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RECONSTRUCTION OF THE ESOPHAGUS WITH LEFT COLON
RECONSTRUCTION OF THE ESOPHAGUS W I T H LEFT COLON Ronald Belsey, M.S., F.R.C.S. (by invitation),
Bristol, England
Sponsored by O. Theron Clagett, M.D., Rochester,
Minn.
M
OST obstructive esophageal lesions calling for excision and reconstruction of the gullet occur at an age when the sole remaining physical pleasures in life for the majority of patients are eating and drinking. The patient is the final arbiter in assessing the clinical value of any method of esophageal recon struction. The radiological demonstration of the passage of a bolus from the mouth to the stomach, the deferment of starvation and dehydration, are not enough to satisfy the patient. Only when his ability to eat and drink with pleasure and satisfaction has been fully restored will the patient consider the ordeal to have been worth while. The critical appraisal of the results of esophageal reconstruction, as revealed by long-term follow-up surveys in the out-patient clinic, suggests that existing operative procedures are far from satisfactory when viewed in the light of the' patient's subjective experience dur ing the act of eating. A satisfactory reconstructive technique must fulfill certain criteria: (1) the mortality and morbidity risks of the operation must be acceptable; (2) it must be possible to excise the obstructing lesion as radically as necessary and reconstruct the gullet in one stage; (3) sufficient viscus must be available to replace the entire esophagus when necessary; (4) the method must be appli cable to infants and children as well as adults; and (5) the relief of the pa tient's dysphagia must be complete and lasting. Kecently there has emerged an increasing dissatisfaction with the long-term results of esophagogastric anastomoses. This can be a satisfactory operation, and in some cases may fulfill all the criteria mentioned. In approximately 27 per cent of the patients who survive more than 6 months, reflux esophagitis will develop above the anastomosis and the discomfort and dysphagia may recur. In a higher percentage of cases the patient will experience varying degrees of distress due to postural regurgitation of gastric secretion and bile, reduced gastric capacity, and nutritional disorders. This communication records a clinical trial of alternative methods of re construction with particular emphasis on the long-term functional results. Jejunal transplants were given a clinical trial but were found unsatisfactory Prom the Frenchay Hospital, Bristol, England. Read at "the Forty-fourth Annual Meeting of The American Association for Thoracic Surgery, Montreal, Canada, April 27, 28, and 29, 1964. 33
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on two counts. First, in infants and children the blood supply to the jejunum may be precarious and long segment transplants hazardous. Second, a trouble some alkaline esophagitis may occur proximal to an esophagojejunal anasto mosis. The author has abandoned the use of pedicle jejunal transplants except to bypass nonresectable malignant growths of the cardia and lower third of the esophagus. The terminal ilium and ascending colon have been widely used to bypass esophageal growths. The transplant is usually passed up through the anterior mediastinum and interposed between the cervical esophagus and stomach. This technique is essentially a palliative procedure only; excision of the esophageal stricture involves a further major operation at a later date. Two-stage opera tions for malignant disease are unsatisfactory unless the growth can be excised at the first stage. The transplantation of the left half of the transverse colon and the splenic flexure, with its blood supply maintained from the left colic artery, has certain advantages over other methods. An isoperistaltic transplant of sufficient length to replace the entire esophagus is available. The blood supply is robust, even in infants and small children. Through a left thoracoabdominal approach, a onestage excision and reconstruction can be carried out for strictures or growths of the esophagus situated at any level. In dealing with growths of the upper third, or the cervical esophagus, the proximal anastomosis can be performed easily through a separate cervical incision after closure of the thoracotomy wound. The left-sided approach has a further advantage. In the event of some anatomical or pathological feature, such as an abnormality of the marginal artery of the colon or advanced mesenteric endarteritis, contraindicating the use of colon for the reconstruction, an alternative procedure in the form of an esophagogastric anastomosis is immediately available through the same incision. CLINICAL MATERIAL
Esophageal reconstruction with left colon transplant has now been carried out in 105 patients, ranging in age from 15 months to 78 years. The longest follow-up period is now 6 years, and 85 of the patients have been observed for longer than a year. The pathological conditions demanding resection in this series are tabulated in Table I. Of the 82 patients with benign fibrous strictures of the esophagus, TABLE I. L E F T COLON TRANSPLANTS FOR ESOPHAGEAL REPLACEMENT
Total number of cases Benign fibrous strictures Chronic reflux esophagitis Lye strictures Congenital esophageal atresia Malignant strictures of the esophagus
79 3
82 10 13
Adults, 16 to 78 years Infants and children, 15 months to 10 years
74 31
"Short segment" colon transplants "Long segment" colon transplants
70 29
105
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in 79 the stenosis was due to severe chronic reflux esophagitis secondary to an hiatus hernia. In 4 of these cases a previous esophagogastrectomy and anasto mosis had been performed, with the subsequent development of recurrent esophagitis above the anastomosis in spite of a two thirds gastric resection, bilateral vagotomy, pyloroplasty, and a high esophagogastric anastomosis—all recognized methods of discouraging recurrent esophagitis. In these 4 cases the original anastomosis was dismantled, the tubular gastric remnant was returned to the abdomen, a further esophageal resection was performed and the gullet was reconstructed by means of a long segment colon transplant, the upper anas tomosis to the cervical esophagus being performed in the neck through a separate incision. In 2 patients a Heller operation for associated achalasia had been performed previously, with the subsequent development of reflux esophagitis and fibrous stenosis. Two patients had undergone a partial gastrectomy of the Polya type, in an attempt to control the esophagitis. This operation enjoyed a brief vogue of popularity but has now been abandoned in most centers due to its failure to prevent the subsequent development of fibrous esophageal strictures. Under these circumstances an esophagogastric anastomosis following resection of the stricture may be technically impossible and reconstruction with a colon or jejunal transplant becomes obligatory. In 3 patients the obstruction resulted from extensive or multiple chemical strictures of the gullet, either accidental or suicidal in origin. Thirty-one of the reconstructions were performed in infants or children under the age of 10 years. Ten of the infants were cases of congenital atresia of the esophagus in whom no primary anastomosis was possible because of the length of the gap between the two esophageal segments and in whom a tem porary esophagostomy and gastrostomy were performed at the first operation when the tracheoesophageal fistula was closed shortly after birth. Subsequently a reconstruction of the entire intrathoracic esophagus was carried out with the use of a long segment colon transplant, when the infant was between 15 months and 2 years old. The 105 reconstructions performed in this series of cases fall into two groups, depending upon the length of colon transplanted and the position of the proximal anastomosis below or above the aortic arch. In 76 cases, a "short seg ment" transplant was used to replace the lower half of the esophagus and the proximal anastomosis was performed just below the aortic arch. In 29 cases, a "long segment" transplant was used to replace the greater portion of the esopha gus and the proximal anastomosis was performed above the aortic arch, either at the apex of the thoracic cavity (7 cases) or to the cervical esophagus through a separate cervical incision (22 cases). The latter technique is advocated, as be ing easier and less time-consuming. The indications for the long segment operation in cases of benign stenosis, other than cases of chemical strictures, were recurrent esophagitis and stenosis following a previous esophagogastrectomy, and cases in which a developmentally abnormal lower esophagus, lined with gastric mucosa, had been complicated by esophagitis and fibrous stenosis occurring just above the mucosal junction situa ted at an abnormally high level in the region of the aortic arch. Of the 13 cases of malignant stenosis of the esophagus, in 10 the growth was
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Pig. 1.—Achalasia of the cardia. Short segment colon transplant for fibrous stenosis at the cardia after unsuccessful Heller's operation and reflux esophagitis.
Pig. 2.—Short segment colon transplant for multiple lye strictures of the esophagus. The upper stricture was excised and continuity restored by end-to-end esophageal anastomosis.
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situated in the middle or upper third of the organ. For carcinomata of the midthird, an esophagogastric resection and anastomosis performed through the right pleural cavity is a satisfactory operation. However, in some cases the right-sided approach may be contraindicated by previous pleural sepis and its sequelae. Moreover, in some instances the stomach is so contracted as a result of chronic starvation that insufficient viscus is available to permit a satisfactory reconstruc tion at an adequate level above the resected growth. In these circumstances a long segment left colon transplant is the better procedure. PREOPERATIVE PREPARATION
In preparing a patient for a colon transplant procedure, great care must be taken to avoid disturbing the normal bowel routine for that particular patient. Aperients and colon washouts are avoided. The patient is placed on a high pro tein, low residue diet for 7 to 14 days prior to operation. Dental toilet, physiotheraphy, and preliminary blood transfusion, when indicated, are carried out during this period. Neomycin is administered for the last 48 hours before opera tion. In 6 cases a colon transplant was performed successfully without any prep aration at all; hard scybala were milked out of the transplant before the anas tomoses were performed but no other precautions against infection were taken. The constipated colon is easier to cleanse than the colon reduced to the state of a sewage works by too much attention.
Fig. 3.—A, Benign fibrous stricture of the esophagus secondary to hiatus hernia prior to esophagogastrectomy. B, Recurrent esophagitis and stenosis above the esophagogastric anas tomosis. C, Long segment colon transplant after dismantling the previous anastomosis, further esophageal resection, and restoration of the gastric remnant to the abdominal cavity.
Fig. 4.—A, Fibrous stenosis of the esophagus above the mucosal Junction in a case of hiatus hernia and esophagus lined with gastric mucosa. B, Following esophagectomy, reduction of the hiatus hernia and long segment colon transplant. C, Another example of a long segment colon transplant for a high benign stricture.
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THE SHORT SEGMENT OPERATION
With the patient in the right lateral position, the left chest is entered through the sixth intercostal space and the incision carried forward across the costal margin to the lateral border of the rectus sheath. The diaphragm is partial ly separated from the chest wall at its periphery rather than incised across the dome. A suitable length of colon is prepared by division of the marginal artery just distal to the two brances of the left colic artery, or between them, and again in the region of the middle colic artery (Pig. 5). This segment of colon is isola ted on a vascular pedicle of the left colic artery. Continuity of the colon is re stored by end-to-end anastomosis. A pyloromyotomy is performed. The cardia is divided and closed, and the esophagus is resected from the cardia to a point
Fig-. 5.—Blood supply to the colon showing- points of division for short and long segment colon transplants. The dotted lines represent inconstant vessels which can safely be divided. A, Line of incision for short segment colon transplant. B, Line of incision for long segment colon transplant.
well above the obstruction. In the case of a malignant stricture of the esophagus, it is essential that the proximal line of esophageal section be at least 2 inches above the level of the growth to reduce the risk of further obstruction from a local recurrence. The distal end of the transplant is anastomosed to the back of the stomach a third of the distance between the cardia and pylorus, thus maintaining an intra-abdominal segment of transplant. Compression of this segment by the intra-abdominal pressure forms an effective valvular mecha nism that discourages or prevents the reflux of gastric secretion into the trans plant. The proximal end of the transplant is brought up behind the fundus, through the hiatus, and anastomosed end-to-end to the mid-third of the esopha gus close to the aortic arch. All anastomoses are performed with a one layer technique with the use of interrupted sutures of stainless steel wire. The trans-
Pig. 6.—Three examples of short segment colon transplant for benign strictures. Note the compression of the subdiaphragmatic portion of the colon transplant by the intra-abdominal pressure.
two
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Fig. 7.—Long segment colon transplant for carcinoma of the upper third of the esophagus. Lateral roentgenogram shows the position of the transplant in the posterior mediastinum.
plant is loosely sutured to the margins of the esophageal hiatus to prevent tendency for redundant transplant to herniate upward into the thorax. tension on the vascular pedicle of transplant must be avoided. Finally, fundus of the stomach is anchored with two rows of mattress sutures to undersurface of the diaphragm which is then reattached to the chest wall.
any All the the
THE LONG SEGMENT OPERATION
When a long segment of colon is to be interposed between the cervical esoph agus and stomach, it is advisable to divide the descending colon distal to both branches of the left colic artery. The transverse colon is divided between the two branches of the middle colic artery. The segment of colon isolated in this manner is usually adequate for total replacement, but if more colon is needed the middle colic artery can be divided proximal to its point of division and the transverse colon divided further to the right. The operation then pro ceeds in the same manner as the short segment operation up to the stage of the proximal anastomosis. The proximal end of the transplant is brought up through the posterior mediastinum deep to the aortic arch. In some of the earlier cases in this series the anastomosis was performed at the apex of the pleural cavity, with difficulty, unless an additional intercostal incision was made. Recent prac tice has been to close temporarily the proximal end of the transplant and suture
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it loosely to the stump of the esophagus after the major part has been excised. The chest is then closed. The patient is turned on his back and, through an oblique, left-sided, cervical incision along the anterior border of the sternomastoid muscle, the cervical esophagus is dissected free and drawn up to the surface of the wound along with the attached proximal end of the transplant. The latter is then opened, the esophagus trimmed back, and end-to-end onelayer anastomosis is performed with great ease. Because of the obliquity of the superior thoracic inlet, a transplant that will reach the apex of the pleural cavity will be adequate for a cervical anastomosis. When a total esophageal reconstruction for congenital atresia is being performed in an infant, the technique is modified. A long segment transplant is prepared in the usual way, brought up through the left pleural cavity lateral to the aortic arch (as there is no mediastinal tunnel) and closed. A tunnel is made up into the base of the neck. The end of the transplant is drawn up into this tunnel by two wire sutures which are brought out onto the surface of the neck just below the esophagostomy and tied. The chest is then closed. Ten to 14 days later the esophagostomy sinus is excised through a small transverse cervical incision; the end of the transplant is drawn up into the wound by thte two sutures, opened, and anastomosed end-to-end to the open end of the upper esophageal segment. Gastrostomy feeds are continued between the two stages This two-stage operation is well tolerated by infants. In adults a single-stage reconstruction is preferable. In both the short and long segment operations the attachment of the trans plant to the margins of the esophageal hiatus, and of the fundus of the stomach to the undersurface of the diaphragm, are important steps in the operation. Herniation of redundant colon or the fundus of the stomach up into the chest will result in kinking of the transplant and tension on its vascular pedicle. which may jeopardize the viability of the transplant. POSTOPERATIVE CARE
Parenteral fluids are administered for the first 24 hours. During the second day, 1 ounce of water is taken by mouth each hour, and on the third day this intake is doubled. On the fourth day the fluid intake by mouth is increased to 3 ounces hourly and milk drinks, tea, coffee, and fruit drinks are permitted. Soft solids are given by mouth on the fifth day and the intake of solid food is steadily increased until the tenth day when the patient is back on a normal diet. Antibiotics are not administered routinely in the postoperative period and are used only when a specific indication arises. The bowels begin to move nor mally about the fifth postoperative day. Aperients and enemas are avoided. In cases of atresia, the gastrostomy tube is removed as soon as the proximal esophagocolic anastomosis is soundly healed and normal mouth feeding has become established. CONTRAINDICATIONS
Variation in the anatomy of the marginal artery to the splenic flexure of the colon may be encountered. The vessel may break up into a plexus of
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small vessels and the blood supply from the left colic artery through this plexus may be inadequate to maintain the viability of the proximal end of the trans plant. The presence of marked mesenteric arteriosclerosis, as manifested by hard, palpably thickened, vessels with little or no pulsation, is a further contrain dication. The blood supply to the colon transplant, unlike that to the stomach, is dependent upon one vessel, and thrombosis resulting from minor trauma to the vessel will inevitably lead to necrosis of the transplant. Under these cir cumstances it is wiser to abandon the procedure and resort to the stomach, with its less vulnerable blood supply, for the reconstruction. In 7 patients a change in plan was made at operation for these reasons. No case has so far been encountered in which the presence of intrinsic in flammatory disease of the colon has precluded its transplantation. What might transpire were a patient to develop chronic ulcerative colitis following a colon transplant operation is open to conjecture. Inadequate or improper preparation of the large bowel may persuade the surgeon to abandon the procedure and resort to an esophagogastric anastomosis. The overzealous use of aperients and colon washouts is the worst possible pre lude to this form of large bowel surgery. POSTOPERATIVE
MORTALITY
In this series of 105 esophageal reconstructions by colon transplantation there were five postoperative fatalities, a mortality rate of slightly under 4.8 per cent. Three deaths followed resection and reconstruction of the esophagus for benign stricture, one for carcinoma of the esophagus, and one for congenital atresia of the esophagus. The mortality rate following the long segment opera tion was not appreciably higher than that following the short segment pro cedure. TABLE IT. CAUSES OF D E A T H FOLLOWING COLON TRANSPLANT TOR ESOPHAGEAL RECONSTRUCTION* NO.
1
|
LESION
|
CAUSE OP DEATH
Carcinoma mid-third
Calcine aortic stenosis and mitral stenosis 2 Benign fibrous strictures Infarction and necrosis of trans plant 3 Benign fibrous strictures Infective hepatitis 4 Benign fibrous strictures Streptomycin reaction, anuria 5 Congenital esophageal atresia Small bowel obstruction •Number of reconstructions, 105; 5 postoperative deaths (4.8%).
The causes of death were as follows: 1. Male, 57 years of age, died on thirteenth postoperative day from gangrene of the colon transplant. This patient had advanced generalized and mesenteric arteriosclerosis and had previously undergone a mid-thigh leg amputation for gangrene. Herniation of the fundus of the stomach through the hiatus—the fundus had not been sutured to the undersurface of the diaphragm—probably precipitated thrombosis of the vascular pedicle of the transplant. A definite contraindication to colon transplant had been ignored in this case.
Fig. 8. -Redundancy of the colon transplant and herniation into the chest due to lack of hiatal fixation. The illustration on the right shows herniation of the stomach through the hiatus from the same cause.
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2. Male, 63 years of age, died 2 weeks after operation from infective hepatitis, probably as a result of a preoperative blood transfusion. No other complication was present. 3. Female, 59 years of age, died on seventh postoperative day from anuria and bronchopneumonia secondary to a severe streptomycin reaction. All anastomoses were satisfactory. 4. Male, 53 years of age, died suddenly from cardiac arrest on third postoperative day following resection for an advanced carcinoma of the mid-third of the esophagus associated with achalasia of the cardia. Autopsy revealed gross calcine aortic stenosis and chronic rheumatic mitral disease but no other complications. 5. Male child, 2 years of age, died 2 months following reconstruction for congenital atresia of the esophagus from small bowel obstruction due to adhesions. This patient also suffered from congenital stenosis of the trachea and hydrocephalus.
The first and fifth fatalities were undoubtedly related to the nature of the operation. The first- patient should not have been submitted to this procedure in the light of further experience. In the other 3 cases, death was not related to the type of operation and could have followed any operative pro cedure. There has been one postoperative fatality in the last 80 cases. MORBIDITY
RATE
Nonfatal complications are listed in Table I I I . In 2 cases the colon trans planted necrosed due to venous obstruction and infarction. In neither case had the transplant been anchored to the margins of the hiatus and herniation upward into the pleural cavity led to tension on, and obstruction of, the veins returning from the transplant. I n both instances the situation was successfully resolved by excision of the transplant and replacement by an esophagogastric anastomosis, as an emergency procedure.
TABLE I I I .
NONFATAL POSTOPERATIVE COMPLICATIONS FOLLOWING L E F T COLON TRANSPLANT
Temporary cervical salivary fistulas Infarction and necrosis of colon transplant Kinking and obstruction of redundant intrathoracic colon Pleural infection Superficial wound infection
2 2 1 3 2
The two instances of cervical salivary fistulas occurred in infants in whom a long segment transplant had been used in a staged reconstruction for con genital esophageal atresia. The leaks occurred from the cervical anastomoses, lasted for a few days only, and then healed spontaneously. Upward herniation of a redundant transplant and obstruction by kinking occurred in 1 case, and necessiated thoracotomy and reduction of the redundant colon back into the abdominal cavity. This complication has been eliminated by suturing the transplant to the margins of the hiatus. Approximately one half of the adult patients experienced mild diarrhea during the first 2 weeks following operation but no subsequent bowel irregu larity.
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Convalescence was completely uneventful in 90 of the 100 operative sur vivors; only mild complications occurred in an additional 7 cases. There were no intrathoracic or intra-abdominal anastomotic leaks, no peritoneal sepsis, and only 3 cases of pleural infection due to operative contamination. Despite a longer and more complicated operation involving three anastomoses as against the single anastomosis in a gastric reconstruction, the postoperative course was conspicuously smoother than that normally encountered following the latter procedure; there was no instance of postoperative regurgitation, with the attendant risk of aspiration pneumonitis, a serious and not uncommon com plication after an esophagogastrostomy. LATE RESULTS
Ninety-eight patients were available for study with a view to assessing the long-term functional results of esophageal reconstruction by colon trans plants. Eighty-six patients have been followed for over a year. The main in terest in this study is the long-term follow-up of cases treated for benign esophageal obstruction. The surgery of malignant esophageal obstruction is es sentially palliative and few patients will survive long enough for the late results to be of clinical significance.
TABLE IV.
LATE
EESULTS*
Esophagogastric Besection and Anastomosis (1950-1960) 96 cases—7 postoperative deaths (7.3%) ; 4 anastomotic leaks 89 operative survivors: " A " : 39 ( 4 4 % ) : symptom-free " B " : 27 ( 2 9 % ) : mild symptoms; patient satisfied " C " : 17 ( 2 0 % ) : recurrent esophagitis; dilatation, pyloromyotomy " D " : 6 ( 7%) : recurrent stenosis, further resection necessary (4 colon transplants, 1 more radical esophago gastric resection, 1 local resection of stricture) Colon Transplants 92 cases—4 postoperative deaths (4.3%) ; no intrathoracic leaks 88 operative survivors (2 operative failures) " A " : 71 ( 8 1 % ) : symptom-free ) No recurrent reflux, " B " : 15 (17%) : mild symptoms ( esophagitis, or stenosis. ♦Review of comparative results of esophagogastric anastomosis and left colon transplant following esophageal resection and reconstruction for benign esophageal obstruction.
The only worth-while indication of the clinical value of any method of esophageal reconstruction is the patient's satisfaction or dissatisfaction with the procedure. "The customer is always right," and if the customer is satisfied the operation has succeeded. The object of the exercise is to restore the patient's ability and pleasure in eating and drinking. The long-term functional result in the series under review have largely been assessed on this basis in the followup clinic. The appearances seen in postoperative barium studies bear little relation ship to the clinical success of the procedure. "With the patient in the erect position, barium passed to the stomach with only slight delay at the hiatus or
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the cologastric anastomosis, or both. The degree of delay was not necessarily related to the presence of redundant loops of colon above these points. With the patient in the horizontal position or with the head tilted 20 degrees down ward, barium passed without delay from esophagus to colon transplant. On repeated swallowing, in patients with a short colon transplant, barium filled the transplant and then entered the stomach. In patients with a long colon transplant, barium filled the transplant either down to about the level of the carina or, in some, down to the level of the diaphragm, after which the upper esophagus failed to empty completely into the colon and the patient complained of feeling "full up." As the upper end of colon transplant became filled, re flux of barium up the lower portion of the esophagus occurred frequently as the esophagus relaxed. No reflux into the pharynx was seen. No movement was seen in the colon transplant at any time. A variable amount of residual barium remained in the colon transplant for 1 to 2 hours. The transplanted colon appears to act as a passive conducting tube only. Barium passes through it primarily under the influence of gravity but in the horizontal position the peristalsis of the esophagus above the transplant is sufficient to force barium through a short length of colon. Normal drinking is, therefore, possible in the horizontal or head down position if the transplant is short. The final diameter of the transplant varies within wide limits and is un predictable before or at operation. Again, the functional efficiency of the transplant does not appear to be affected by the dilatation occasionally seen. Colons undoubtedly vary in intrinsic activity and work capacity; an attempt to assess this charasteristic may play an increasingly important part in the selection of patients for colon' transplantation in the future. The less than satisfactory long-term results in this series occurred in 17 per cent of the cases and were characterized by a sensation that the bolus was slow in passing down the gullet and necessitated that meals be consumed slowly, although no regurgitation occurred and a full normal diet could be taken. This occurred only in elderly patients after a long segment transplant. One patient graphically described the experience as a "sensation of frustration in her chest whilst eating." Children and young adults never displayed any delay in swallowing, even after a total esophageal reconstruction. This result, when it occurs, is undoubtedly due to a sluggishly acting colon rather than any form of mechanical obstruction. Eighty-six cases of colon transplantation for benign esophageal stenosis have been followed up for varying periods up to 6 years. Barium swallow examinations have been performed at regular yearly intervals. There has been no justification for submitting any of these patients to repeat esophagoseopies. None of these patients has complained of recurrent heartburn or acid reflux, vomiting, or postural regurgitation; nor has there been any symptomatic or radiological evidence of any recurrent esophagitis or stenosis. No additional surgery or dilatation procedures have been necessary in this group. Of the 12 patients who survived long segment colon transplation for high malignant strictures of the esophagus, palliation was satisfactory. One patient is alive and free from recurrence 4 years after resection. Ten have succumbed
Fig. 9.—Short segment colon transplant for benign esophageal strictures; shows variation in diameter of the transplant. In all 3 cases the functional result was equally satisfactory.
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Pig. 10.—Three cases of esophageal reconstruction by long segment colon transplant for congenital atresia of the esophagus. Barium studies made 6 years following the operation. In C, there is some redun dancy of the transplant.
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Fig. 11.—Three examples of long segment colon transplants for carcinomata of the upper two thirds of the esophagus.
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to a recurrence of the growth 5 to 15 months following the operation. In only 1 case was there any recurrence of the dysphagia due to invasion of the colon transplant by a mcdiastinal metastasis. One of the main objects of this exercise was to determine the relative merits and demerits of esophageal reconstruction by a colon transplant as against those of reconstruction with a gastric tube when performed on a similar group of patients by the same surgical team. The potential operative risks would appear to be higher in colon transplantation in view of the greater length and complexity of the procedure with three anastomoses involved. In fact this fear was unjustified; the operative mortality rate (4.8 per cent) was lower, and the average convalescence was significantly smoother. The main difference was observed in the long-term results. After an esophagogastrectomy, 27 per cent of patients developed recurrent esophagitis above the level of the anastomosis despite a two thirds gastric resection, a gastric drainage procedure, and a high anastomosis. Seven per cent needed further major surgery for re current stenosis. Many of the patients complained of postural regurgitation and a reduced capacity for food, which necessitated modification of their dietetic regimen. As yet no satisfactory method of creating a valvular mechanism at the anastomosis has been devised. Children subjected to this procedure showed retardation of growth for 2 to 3 years following operation but subsequently caught up with the other members of the family. This has not been seen follow ing a colon transplant. On the other hand, an esophagogastrostomy is a quick, simple procedure involving but a single anastomosis and is well tolerated by elderly or depleted patients as far as operative shock is concerned. However, a significant incidence (4 per cent) of anastomotic leaks occur in the postoperative period and this complication is usually catastrophic, although an occasional patient can be saved by immediate thoracotomy and revision of the anastomosis. As far as the long-term results are concerned, none of this group experienced any delay in swallowing, as occasionally experienced by the colon transplant patients, in the absence of recurrent esophagitis. The results of this comparative investigation are summarized in Table IV. The cases of esophagogastrectomy were a consecutive series treated between 1950 and 1959, at which time colon transplantation was not used as a routine alternative procedure, so the two series relate to comparable clinical material. As a result of the experience gained during this investigation, the policy in the Regional Thoracic Surgical Unit in Bristol in regard to the management of benign esophageal obstruction has now crystallized along the following lines. For congenital esophageal atresia, long segment left colon transplantation is the only method of staged reconstruction employed. For restoring esophageal continuity following resection of fibrous strictures due to reflux esophagitis or chemical burns, left colon transplantation is the method preferred whenever the blood supply to the splenic flexure of colon is adequate to support the trans plant. Following esophagectomy for malignant disease, esophagogastrostomy is the method of choice and, at present, a left colon transplant is used only when the growth is situated in the upper third of the organ or when a contracted
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"starvation" stomach is inadequate to bridge the gap. The late incidence of re flux esophagitis following this operation is of little practical importance in cases of malignancy. The surprising feature that emerged during this study was the benign con valescence that followed a complicated procedure taking 3 to 4 hours to com plete, often in elderly and depleted patients. It suggests that colon is a far easier viscus to handle in this context than stomach. There were no intrathoracic leaks in this series, whereas in a comparable series of esophagogastrostomies there was a 4.5 per cent incidence of anastomotic leaks. It has long been the author's impression that the secretory activity of the stomach itself is frequently re sponsible for the leak. A trickle of peptic juice through a minute defect at the anastomotic suture line and digestion of the adjacent tissues might well be the starting point of a clinical leak with all its catastrophic implications. The lack of peptic ferment in the secretion of the left colon may well account for the ease with which satisfactory and safe anastomosis can be achieved with a simple one-layer technique when using left colon transplantation for esophageal re construction. Another significant feature of the early postoperative course 'was the absence of regurgitation and severe pulmonary complications. Basal segmental or lobar atelectasis was occasionally seen but this always responded to efficient physio therapy, and caused no anxiety. On the other hand, after esophagogastrostomy, some patients of comparable clinical status succumbed to a fulminating pneumonitis or bronchopneumonia which may well have been initiated by the re gurgitation and aspiration of gastric secretion from the transplanted viscus. The main problem presented by this technique is whether left colon will remain a functionally satisfactory replacement for the normal esophageal pump over a long period of time. Also, how to predict the functionally sluggish colon that fails to satisfy the patient's pleasure in eating and which leads occasionally to a clinical result, which is less than satisfactory, assuming that colonic con traction plays any part in the efficiency of the transplant. The incidence of this late result is low and the patients are still grateful, but any lack of perfection must be fully appraised and critically examined. Gone are the days when the main object of the surgeon was to get his patients out of hospital alive, or so we may hope. It is the long-term functional results of reconstructive surgery that must now become our concern and target. The longest follow-up period in this series has been 6 years and, although there has been no evidence of any functional deterioration over this period, 6 years is a short time in a patient's normal life span. A much longer follow-up survey is necessary before any final judgment can be passed on the clinical value of this method. The absence of any evidence of recurrent esophagitis has been gratifying. The lower end of the colon transplant is not readily accessible to direct exami nation but as yet no case has been encountered where the reflux of gastric secretion into the transplant has given rise to trouble. I t may be that the tech nique adopted in this series to discourage reflux by creating a valvular mech anism at the cologastric junction has been effective. Again, the mucus secreting
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January, 1965
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activity of the colon may protect it against peptic erosion. We know that in the days when gastrocolie fistulas were common the colonic mueosa adjacent to the fistula remained remarkably healthy. What transpires when one of these patients develops chronic ulcerative colitis? This question remains unanswered, but if and when colitis ever does supervene some insight into its etiology may then be gleaned. SUMMARY
1. The clinical applications of left colon transplants in the management of irreversible esophageal obstruction in 105 patients, and the early and late results, are reviewed. 2. Left colon transplantation satisfied the five criteria of successful esopha geal reconstruction. 3. The procedure permits a single-stage excision and reconstruction of the obstructed esophagus. 4. The left-sided thoracoabdominal approach allows a choice of two methods of restoring esophageal continuity, depending upon anatomical and pathological considerations revealed at operation. 5. On the evidence revealed by this investigation, left colon interposition is preferable to esophagogastrostomy, on the score of operative risks and im proved late results, in the management of benign esophageal stenosis. Esophago gastrostomy may still be the method of choice in the majority of cases of malignant obstruction. ADDENDUM
A further 13 esophageal reconstructions with left colon for benign esophageal strictures and congenital atresia of the esophagus have now been completed without any postoperative complications, bringing the over-all mortality rate down to 4.2 per cent. The preoperative use of neomycin or any other antibiotic to sterilize the bowel has now been discontinued as it appears to bo unnecessary. DISCUSSION DR. HASSAN N A J A P I , Chicago, 111.—I asked for permission to discuss this paper (a wonderful presentation by Mr. Belsey) in order to show you an unusual approach to the surgical repair of esophagocolic stricture following colon transplantation. [Slide] On the left of the slide, you see complete obstruction of the initial portion of the thoracic esophagus in a 20-year-old girl who developed extensive esophageal stricture following accidental ingestion of lye at the age of 14 years. At that time, she was in Europe. She came to the United States at the age of 19. An attempt to restore the gastroesophageal continuity by bringing the stomach up to the esophagus failed. She was then referred to the Presbyterian-St. Luke's Hospital. We saw her at the age of 20 years. At that time, she weighed 52 pounds and was cachectic. With gastrostomy feedings, her condition improved, and she underwent right hemicolon transplantation which was done substernally. Unfortunately, after the colon trans plantation, a leak developed at the upper anastomosis and was transient, but the stricture formation at the site of the anastomosis continued and progressed proximally into the esophagus and distally into the colon. [Slide] On your left, you see marked narrowing of the esophagocolic region made 8 months after colon transplantation. This progressed to almost complete obstruction 2 % years
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following the colon interposition. At this time, she weighed 70 pounds. She refused to be fed through a gastrostomy tube. I n spite of her precarious nutritional condition, we were forced to proceed with exploration, hoping we could resolve the situation with definitive procedure. At operation, through the left neck incision combined with longitudinal sternotomy, the stricture, cervical esophagus, and the mediastinal colon were exposed. The stricture was found to be 2% inches long, surrounded by extensive scarring and firm tissue; it immediately became evident that reanastomosis of the colon to the esophagus was impossible. As it seemed completely hopeless, and we were thinking in terms of utilizing one of many unsatisfactory measures for palliation, it suddenly occurred to us that perhaps by removing the taeniae coli, the mediastinal colon could be made longer, and would reach the upper cervical esophagus. Therefore, the taeniae coli, 5 or 6 inches long, were removed without damaging the mucosa, and the serosa of the colon was reapproximated at the two sides of the resected bed of the taeniae coli with interrupted silk sutures. Then the upper end of the colon could be readily brought up to the hypopharyngeal area. An anastomosis was made between the colon and the esophagus at the level of the cricoid cartilage. [Slide] The patient did extremely well. Here she is, 1 year after operation. She still lias a good-sized anastomosis at that level. Two and a half years after surgery there was no evidence of narrowing or stricture. I t is now 4 years after her operation. She now weighs 130 pounds, has married, and is pregnant and leading a normal life and eating a regular diet. I would like to emphasize Dr. Holinger's point in regard to postoperative esophageal dilatation. I would say that the major credit should go to the E N T department for their persuasive manner in doing the esophageal dilatation in this patient. At the present time, she passes a No. 36 bougie once a week at home, without coming to the hospital. She is seen at yearly intervals. DE. CHARLES PEARCE, New Orleans, La.—I would like to compliment Mr. Belsey on his presentation and on the excellent results he has obtained. I think there is an additional group of patients in whom colon interposition may prove useful, i.e., patients with carcinoma of the cervical esophagus or hypopharynx, particularly if they have received previous irradiation. Interposition of the colon was used, for example, in a 44-year-old man with extensive carcinoma of the entire cervical esophagus, hypopharynx, and larynx, as well as adjacent structures. Because of previous irradiation of the skin, a Wookey procedure was not considered feasible. Instead, at one operation, the structures of the anterior portion of the neck were excised en bloc, the right side of the colon was brought up with the attached terminal ileum to provide additional length, and the ileum was anas tomosed end-to-side to the hypopharynx. The patient gained 30 pounds within 4 months and was doing well when last seen, 1 year after operation. Leaving the terminal ileum attached to the colon provides additional length for high anastomosis, when necessary. I n 4 patients with strictures in the cervical esophagus and hypopharynx, we have used the right side of the colon with attached terminal ileum for side-to-side anastomosis to the hypopharynx. In all of them, results were excellent. DR. I V A N D. BARONOFSKY, San Diego, Calif .—I would like to disagree on a couple of things with Mr. Belsey, even though he is our invited guest, and I do apologize for dis agreeing. First of all, I do not believe it is necessary to one-stage these procedures, and also I don't think it necessary to resect the esophagus. I think it is entirely possible to just bypass some of these strictures and get an excellent result, especially in cases of lye strictures. Certainly in carcinoma of the esophagus in the middle or upper third, I think it is sometimes better to stage the procedure so that one can radiate first with half a cancerocidal dose, bypass with the left colon (which is the important point the speaker brought u p ) , radiate it again for about 2 weeks after the anastomosis has been completed, and then re move the esophagus in a simple procedure from the right side. I do appreciate Mr. Belsey's consummate skill in being able to do these anastomoses
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in the intratlioracic manner. However, for those of us who are not that capable, a breakdown of the intrapleural anastomosis can give what is commonly known in high academic circles as "a mess," whereas if the same breakdown occurs in the neck it closes in a few days. I also think the colon should be brought up in the substernal fashion without entering either pleura. DR. J O H N F . HIGGINSON, Santa Barbara, Calif.—I had not intended to discuss this paper but when I heard mentioned again by several of the preceding speakers the leaving-in of the bypassed long-standing strietured esophagus, I felt I should muddy the waters a little more, or at least arouse some concern regarding nonremoval. I had 1 of these patients who was 39 years of age when I first saw him. He had been esophagoscoped dozens of times and dilated hundreds of times for a lye stricture since childhood, by various men in Chicago, Los Angeles, and various other cities before I had the misfortune of being asked to treat him for almost total final obstruction. Attempted esophagoscopy shortly before I operated upon him did not yield any more information other than obstruction. Removal of the esophagus was planned and carried out with considerable difficulty, since the esophagus had been perforated several times during previous dilatations. The specimen yielded a shocking surprise in that it was a total mass of scar and car cinoma from bottom to top. I suppose most of these lye strictures probably can be safely bypassed and left unremoved, but I think it may be difficult to know or guess which can so be safely bypassed and which ones should be removed because of malignant potential. DR. ROBERT E. GROSS, Boston, Mass.—I would like to ask Mr. Belsey about his third point, when he said the technique should be applicable to infants and children. I am a little afraid of colon transplants in infants. We lost two babies a few months of age, so we have a rule not to do these colon transplants in patients who are under 1 year of age. I could not tell from the chart just how young the youngest patient was Mr. Belsey had operated upon. MR. B E L S E Y (Closing).—I was very much interested in the case of recurrent stenosis at the top of the colon transplant. I wonder whether that could have been due to some ischemic change leading to slow progressive fibrosis of the transplant. We have not seen that. Regarding Dr. Baronofsky's points, we are fundamentally opposed to staged operations which do not lead to the excision of the growth at the first stage. We have tried these in the past, and so often we have found that we have never gotten around to the second stage at all. Our philosophy regarding carcinoma of the esophagus is one of despair, in that we regard all esophageal surgery for carcinoma or malignant disease as purely palliative, with the sole objective of restoring the patient's ability' to swallow during his last remaining 12 months on this earth. However, every now and again you are lucky and you do cure a patient of his disease purely by accident. For that reason, we do like to excise the carcinoma rather than bypass it. We have had virtually no joy at all from irradiation of these growths. In regard to Dr. Baronofsky's point about leaks, I think as a result of my experience that colon is a far easier viscus to handle than is stomach or jejunum. I don't know why we don't get more leaks. I t is probably due to the fact t h a t the colon does not secrete peptic juice which can digest its own leak through some small defect between two adjacent sutures. As far as the transpleural approach to the esophagus is concerned, I think in 1964, with all the adjuncts of modern surgery and anesthesia, this does not add any additional risk to an operative procedure on the esophagus.
Bristol, England
Sponsored by O. Theron Clagett, M.D., Rochester,
Minn.
M
OST obstructive esophageal lesions calling for excision and reconstruction of the gullet occur at an age when the sole remaining physical pleasures in life for the majority of patients are eating and drinking. The patient is the final arbiter in assessing the clinical value of any method of esophageal recon struction. The radiological demonstration of the passage of a bolus from the mouth to the stomach, the deferment of starvation and dehydration, are not enough to satisfy the patient. Only when his ability to eat and drink with pleasure and satisfaction has been fully restored will the patient consider the ordeal to have been worth while. The critical appraisal of the results of esophageal reconstruction, as revealed by long-term follow-up surveys in the out-patient clinic, suggests that existing operative procedures are far from satisfactory when viewed in the light of the' patient's subjective experience dur ing the act of eating. A satisfactory reconstructive technique must fulfill certain criteria: (1) the mortality and morbidity risks of the operation must be acceptable; (2) it must be possible to excise the obstructing lesion as radically as necessary and reconstruct the gullet in one stage; (3) sufficient viscus must be available to replace the entire esophagus when necessary; (4) the method must be appli cable to infants and children as well as adults; and (5) the relief of the pa tient's dysphagia must be complete and lasting. Kecently there has emerged an increasing dissatisfaction with the long-term results of esophagogastric anastomoses. This can be a satisfactory operation, and in some cases may fulfill all the criteria mentioned. In approximately 27 per cent of the patients who survive more than 6 months, reflux esophagitis will develop above the anastomosis and the discomfort and dysphagia may recur. In a higher percentage of cases the patient will experience varying degrees of distress due to postural regurgitation of gastric secretion and bile, reduced gastric capacity, and nutritional disorders. This communication records a clinical trial of alternative methods of re construction with particular emphasis on the long-term functional results. Jejunal transplants were given a clinical trial but were found unsatisfactory Prom the Frenchay Hospital, Bristol, England. Read at "the Forty-fourth Annual Meeting of The American Association for Thoracic Surgery, Montreal, Canada, April 27, 28, and 29, 1964. 33
J. Thoracic aiul Cardiovas. Surg.
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on two counts. First, in infants and children the blood supply to the jejunum may be precarious and long segment transplants hazardous. Second, a trouble some alkaline esophagitis may occur proximal to an esophagojejunal anasto mosis. The author has abandoned the use of pedicle jejunal transplants except to bypass nonresectable malignant growths of the cardia and lower third of the esophagus. The terminal ilium and ascending colon have been widely used to bypass esophageal growths. The transplant is usually passed up through the anterior mediastinum and interposed between the cervical esophagus and stomach. This technique is essentially a palliative procedure only; excision of the esophageal stricture involves a further major operation at a later date. Two-stage opera tions for malignant disease are unsatisfactory unless the growth can be excised at the first stage. The transplantation of the left half of the transverse colon and the splenic flexure, with its blood supply maintained from the left colic artery, has certain advantages over other methods. An isoperistaltic transplant of sufficient length to replace the entire esophagus is available. The blood supply is robust, even in infants and small children. Through a left thoracoabdominal approach, a onestage excision and reconstruction can be carried out for strictures or growths of the esophagus situated at any level. In dealing with growths of the upper third, or the cervical esophagus, the proximal anastomosis can be performed easily through a separate cervical incision after closure of the thoracotomy wound. The left-sided approach has a further advantage. In the event of some anatomical or pathological feature, such as an abnormality of the marginal artery of the colon or advanced mesenteric endarteritis, contraindicating the use of colon for the reconstruction, an alternative procedure in the form of an esophagogastric anastomosis is immediately available through the same incision. CLINICAL MATERIAL
Esophageal reconstruction with left colon transplant has now been carried out in 105 patients, ranging in age from 15 months to 78 years. The longest follow-up period is now 6 years, and 85 of the patients have been observed for longer than a year. The pathological conditions demanding resection in this series are tabulated in Table I. Of the 82 patients with benign fibrous strictures of the esophagus, TABLE I. L E F T COLON TRANSPLANTS FOR ESOPHAGEAL REPLACEMENT
Total number of cases Benign fibrous strictures Chronic reflux esophagitis Lye strictures Congenital esophageal atresia Malignant strictures of the esophagus
79 3
82 10 13
Adults, 16 to 78 years Infants and children, 15 months to 10 years
74 31
"Short segment" colon transplants "Long segment" colon transplants
70 29
105
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in 79 the stenosis was due to severe chronic reflux esophagitis secondary to an hiatus hernia. In 4 of these cases a previous esophagogastrectomy and anasto mosis had been performed, with the subsequent development of recurrent esophagitis above the anastomosis in spite of a two thirds gastric resection, bilateral vagotomy, pyloroplasty, and a high esophagogastric anastomosis—all recognized methods of discouraging recurrent esophagitis. In these 4 cases the original anastomosis was dismantled, the tubular gastric remnant was returned to the abdomen, a further esophageal resection was performed and the gullet was reconstructed by means of a long segment colon transplant, the upper anas tomosis to the cervical esophagus being performed in the neck through a separate incision. In 2 patients a Heller operation for associated achalasia had been performed previously, with the subsequent development of reflux esophagitis and fibrous stenosis. Two patients had undergone a partial gastrectomy of the Polya type, in an attempt to control the esophagitis. This operation enjoyed a brief vogue of popularity but has now been abandoned in most centers due to its failure to prevent the subsequent development of fibrous esophageal strictures. Under these circumstances an esophagogastric anastomosis following resection of the stricture may be technically impossible and reconstruction with a colon or jejunal transplant becomes obligatory. In 3 patients the obstruction resulted from extensive or multiple chemical strictures of the gullet, either accidental or suicidal in origin. Thirty-one of the reconstructions were performed in infants or children under the age of 10 years. Ten of the infants were cases of congenital atresia of the esophagus in whom no primary anastomosis was possible because of the length of the gap between the two esophageal segments and in whom a tem porary esophagostomy and gastrostomy were performed at the first operation when the tracheoesophageal fistula was closed shortly after birth. Subsequently a reconstruction of the entire intrathoracic esophagus was carried out with the use of a long segment colon transplant, when the infant was between 15 months and 2 years old. The 105 reconstructions performed in this series of cases fall into two groups, depending upon the length of colon transplanted and the position of the proximal anastomosis below or above the aortic arch. In 76 cases, a "short seg ment" transplant was used to replace the lower half of the esophagus and the proximal anastomosis was performed just below the aortic arch. In 29 cases, a "long segment" transplant was used to replace the greater portion of the esopha gus and the proximal anastomosis was performed above the aortic arch, either at the apex of the thoracic cavity (7 cases) or to the cervical esophagus through a separate cervical incision (22 cases). The latter technique is advocated, as be ing easier and less time-consuming. The indications for the long segment operation in cases of benign stenosis, other than cases of chemical strictures, were recurrent esophagitis and stenosis following a previous esophagogastrectomy, and cases in which a developmentally abnormal lower esophagus, lined with gastric mucosa, had been complicated by esophagitis and fibrous stenosis occurring just above the mucosal junction situa ted at an abnormally high level in the region of the aortic arch. Of the 13 cases of malignant stenosis of the esophagus, in 10 the growth was
36
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Pig. 1.—Achalasia of the cardia. Short segment colon transplant for fibrous stenosis at the cardia after unsuccessful Heller's operation and reflux esophagitis.
Pig. 2.—Short segment colon transplant for multiple lye strictures of the esophagus. The upper stricture was excised and continuity restored by end-to-end esophageal anastomosis.
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situated in the middle or upper third of the organ. For carcinomata of the midthird, an esophagogastric resection and anastomosis performed through the right pleural cavity is a satisfactory operation. However, in some cases the right-sided approach may be contraindicated by previous pleural sepis and its sequelae. Moreover, in some instances the stomach is so contracted as a result of chronic starvation that insufficient viscus is available to permit a satisfactory reconstruc tion at an adequate level above the resected growth. In these circumstances a long segment left colon transplant is the better procedure. PREOPERATIVE PREPARATION
In preparing a patient for a colon transplant procedure, great care must be taken to avoid disturbing the normal bowel routine for that particular patient. Aperients and colon washouts are avoided. The patient is placed on a high pro tein, low residue diet for 7 to 14 days prior to operation. Dental toilet, physiotheraphy, and preliminary blood transfusion, when indicated, are carried out during this period. Neomycin is administered for the last 48 hours before opera tion. In 6 cases a colon transplant was performed successfully without any prep aration at all; hard scybala were milked out of the transplant before the anas tomoses were performed but no other precautions against infection were taken. The constipated colon is easier to cleanse than the colon reduced to the state of a sewage works by too much attention.
Fig. 3.—A, Benign fibrous stricture of the esophagus secondary to hiatus hernia prior to esophagogastrectomy. B, Recurrent esophagitis and stenosis above the esophagogastric anas tomosis. C, Long segment colon transplant after dismantling the previous anastomosis, further esophageal resection, and restoration of the gastric remnant to the abdominal cavity.
Fig. 4.—A, Fibrous stenosis of the esophagus above the mucosal Junction in a case of hiatus hernia and esophagus lined with gastric mucosa. B, Following esophagectomy, reduction of the hiatus hernia and long segment colon transplant. C, Another example of a long segment colon transplant for a high benign stricture.
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03 00
Vol. 49, No. I
J a n u a r y , 1965
RECONSTRUCTION O F ESOPHAGUS
39 UxJ
THE SHORT SEGMENT OPERATION
With the patient in the right lateral position, the left chest is entered through the sixth intercostal space and the incision carried forward across the costal margin to the lateral border of the rectus sheath. The diaphragm is partial ly separated from the chest wall at its periphery rather than incised across the dome. A suitable length of colon is prepared by division of the marginal artery just distal to the two brances of the left colic artery, or between them, and again in the region of the middle colic artery (Pig. 5). This segment of colon is isola ted on a vascular pedicle of the left colic artery. Continuity of the colon is re stored by end-to-end anastomosis. A pyloromyotomy is performed. The cardia is divided and closed, and the esophagus is resected from the cardia to a point
Fig-. 5.—Blood supply to the colon showing- points of division for short and long segment colon transplants. The dotted lines represent inconstant vessels which can safely be divided. A, Line of incision for short segment colon transplant. B, Line of incision for long segment colon transplant.
well above the obstruction. In the case of a malignant stricture of the esophagus, it is essential that the proximal line of esophageal section be at least 2 inches above the level of the growth to reduce the risk of further obstruction from a local recurrence. The distal end of the transplant is anastomosed to the back of the stomach a third of the distance between the cardia and pylorus, thus maintaining an intra-abdominal segment of transplant. Compression of this segment by the intra-abdominal pressure forms an effective valvular mecha nism that discourages or prevents the reflux of gastric secretion into the trans plant. The proximal end of the transplant is brought up behind the fundus, through the hiatus, and anastomosed end-to-end to the mid-third of the esopha gus close to the aortic arch. All anastomoses are performed with a one layer technique with the use of interrupted sutures of stainless steel wire. The trans-
Pig. 6.—Three examples of short segment colon transplant for benign strictures. Note the compression of the subdiaphragmatic portion of the colon transplant by the intra-abdominal pressure.
two
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o
Fig. 7.—Long segment colon transplant for carcinoma of the upper third of the esophagus. Lateral roentgenogram shows the position of the transplant in the posterior mediastinum.
plant is loosely sutured to the margins of the esophageal hiatus to prevent tendency for redundant transplant to herniate upward into the thorax. tension on the vascular pedicle of transplant must be avoided. Finally, fundus of the stomach is anchored with two rows of mattress sutures to undersurface of the diaphragm which is then reattached to the chest wall.
any All the the
THE LONG SEGMENT OPERATION
When a long segment of colon is to be interposed between the cervical esoph agus and stomach, it is advisable to divide the descending colon distal to both branches of the left colic artery. The transverse colon is divided between the two branches of the middle colic artery. The segment of colon isolated in this manner is usually adequate for total replacement, but if more colon is needed the middle colic artery can be divided proximal to its point of division and the transverse colon divided further to the right. The operation then pro ceeds in the same manner as the short segment operation up to the stage of the proximal anastomosis. The proximal end of the transplant is brought up through the posterior mediastinum deep to the aortic arch. In some of the earlier cases in this series the anastomosis was performed at the apex of the pleural cavity, with difficulty, unless an additional intercostal incision was made. Recent prac tice has been to close temporarily the proximal end of the transplant and suture
BELSEY
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J. Thoracic and Cardiovas. Surg.
it loosely to the stump of the esophagus after the major part has been excised. The chest is then closed. The patient is turned on his back and, through an oblique, left-sided, cervical incision along the anterior border of the sternomastoid muscle, the cervical esophagus is dissected free and drawn up to the surface of the wound along with the attached proximal end of the transplant. The latter is then opened, the esophagus trimmed back, and end-to-end onelayer anastomosis is performed with great ease. Because of the obliquity of the superior thoracic inlet, a transplant that will reach the apex of the pleural cavity will be adequate for a cervical anastomosis. When a total esophageal reconstruction for congenital atresia is being performed in an infant, the technique is modified. A long segment transplant is prepared in the usual way, brought up through the left pleural cavity lateral to the aortic arch (as there is no mediastinal tunnel) and closed. A tunnel is made up into the base of the neck. The end of the transplant is drawn up into this tunnel by two wire sutures which are brought out onto the surface of the neck just below the esophagostomy and tied. The chest is then closed. Ten to 14 days later the esophagostomy sinus is excised through a small transverse cervical incision; the end of the transplant is drawn up into the wound by thte two sutures, opened, and anastomosed end-to-end to the open end of the upper esophageal segment. Gastrostomy feeds are continued between the two stages This two-stage operation is well tolerated by infants. In adults a single-stage reconstruction is preferable. In both the short and long segment operations the attachment of the trans plant to the margins of the esophageal hiatus, and of the fundus of the stomach to the undersurface of the diaphragm, are important steps in the operation. Herniation of redundant colon or the fundus of the stomach up into the chest will result in kinking of the transplant and tension on its vascular pedicle. which may jeopardize the viability of the transplant. POSTOPERATIVE CARE
Parenteral fluids are administered for the first 24 hours. During the second day, 1 ounce of water is taken by mouth each hour, and on the third day this intake is doubled. On the fourth day the fluid intake by mouth is increased to 3 ounces hourly and milk drinks, tea, coffee, and fruit drinks are permitted. Soft solids are given by mouth on the fifth day and the intake of solid food is steadily increased until the tenth day when the patient is back on a normal diet. Antibiotics are not administered routinely in the postoperative period and are used only when a specific indication arises. The bowels begin to move nor mally about the fifth postoperative day. Aperients and enemas are avoided. In cases of atresia, the gastrostomy tube is removed as soon as the proximal esophagocolic anastomosis is soundly healed and normal mouth feeding has become established. CONTRAINDICATIONS
Variation in the anatomy of the marginal artery to the splenic flexure of the colon may be encountered. The vessel may break up into a plexus of
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small vessels and the blood supply from the left colic artery through this plexus may be inadequate to maintain the viability of the proximal end of the trans plant. The presence of marked mesenteric arteriosclerosis, as manifested by hard, palpably thickened, vessels with little or no pulsation, is a further contrain dication. The blood supply to the colon transplant, unlike that to the stomach, is dependent upon one vessel, and thrombosis resulting from minor trauma to the vessel will inevitably lead to necrosis of the transplant. Under these cir cumstances it is wiser to abandon the procedure and resort to the stomach, with its less vulnerable blood supply, for the reconstruction. In 7 patients a change in plan was made at operation for these reasons. No case has so far been encountered in which the presence of intrinsic in flammatory disease of the colon has precluded its transplantation. What might transpire were a patient to develop chronic ulcerative colitis following a colon transplant operation is open to conjecture. Inadequate or improper preparation of the large bowel may persuade the surgeon to abandon the procedure and resort to an esophagogastric anastomosis. The overzealous use of aperients and colon washouts is the worst possible pre lude to this form of large bowel surgery. POSTOPERATIVE
MORTALITY
In this series of 105 esophageal reconstructions by colon transplantation there were five postoperative fatalities, a mortality rate of slightly under 4.8 per cent. Three deaths followed resection and reconstruction of the esophagus for benign stricture, one for carcinoma of the esophagus, and one for congenital atresia of the esophagus. The mortality rate following the long segment opera tion was not appreciably higher than that following the short segment pro cedure. TABLE IT. CAUSES OF D E A T H FOLLOWING COLON TRANSPLANT TOR ESOPHAGEAL RECONSTRUCTION* NO.
1
|
LESION
|
CAUSE OP DEATH
Carcinoma mid-third
Calcine aortic stenosis and mitral stenosis 2 Benign fibrous strictures Infarction and necrosis of trans plant 3 Benign fibrous strictures Infective hepatitis 4 Benign fibrous strictures Streptomycin reaction, anuria 5 Congenital esophageal atresia Small bowel obstruction •Number of reconstructions, 105; 5 postoperative deaths (4.8%).
The causes of death were as follows: 1. Male, 57 years of age, died on thirteenth postoperative day from gangrene of the colon transplant. This patient had advanced generalized and mesenteric arteriosclerosis and had previously undergone a mid-thigh leg amputation for gangrene. Herniation of the fundus of the stomach through the hiatus—the fundus had not been sutured to the undersurface of the diaphragm—probably precipitated thrombosis of the vascular pedicle of the transplant. A definite contraindication to colon transplant had been ignored in this case.
Fig. 8. -Redundancy of the colon transplant and herniation into the chest due to lack of hiatal fixation. The illustration on the right shows herniation of the stomach through the hiatus from the same cause.
E5
** #*
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January, 1965
2. Male, 63 years of age, died 2 weeks after operation from infective hepatitis, probably as a result of a preoperative blood transfusion. No other complication was present. 3. Female, 59 years of age, died on seventh postoperative day from anuria and bronchopneumonia secondary to a severe streptomycin reaction. All anastomoses were satisfactory. 4. Male, 53 years of age, died suddenly from cardiac arrest on third postoperative day following resection for an advanced carcinoma of the mid-third of the esophagus associated with achalasia of the cardia. Autopsy revealed gross calcine aortic stenosis and chronic rheumatic mitral disease but no other complications. 5. Male child, 2 years of age, died 2 months following reconstruction for congenital atresia of the esophagus from small bowel obstruction due to adhesions. This patient also suffered from congenital stenosis of the trachea and hydrocephalus.
The first and fifth fatalities were undoubtedly related to the nature of the operation. The first- patient should not have been submitted to this procedure in the light of further experience. In the other 3 cases, death was not related to the type of operation and could have followed any operative pro cedure. There has been one postoperative fatality in the last 80 cases. MORBIDITY
RATE
Nonfatal complications are listed in Table I I I . In 2 cases the colon trans planted necrosed due to venous obstruction and infarction. In neither case had the transplant been anchored to the margins of the hiatus and herniation upward into the pleural cavity led to tension on, and obstruction of, the veins returning from the transplant. I n both instances the situation was successfully resolved by excision of the transplant and replacement by an esophagogastric anastomosis, as an emergency procedure.
TABLE I I I .
NONFATAL POSTOPERATIVE COMPLICATIONS FOLLOWING L E F T COLON TRANSPLANT
Temporary cervical salivary fistulas Infarction and necrosis of colon transplant Kinking and obstruction of redundant intrathoracic colon Pleural infection Superficial wound infection
2 2 1 3 2
The two instances of cervical salivary fistulas occurred in infants in whom a long segment transplant had been used in a staged reconstruction for con genital esophageal atresia. The leaks occurred from the cervical anastomoses, lasted for a few days only, and then healed spontaneously. Upward herniation of a redundant transplant and obstruction by kinking occurred in 1 case, and necessiated thoracotomy and reduction of the redundant colon back into the abdominal cavity. This complication has been eliminated by suturing the transplant to the margins of the hiatus. Approximately one half of the adult patients experienced mild diarrhea during the first 2 weeks following operation but no subsequent bowel irregu larity.
BELSEY
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J. Thoracic and Cardiovas. Surg.
Convalescence was completely uneventful in 90 of the 100 operative sur vivors; only mild complications occurred in an additional 7 cases. There were no intrathoracic or intra-abdominal anastomotic leaks, no peritoneal sepsis, and only 3 cases of pleural infection due to operative contamination. Despite a longer and more complicated operation involving three anastomoses as against the single anastomosis in a gastric reconstruction, the postoperative course was conspicuously smoother than that normally encountered following the latter procedure; there was no instance of postoperative regurgitation, with the attendant risk of aspiration pneumonitis, a serious and not uncommon com plication after an esophagogastrostomy. LATE RESULTS
Ninety-eight patients were available for study with a view to assessing the long-term functional results of esophageal reconstruction by colon trans plants. Eighty-six patients have been followed for over a year. The main in terest in this study is the long-term follow-up of cases treated for benign esophageal obstruction. The surgery of malignant esophageal obstruction is es sentially palliative and few patients will survive long enough for the late results to be of clinical significance.
TABLE IV.
LATE
EESULTS*
Esophagogastric Besection and Anastomosis (1950-1960) 96 cases—7 postoperative deaths (7.3%) ; 4 anastomotic leaks 89 operative survivors: " A " : 39 ( 4 4 % ) : symptom-free " B " : 27 ( 2 9 % ) : mild symptoms; patient satisfied " C " : 17 ( 2 0 % ) : recurrent esophagitis; dilatation, pyloromyotomy " D " : 6 ( 7%) : recurrent stenosis, further resection necessary (4 colon transplants, 1 more radical esophago gastric resection, 1 local resection of stricture) Colon Transplants 92 cases—4 postoperative deaths (4.3%) ; no intrathoracic leaks 88 operative survivors (2 operative failures) " A " : 71 ( 8 1 % ) : symptom-free ) No recurrent reflux, " B " : 15 (17%) : mild symptoms ( esophagitis, or stenosis. ♦Review of comparative results of esophagogastric anastomosis and left colon transplant following esophageal resection and reconstruction for benign esophageal obstruction.
The only worth-while indication of the clinical value of any method of esophageal reconstruction is the patient's satisfaction or dissatisfaction with the procedure. "The customer is always right," and if the customer is satisfied the operation has succeeded. The object of the exercise is to restore the patient's ability and pleasure in eating and drinking. The long-term functional result in the series under review have largely been assessed on this basis in the followup clinic. The appearances seen in postoperative barium studies bear little relation ship to the clinical success of the procedure. "With the patient in the erect position, barium passed to the stomach with only slight delay at the hiatus or
Vol.49, No. 1 January, 1965
EECONSTEUCTION OF ESOPHAGUS
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the cologastric anastomosis, or both. The degree of delay was not necessarily related to the presence of redundant loops of colon above these points. With the patient in the horizontal position or with the head tilted 20 degrees down ward, barium passed without delay from esophagus to colon transplant. On repeated swallowing, in patients with a short colon transplant, barium filled the transplant and then entered the stomach. In patients with a long colon transplant, barium filled the transplant either down to about the level of the carina or, in some, down to the level of the diaphragm, after which the upper esophagus failed to empty completely into the colon and the patient complained of feeling "full up." As the upper end of colon transplant became filled, re flux of barium up the lower portion of the esophagus occurred frequently as the esophagus relaxed. No reflux into the pharynx was seen. No movement was seen in the colon transplant at any time. A variable amount of residual barium remained in the colon transplant for 1 to 2 hours. The transplanted colon appears to act as a passive conducting tube only. Barium passes through it primarily under the influence of gravity but in the horizontal position the peristalsis of the esophagus above the transplant is sufficient to force barium through a short length of colon. Normal drinking is, therefore, possible in the horizontal or head down position if the transplant is short. The final diameter of the transplant varies within wide limits and is un predictable before or at operation. Again, the functional efficiency of the transplant does not appear to be affected by the dilatation occasionally seen. Colons undoubtedly vary in intrinsic activity and work capacity; an attempt to assess this charasteristic may play an increasingly important part in the selection of patients for colon' transplantation in the future. The less than satisfactory long-term results in this series occurred in 17 per cent of the cases and were characterized by a sensation that the bolus was slow in passing down the gullet and necessitated that meals be consumed slowly, although no regurgitation occurred and a full normal diet could be taken. This occurred only in elderly patients after a long segment transplant. One patient graphically described the experience as a "sensation of frustration in her chest whilst eating." Children and young adults never displayed any delay in swallowing, even after a total esophageal reconstruction. This result, when it occurs, is undoubtedly due to a sluggishly acting colon rather than any form of mechanical obstruction. Eighty-six cases of colon transplantation for benign esophageal stenosis have been followed up for varying periods up to 6 years. Barium swallow examinations have been performed at regular yearly intervals. There has been no justification for submitting any of these patients to repeat esophagoseopies. None of these patients has complained of recurrent heartburn or acid reflux, vomiting, or postural regurgitation; nor has there been any symptomatic or radiological evidence of any recurrent esophagitis or stenosis. No additional surgery or dilatation procedures have been necessary in this group. Of the 12 patients who survived long segment colon transplation for high malignant strictures of the esophagus, palliation was satisfactory. One patient is alive and free from recurrence 4 years after resection. Ten have succumbed
Fig. 9.—Short segment colon transplant for benign esophageal strictures; shows variation in diameter of the transplant. In all 3 cases the functional result was equally satisfactory.
u J° n C/in*
< 2 u
w
00
Pig. 10.—Three cases of esophageal reconstruction by long segment colon transplant for congenital atresia of the esophagus. Barium studies made 6 years following the operation. In C, there is some redun dancy of the transplant.
o
► ^
o a
o
V-
o
O
d q
GO
ts o o
Fig. 11.—Three examples of long segment colon transplants for carcinomata of the upper two thirds of the esophagus.
fc
t-1 w tef
o
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RECONSTRUCTION OF ESOPHAGUS
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to a recurrence of the growth 5 to 15 months following the operation. In only 1 case was there any recurrence of the dysphagia due to invasion of the colon transplant by a mcdiastinal metastasis. One of the main objects of this exercise was to determine the relative merits and demerits of esophageal reconstruction by a colon transplant as against those of reconstruction with a gastric tube when performed on a similar group of patients by the same surgical team. The potential operative risks would appear to be higher in colon transplantation in view of the greater length and complexity of the procedure with three anastomoses involved. In fact this fear was unjustified; the operative mortality rate (4.8 per cent) was lower, and the average convalescence was significantly smoother. The main difference was observed in the long-term results. After an esophagogastrectomy, 27 per cent of patients developed recurrent esophagitis above the level of the anastomosis despite a two thirds gastric resection, a gastric drainage procedure, and a high anastomosis. Seven per cent needed further major surgery for re current stenosis. Many of the patients complained of postural regurgitation and a reduced capacity for food, which necessitated modification of their dietetic regimen. As yet no satisfactory method of creating a valvular mechanism at the anastomosis has been devised. Children subjected to this procedure showed retardation of growth for 2 to 3 years following operation but subsequently caught up with the other members of the family. This has not been seen follow ing a colon transplant. On the other hand, an esophagogastrostomy is a quick, simple procedure involving but a single anastomosis and is well tolerated by elderly or depleted patients as far as operative shock is concerned. However, a significant incidence (4 per cent) of anastomotic leaks occur in the postoperative period and this complication is usually catastrophic, although an occasional patient can be saved by immediate thoracotomy and revision of the anastomosis. As far as the long-term results are concerned, none of this group experienced any delay in swallowing, as occasionally experienced by the colon transplant patients, in the absence of recurrent esophagitis. The results of this comparative investigation are summarized in Table IV. The cases of esophagogastrectomy were a consecutive series treated between 1950 and 1959, at which time colon transplantation was not used as a routine alternative procedure, so the two series relate to comparable clinical material. As a result of the experience gained during this investigation, the policy in the Regional Thoracic Surgical Unit in Bristol in regard to the management of benign esophageal obstruction has now crystallized along the following lines. For congenital esophageal atresia, long segment left colon transplantation is the only method of staged reconstruction employed. For restoring esophageal continuity following resection of fibrous strictures due to reflux esophagitis or chemical burns, left colon transplantation is the method preferred whenever the blood supply to the splenic flexure of colon is adequate to support the trans plant. Following esophagectomy for malignant disease, esophagogastrostomy is the method of choice and, at present, a left colon transplant is used only when the growth is situated in the upper third of the organ or when a contracted
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J. Thoracic and Cardiovas. Surg.
"starvation" stomach is inadequate to bridge the gap. The late incidence of re flux esophagitis following this operation is of little practical importance in cases of malignancy. The surprising feature that emerged during this study was the benign con valescence that followed a complicated procedure taking 3 to 4 hours to com plete, often in elderly and depleted patients. It suggests that colon is a far easier viscus to handle in this context than stomach. There were no intrathoracic leaks in this series, whereas in a comparable series of esophagogastrostomies there was a 4.5 per cent incidence of anastomotic leaks. It has long been the author's impression that the secretory activity of the stomach itself is frequently re sponsible for the leak. A trickle of peptic juice through a minute defect at the anastomotic suture line and digestion of the adjacent tissues might well be the starting point of a clinical leak with all its catastrophic implications. The lack of peptic ferment in the secretion of the left colon may well account for the ease with which satisfactory and safe anastomosis can be achieved with a simple one-layer technique when using left colon transplantation for esophageal re construction. Another significant feature of the early postoperative course 'was the absence of regurgitation and severe pulmonary complications. Basal segmental or lobar atelectasis was occasionally seen but this always responded to efficient physio therapy, and caused no anxiety. On the other hand, after esophagogastrostomy, some patients of comparable clinical status succumbed to a fulminating pneumonitis or bronchopneumonia which may well have been initiated by the re gurgitation and aspiration of gastric secretion from the transplanted viscus. The main problem presented by this technique is whether left colon will remain a functionally satisfactory replacement for the normal esophageal pump over a long period of time. Also, how to predict the functionally sluggish colon that fails to satisfy the patient's pleasure in eating and which leads occasionally to a clinical result, which is less than satisfactory, assuming that colonic con traction plays any part in the efficiency of the transplant. The incidence of this late result is low and the patients are still grateful, but any lack of perfection must be fully appraised and critically examined. Gone are the days when the main object of the surgeon was to get his patients out of hospital alive, or so we may hope. It is the long-term functional results of reconstructive surgery that must now become our concern and target. The longest follow-up period in this series has been 6 years and, although there has been no evidence of any functional deterioration over this period, 6 years is a short time in a patient's normal life span. A much longer follow-up survey is necessary before any final judgment can be passed on the clinical value of this method. The absence of any evidence of recurrent esophagitis has been gratifying. The lower end of the colon transplant is not readily accessible to direct exami nation but as yet no case has been encountered where the reflux of gastric secretion into the transplant has given rise to trouble. I t may be that the tech nique adopted in this series to discourage reflux by creating a valvular mech anism at the cologastric junction has been effective. Again, the mucus secreting
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January, 1965
RECONSTRUCTION O F ESOPHAGUS
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activity of the colon may protect it against peptic erosion. We know that in the days when gastrocolie fistulas were common the colonic mueosa adjacent to the fistula remained remarkably healthy. What transpires when one of these patients develops chronic ulcerative colitis? This question remains unanswered, but if and when colitis ever does supervene some insight into its etiology may then be gleaned. SUMMARY
1. The clinical applications of left colon transplants in the management of irreversible esophageal obstruction in 105 patients, and the early and late results, are reviewed. 2. Left colon transplantation satisfied the five criteria of successful esopha geal reconstruction. 3. The procedure permits a single-stage excision and reconstruction of the obstructed esophagus. 4. The left-sided thoracoabdominal approach allows a choice of two methods of restoring esophageal continuity, depending upon anatomical and pathological considerations revealed at operation. 5. On the evidence revealed by this investigation, left colon interposition is preferable to esophagogastrostomy, on the score of operative risks and im proved late results, in the management of benign esophageal stenosis. Esophago gastrostomy may still be the method of choice in the majority of cases of malignant obstruction. ADDENDUM
A further 13 esophageal reconstructions with left colon for benign esophageal strictures and congenital atresia of the esophagus have now been completed without any postoperative complications, bringing the over-all mortality rate down to 4.2 per cent. The preoperative use of neomycin or any other antibiotic to sterilize the bowel has now been discontinued as it appears to bo unnecessary. DISCUSSION DR. HASSAN N A J A P I , Chicago, 111.—I asked for permission to discuss this paper (a wonderful presentation by Mr. Belsey) in order to show you an unusual approach to the surgical repair of esophagocolic stricture following colon transplantation. [Slide] On the left of the slide, you see complete obstruction of the initial portion of the thoracic esophagus in a 20-year-old girl who developed extensive esophageal stricture following accidental ingestion of lye at the age of 14 years. At that time, she was in Europe. She came to the United States at the age of 19. An attempt to restore the gastroesophageal continuity by bringing the stomach up to the esophagus failed. She was then referred to the Presbyterian-St. Luke's Hospital. We saw her at the age of 20 years. At that time, she weighed 52 pounds and was cachectic. With gastrostomy feedings, her condition improved, and she underwent right hemicolon transplantation which was done substernally. Unfortunately, after the colon trans plantation, a leak developed at the upper anastomosis and was transient, but the stricture formation at the site of the anastomosis continued and progressed proximally into the esophagus and distally into the colon. [Slide] On your left, you see marked narrowing of the esophagocolic region made 8 months after colon transplantation. This progressed to almost complete obstruction 2 % years
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following the colon interposition. At this time, she weighed 70 pounds. She refused to be fed through a gastrostomy tube. I n spite of her precarious nutritional condition, we were forced to proceed with exploration, hoping we could resolve the situation with definitive procedure. At operation, through the left neck incision combined with longitudinal sternotomy, the stricture, cervical esophagus, and the mediastinal colon were exposed. The stricture was found to be 2% inches long, surrounded by extensive scarring and firm tissue; it immediately became evident that reanastomosis of the colon to the esophagus was impossible. As it seemed completely hopeless, and we were thinking in terms of utilizing one of many unsatisfactory measures for palliation, it suddenly occurred to us that perhaps by removing the taeniae coli, the mediastinal colon could be made longer, and would reach the upper cervical esophagus. Therefore, the taeniae coli, 5 or 6 inches long, were removed without damaging the mucosa, and the serosa of the colon was reapproximated at the two sides of the resected bed of the taeniae coli with interrupted silk sutures. Then the upper end of the colon could be readily brought up to the hypopharyngeal area. An anastomosis was made between the colon and the esophagus at the level of the cricoid cartilage. [Slide] The patient did extremely well. Here she is, 1 year after operation. She still lias a good-sized anastomosis at that level. Two and a half years after surgery there was no evidence of narrowing or stricture. I t is now 4 years after her operation. She now weighs 130 pounds, has married, and is pregnant and leading a normal life and eating a regular diet. I would like to emphasize Dr. Holinger's point in regard to postoperative esophageal dilatation. I would say that the major credit should go to the E N T department for their persuasive manner in doing the esophageal dilatation in this patient. At the present time, she passes a No. 36 bougie once a week at home, without coming to the hospital. She is seen at yearly intervals. DE. CHARLES PEARCE, New Orleans, La.—I would like to compliment Mr. Belsey on his presentation and on the excellent results he has obtained. I think there is an additional group of patients in whom colon interposition may prove useful, i.e., patients with carcinoma of the cervical esophagus or hypopharynx, particularly if they have received previous irradiation. Interposition of the colon was used, for example, in a 44-year-old man with extensive carcinoma of the entire cervical esophagus, hypopharynx, and larynx, as well as adjacent structures. Because of previous irradiation of the skin, a Wookey procedure was not considered feasible. Instead, at one operation, the structures of the anterior portion of the neck were excised en bloc, the right side of the colon was brought up with the attached terminal ileum to provide additional length, and the ileum was anas tomosed end-to-side to the hypopharynx. The patient gained 30 pounds within 4 months and was doing well when last seen, 1 year after operation. Leaving the terminal ileum attached to the colon provides additional length for high anastomosis, when necessary. I n 4 patients with strictures in the cervical esophagus and hypopharynx, we have used the right side of the colon with attached terminal ileum for side-to-side anastomosis to the hypopharynx. In all of them, results were excellent. DR. I V A N D. BARONOFSKY, San Diego, Calif .—I would like to disagree on a couple of things with Mr. Belsey, even though he is our invited guest, and I do apologize for dis agreeing. First of all, I do not believe it is necessary to one-stage these procedures, and also I don't think it necessary to resect the esophagus. I think it is entirely possible to just bypass some of these strictures and get an excellent result, especially in cases of lye strictures. Certainly in carcinoma of the esophagus in the middle or upper third, I think it is sometimes better to stage the procedure so that one can radiate first with half a cancerocidal dose, bypass with the left colon (which is the important point the speaker brought u p ) , radiate it again for about 2 weeks after the anastomosis has been completed, and then re move the esophagus in a simple procedure from the right side. I do appreciate Mr. Belsey's consummate skill in being able to do these anastomoses
Vol. 49, No. l January, 1965
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in the intratlioracic manner. However, for those of us who are not that capable, a breakdown of the intrapleural anastomosis can give what is commonly known in high academic circles as "a mess," whereas if the same breakdown occurs in the neck it closes in a few days. I also think the colon should be brought up in the substernal fashion without entering either pleura. DR. J O H N F . HIGGINSON, Santa Barbara, Calif.—I had not intended to discuss this paper but when I heard mentioned again by several of the preceding speakers the leaving-in of the bypassed long-standing strietured esophagus, I felt I should muddy the waters a little more, or at least arouse some concern regarding nonremoval. I had 1 of these patients who was 39 years of age when I first saw him. He had been esophagoscoped dozens of times and dilated hundreds of times for a lye stricture since childhood, by various men in Chicago, Los Angeles, and various other cities before I had the misfortune of being asked to treat him for almost total final obstruction. Attempted esophagoscopy shortly before I operated upon him did not yield any more information other than obstruction. Removal of the esophagus was planned and carried out with considerable difficulty, since the esophagus had been perforated several times during previous dilatations. The specimen yielded a shocking surprise in that it was a total mass of scar and car cinoma from bottom to top. I suppose most of these lye strictures probably can be safely bypassed and left unremoved, but I think it may be difficult to know or guess which can so be safely bypassed and which ones should be removed because of malignant potential. DR. ROBERT E. GROSS, Boston, Mass.—I would like to ask Mr. Belsey about his third point, when he said the technique should be applicable to infants and children. I am a little afraid of colon transplants in infants. We lost two babies a few months of age, so we have a rule not to do these colon transplants in patients who are under 1 year of age. I could not tell from the chart just how young the youngest patient was Mr. Belsey had operated upon. MR. B E L S E Y (Closing).—I was very much interested in the case of recurrent stenosis at the top of the colon transplant. I wonder whether that could have been due to some ischemic change leading to slow progressive fibrosis of the transplant. We have not seen that. Regarding Dr. Baronofsky's points, we are fundamentally opposed to staged operations which do not lead to the excision of the growth at the first stage. We have tried these in the past, and so often we have found that we have never gotten around to the second stage at all. Our philosophy regarding carcinoma of the esophagus is one of despair, in that we regard all esophageal surgery for carcinoma or malignant disease as purely palliative, with the sole objective of restoring the patient's ability' to swallow during his last remaining 12 months on this earth. However, every now and again you are lucky and you do cure a patient of his disease purely by accident. For that reason, we do like to excise the carcinoma rather than bypass it. We have had virtually no joy at all from irradiation of these growths. In regard to Dr. Baronofsky's point about leaks, I think as a result of my experience that colon is a far easier viscus to handle than is stomach or jejunum. I don't know why we don't get more leaks. I t is probably due to the fact t h a t the colon does not secrete peptic juice which can digest its own leak through some small defect between two adjacent sutures. As far as the transpleural approach to the esophagus is concerned, I think in 1964, with all the adjuncts of modern surgery and anesthesia, this does not add any additional risk to an operative procedure on the esophagus.