried out when a tubed gastric flap longer than 26 cm in length is constructed after the completion of pyloroplasty. A retrosternal tunnel to elevate a tubed gastric flap can save some distance in reaching the cervical esophagus and can prevent compression on the flap exerted by the overlying skin and clavicula. Using our procedures we have never encountered compromised local circulation evidenced by venous congestion, dilatation, or discoloration. A retrosternal tunnel was used in our study to elevate tubed gastric flaps. With antesternal subcutaneous tunnel, the lifted tubed gastric flap is compressed by overlying skin and local circulation is compromised, particularly at the site of esophagogastrostomy, thus leading to anastomotic insufficiency. With the retrosternal tunnel, food stuffs in a traditional lifted stomach compress the adjacent organs. However, a narrow tubed flap does not compress the adjacent organs. Summary
As an esophageal substitute, a tubed gastric flap 2.5 cm in inner diameter and 38 cm in length, was constructed from the gastric wall along the greater curvature; a pedicle was attached to the gastric antrum, and its oral stump was brought up into the left supraclavicular fossa through a retrosternal tunnel to perform an esophagogastrostomy. Anastomotic
601
Yamato et al
breakdown occurred which this procedure
in only three was used.
of fifty cases in
References 1. Hanyu F, Sakakibara H, Kobayashi S: Radical operation for the carcinoma of mid-thoracic esophagus. R&ho Geka (Japan) 26: 731, 1971. 2. Heimlich HJ: Esophagoplasty with reversed gastric tube. Am J Surg 123: 80, 1972. 3. Huguier M, Gordin F, Maillard JN, Lortat-Jacob JL: Results of 117 esophageal replacements. Surg Gynecol Obstet 130: 1054,197o. 4. Parker EF, Gregorie HB, Arrants JE, Ravenei JM: Carcinoma of the esophagus. Ann Surg 171: 746, 1970. 5. lnokuchi K, Nakamura T: The breakdown of the suture line in the surgery of the esophageal cancer. Rinsho Geka (Japan) 20: 593, 1965.
602
6. Nakayama K, Hanyu F, Endo M: Complications following antethoracic esophagogastrostomy. Geka Shinryo (Japan) 13: 391.1971. 7. Katsura S, Abo S: Leakage following operation for the carcinoma of the esophagus. C/in Surg (Japan) 20: 583, 1965. 8. Yamato T: Experimental and clinical studies on reconstruction of esophagus with special reference to formation of autogenous gastric tubed flap and its usefulness following a subtotal esophagectomy. Osaka City Med J 24: 709, 1975. 9. lnokuchi K, Nakamura T, Sugimachi K, Hirano M: Our procedures for esophageal reconstruction. Rinsho Geka (Japan) 29: 753, 1974. 10. Kurachi M: Experimental studies on intrathoracic reconstruction of the esophagus. J Juzen Med Sot 80: 595,197l. 11. Heimlich l-N, Winefield JM: The use of a gastric tube to replace or by-pass the esophagus. Surg 37: 549, 1955. 12. Uchiyama, H, Kajasa T: The breakdown of the suture line in the surgery of the esophageal cancer. Rinsho Geka (Japan) 20: 587, 1965.
The American Journal of Surgery