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Reconstruction of the Oesophagus
Reconstruction of the Oesophagus ROBERT A. MUSTARD, M.D., F.R.C.S. (C.)*
THE past fifteen years have witnessed tremendous improvements in oesophageal surgery. Oesophagectomy with replacement has advanced from being a surgical adventure rarely successful to its present status as a well established surgical technique with a preponderance of successful results. Improvements in anaesthesia, the advent of antibiotics, increased availability of blood transfusion, and improved knowledge of postoperative management have enabled many ingenious extensions of surgical technique to be carried to a successful conclusion. The surgeon's problem now is not a vital decision as to the feasibility of any operation whatever, but rather the difficulty of selecting the best procedure for each particular case. There are now many methods of replacing all or part of the oesophagus. Transplanted stomach, small bowel, and colon have proven their worth; skin tubes have been used for many years; plastic tubes and sections of preserved aorta hold promise for the future. In this field ideas are rapidly changing; techniques have not become "established"; individual experience and personal preference guide each surgeon to his separate conclusion. In this paper an attempt will be made to describe briefly the various methods of oesophageal reconstruction and to indicate the special advantages of each in relation to the site and nature of the obstructing lesion. PREOPERATIVE PREPARATION
Most patients requiring oesophageal replacement are in a state of malnutrition, the extent of which is indicated by the amount of weight loss and the degree of weakness. Before operating on these people an attempt should be made to restore the nutritional balance. As long as the patient can swallow he should be encouraged to take large quantities of high protein, high calorie, liquid feedings with generous supplements of ascorbic acid and vitamin B complex. Where swallowing is difficult it will often be found possible to pass into the stomach a small rubber or
* Surgeon, Toronto General Hospital,· Consulting Surgeon, Ontario Institute of Radiotherapy; Clinical Teacher, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. 979
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plastic tube through which twenty-four-hour constant drip feedings may be administered. Frequently the passage of this tube can be accomplished by the oesophagoscopist when he is examining the lesion. In our experience the most satisfactory preparations for tube feedings are mixtures of normal diet homogenized in a Waring Blender as described by Fallis and Barron. l • It is generally wise to avoid, if possible, preliminary gastrostomy or jejunostomy, unless one is certain that neither stomach nor small bowel will be required for reconstruction of the oesophagus. For patients with marked anaemia or for those whose extensive weight loss suggests a contracted blood volume, preoperative transfusion of 1000 to 2000 cc. of blood should be given during the few days immediately preceding operation. RECONSTRUCTION OF CERVICAL OESOPHAGUS
Stricture of the cervical oesophagus is quite rare, while carcinoma is distressingly common. When dealing with malignant lesions it is frequently necessary to include the larynx in the excised bloc because of the likelihood of its invasion by direct spread from the primary growth. 1. W ookey Two-Stage Operation As a method of reconstruction of the cervical oesophagus the W ookey operation 2 , 3 is as yet unsurpassed. The author has been privileged to learn this procedure from its distinguished originator. The details of the method are depicted in the diagram (Fig. 249). At the first operation a rectangular, full-thickness skin flap is utilized to construct a deep skin~lined groove connecting the pharynx above and oesophagus below. A period of 4 to 8 weeks is required for complete 'healing of all incisions and of the grafted area, and for the skin flap to pick up an adequate blood supply from its new bed. During this interval the patient is fed by a tube introduced into the stomach through the lower segment of the oesophagus. At the second operation a carefully placed circumferential incision around the pharyngostome allows its margins to be turned in and approximated with a double row of fine sutures. Direct closure of the resulting skin defect has, in our experience, always been possible. When healing seems complete the patient is allowed to drink. Swallowing is usually performed without difficulty and a full diet can soon be taken. Fistulae are uncommon except in patients who have undergone preoperative radiation, or who have previous operative scars in the neck. In those cases in which the larynx is excised, care should be taken that the tracheotomy is at least 17~ inches away from the lower margin of the pharyngostome, and separated from it by viable, full-thickness skin. This can usually be accomplished by bringing the cut end of the trachea out a separate stab wound low down in the suprasternal notch. If the two orifices are not separated in this way, the second operation may be very difficult. In those few cases which do not require sacrifice of larynx, the Wookey
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operation is much more easily accomplished, and the final result, from the patient's standpoint, much happier. Care must be taken, however, to preserve the recurrent laryngeal nerves.
The outstanding defect of this procedure, as originally described, was the frequency with which cervical metastases brought the patient to an RE CONSTRUCTION OF CERVICAL OESOPHAGUS [-WOOKEY OPERATION]
of lncislon Tor closure
Fig. 249. The Wookey method of reconstruction of cervical oesophagus. A, Rectangular full thickness skin flap. B, The flap has been tacked down to prevertebral fascia and is now being sutured to pharynx and eosophagus. C, Completion of anastomosis of skin tube to pharynx. D, First stage completed; note tracheotomy brought out stab wound in suprasternal notch; incision for second stage closure of pharyngostome indicated.
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early recurrence of misfortune. Subsequently, various surgeons4 • 5 have extended the procedure to include a unilateral or bilateral lymph node dissection. However, only a modified dissection of the side of the neck on which the skin flap is based can be performed, since the blood supply to the flap must be protected by preservation of the upper two-thirds of the sternomastoid muscle. Dissection of the opposite side of the neck, moreover, carries with it the disadvantage that it removes the shelf of ti'ssue over which the skin flap is folded to form an anterior wall for the pharyngostome-this leads to the formation of a shallow trough rather than a deep groove connecting pharynx and oesophagus. The conversion of this trough to a tube at the second operation is a hazardous undertaking. It is our opinion, therefore, in regard to this contralateral side, that, unless nodes appear to be invaded, one should carry out only such dissection as is compatible with preservation of the sternomastoid muscle. Moreover, we believe that both internal jugular veins should not be sacrificed at the same operation. A further difficulty with the skin flap reconstruction of the cervical oesophagus is the problem in male patients of hair growth in the skin tube. No completely satisfactory solution to this problem has yet been offered. Frequently, of course, it is possible to plan the skin flap so that most of its lies below the hair-bearing area of the neck. When it appears that hair growth may lead to eventual difficulty, radiation therapy may be cautiously applied to the pharyngostome between the two stages of operation in a dosage of about 1500 r over a ten-day period. This will produce temporary epilation so that the final operation can be successfully carried out. Scanty regrowth of hair will occur but will be troublesome only in an occasional case. Finally, it must be clear that, under ordinary circumstances, the lowest level of transection of the oesophagus permitted by the W ookey operation is about % inch below the sternal notch. By basing the skin flap somewhat more caudally, and excising the inner end of the clavicle, a slight gain may be obtained in the length of oesophagus which can be removed. However, not infrequently, with lesions in the lower portion of the cervical oesophagus, the skin flap operation is not feasible, and, instead, one of the procedures designed for lesions of the upper thoracic oesophagus must be attempted. 2. One-Stage-Operation
In recent years a one-stage operation has been devised in an attempt to avoid the prolonged hospitalization required for the two-stage skin flap reconstruction. Mr. V. E. Negus6 of University College Hospital, London, England, proposed in 1950 the replacement of cervical eosophagus by a polythene tube covered with split-skin graft. Reidy 7 has recently described the method (Fig. 250):
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The polythene tube is a 10 inch long funnel ovoid at its upper end with a 272 inch transverse diameter tapering to a circular cross-section 1 inch in diameter at the half-way mark and narrowing further to 72 inch distally; it is trimmed to the appropriate length at the time of operation. The graft on its tubular mold is stitched with plain catgut to the margins of the oesophagus and to the mucosa of the oral pharynx. Three heavy nonabsorbable sutures are introduced transversely through skin, sternomastoid muscles, and polythene tube, and fixed in such a way as to prevent the tube from sliding down into the mediastinum. A firm dressing is maintained in position for three weeks in order to compress the skin flaps onto the underlying graft, and further, to provide a degree of immobility of the head and neck during the healing period. The tube is removed after about three weeks and the patient encouraged to take fluids and food by mouth. RECONSTRUCTION
"tube
graft
Fig. 250. Reconstruction of cervical oesophagus by skin graft on plastic prosthesis.
The main defect of this operation is freely admitted by Mr. Reidy, confirmed by Sir Stanford Cade8 ; stricture develops not infrequently within a relatively few weeks at either end of the grafted area or throughout the whole length of the skin graft segment. Such strictures are seldom amenable to bouginage, and thus it may become necessary to excise the whole area and reconstruct the oesophagus by pedicle skin flaps. Milton Edgerton 9 has recently described a modification of this onestage operation in which he has successfully utilized a framework of tantalum gauze or stainless steel mesh to support the skin graft. This new method of reconstruction merits careful trial in selected
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cases. For the time being, however, it would appear that the Wookey procedure is a somewhat more certain, though more tedious, solution to the problem. REPLACEMENT OF LOWER THORACIC OESOPHAGUS
In this category are included all cases in which the reconstructive anastomosis can be performed below the level of the aortic arch. The method utilized depends to a considerable extent on the nature of the primary obstructing lesion. Malignant Lesions of Lower Thoracic Oesophagus
When dealing with carcinoma in this area, the surgeon's chief concern is to perform a wide excision of oesophagus, upper stomach, and adjacent lymphatic tissues (Fig. 251, A, B).
Oesophago-gastrostomy It is generally agreed that the most favourable approach is by a left thoracoabdominal incision entering the chest along the line of the 8th or the 9th rib and running obliquely downwards and to the right across the recti. The abdominal incision is usually made first, since exploration of the subdiaphragmatic area and liver may determine resectability and curability of the lesion. When these observations are completed the chest is opened and the diaphragm split down to the oesophageal hiatus. The lower oesophagus is now mobilized along with the tumour to as high a level as is considered necessary. When resectability of the tumour has thus been finally verified, the stomach is prepared for transplantation; the gastrosplenic attachments are divided and the greater omentum incised at a distance from the greater curvature so as to preserve the vascular arch of the gastro-epiploic vessels; the gastrohepatic ligament is opened and the left gastric artery divided. The blood supply to the stomach will be found adequately maintained by the right gastric and gastro-epiploic vessels. The lower level of resection is now determined according to the location and extent of the tumour. Frequently it is necessary to sacrifice a portion of the lesser curvature and cardiac end of the stomach. The remaining portion of the stomach is carefully closed; this produces, usually, a tubular organ which can readily be elevated to the required level in the chest. If at this point it appears necessary, mobility of the stomach may be substantially increased by cutting the peritoneal reflection along the right border of the duodenum and developing the readily opened plane behind that structure and the enclosed head of the pancreas. It is important to suspend the stomach in its new location by tacking it to the parietal and mediastinal pleura. The apex of the transplanted stomach should be about 2 inches above the anticipated level of oesophago-gastrostomy. In performing this important anastomosis great care must be taken not to prejudice the blood supply to the upper end of the stomach by carelessly placed sutures. There should be no tension on the suture line, the integrity of which is further protected by careful inversion into the stomach and fixation there by interrupted nonabsorbable sutures.
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It has been our practice, thus far observed without ill effect, to introduce a duodenal tube through the anastomosis into the stomach so that, by the application of suction, postoperative distention of the transplanted stomach may be avoided. LO\IITER
THORACIC
OESOPHAGUS
[ CARCINOMA]
B
[STRICTURE]
D
Fig. 251. Operations for replacement of lower thoracic oesophagus. A, Extent of excision for carcinoma. B, Reconstruction by oesophago-gastrostomy. C, Roux loop of jejunum anastomosed to oesophagus above an irremovable carcinoma. D, Limits of excision for benign stricture of lower oesophagus. E, Reconstruction by oesophago-jejunostomy designed to avoid reflux oesophagitis.
If the neoplasm is judged unresectable, a palliative operation should, whenever possible, be performed, in order to restore and maintain the ability to swallow. This is best accomplished by utilizing a Roux-en-Y loop of the proximal jejunum for anastomosis to the oesophagus above the obstructing tumour. Depending upon circumstances and the sur-
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geon's inclination this may be accomplished either intrathoracically, as advised by Allison10 (Fig. 251, C), or substernally, according to the method of Robertson and Sarjeant,ll which is described below (Fig. 253, C). Benign Lesions of Lower Oesophagus
It should be recognized that, while oesophago-gastrostomy is certainly the most expeditious method of dealing with carcinoma of the lower oesophagus, those who survive face the hazards of a surgical hiatus hernia-regurgitation and substernal distention after eating, and reflux oesophagi tis with its consequent heartburn, haemorrhage, and stricture. These complications are most likely to develop in young persons with an active gastric secretion and in whom little or none of the stomach has been resected. It appears, therefore, that oesophago-gastrostbmy is not an ideal method of treatment for benign strictures of lower oesophagus. As an alternative procedure, resection of the lower oesophagus and upper stomach is advised, with re-establishment of gastrointestinal continuity by means of a Roux-en-Y loop of jejunum according to the method originally proposed by Allison and recently advocated by Barnes and McElwee12 (Fig. 251, D, E). Two theoretical objections may be cited in regard to this procedure. First is the anticipated difficulty of such patients in eating full meals and maintaining a normal state of nutrition. Actually, our limited experience with patients whose stomachs have been excluded by an oesophago-jejunal anastomosis, has suggested that they eat and maintain their nutrition about as well as those who have undergone a radical subtotal gastrectomy for peptic ulceration. Allison13 has recently stated that, of 25 patients who have survived this type of operation for benign lesions, 19 eat slightly small but otherwise normal meals and maintain their weight; only 2 have anaemia; 1 has a "dumping syndrome"; and 3 have occasional diarrhoea and postprandial discomfort. In a personal communication14 he advises that, in addition to eating frequent small meals, all patients with oesophago-jejunostomies should be given liver therapy including vitamin B 12 . As suggested by Barnes and McElwee,12 it may be that the distal segment of stomach, although excluded from the passage of food, protects against the ill effects which seem so often to follow total gastrectomy. The other fear which is expressed in regard to this type of reconstruction is that peptic ulceration may occur in the isolated stomach. This complication has apparently not yet been reported and, indeed, it would seem rather unlikely, since a considerable portion of the acid-bearing area of the stomach is removed and, in addition, a complete vagotomy is performed. As with many other aspects of oesophageal surgery, the final answer to these problems must await the slow verdict of time and experience.
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RECONSTRUCTION OF MIDTHORACIC OESOPHAGUS
In this category will be considered those cases in which the upper level of excision is at or just above the arch of the aorta. Here again the selection of a method of reconstruction is influenced by the nature of the primary oesophageal lesion. Malignant Lesions of Midthoracic Oesophagus
Many methods have been devised for dealing with carcinoma in this area but none, as yet, has attained general approval. 1. Oesophago-gastrostomy
The procedure most widely used is elevation of the stomach into the chest with performance of oesophago-gastrostomy above the level of the neoplasm. This operation is generally quite feasible, its successful accomplishment depending largely on care in mobilizing the stomach and oesophagus so as to ensure an adequate blood supply to the line of anastomosis. There is seldom difficulty in obtaining sufficient length of stomach since none of it is sacrificed. The oesophagus is transected at the cardia and the lower stump carefully closed. The anastomosis is performed between the end of the oesophagus and a short transverse opening made in the anterior aspect of the cardiac portion of stomach. This operation has most frequently been done through a left thoracotomy, entering the chest at about the level of the 5th or 6th rib. It is usually necessary to mobilize the tumour behind the arch of the aorta, transect the oesophagus at a lower level, and then to withdraw the oesophagus from behind the aortic arch for anastomosis superficial to that structure (Fig. 252, A, B). The stomach is mobilized through an incision in the diaphragm, and for this portion of the procedure the surgeon is at somewhat of a disadvantage. By utilizing a left thoraco-abdominal incision the stomach can be managed with increased facility, but the anastomosis high in the chest becomes, of necessity, more difficult. An approach to the mid thoracic oesophagus through the right chest has the advantage that the tumour is no longer hidden behind the aortic arch, but is crossed only by the vena azygos major which may readily be divided. The danger of tearing either aorta or vein is thereby largely circumvented. A right thoraco-abdominal incision may be successfully used but the chest opening is generally too low to permit the anastomosis being done with ease. The author's personal preference is for separate abdominal and right thoracic incisions as first suggested by I vor Lewis I5 and modified by MacManus. 16 This method gives optimal exposure for both abdominal and thoracic procedures while avoiding the interference with postopera-
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tive respiratory function which results from phrenicotomy, division of the diaphragm, and section of the chest margin. MID -THORACIC OESOPHAGUS [CARCINOMA]
(~ '~ ','
B
A
c
D
E
Fig, 252. Operations for carcinoma of midthoracic oesophagus. A, Limits of excision. B, Oesophago-gastrostomy lateral to aortic arch. C, Long Roux loop of jejunum elevated into right upper chest for anastomosis with oesophagus. D, Preparation of colonic transplant. E, Loop of colon brought up through right chest to join oesophagus and jejunum.
The stomach is mobilized through a left upper paramedian incision, while the oesophagectomy and reconstruction are accomplished through a right thoracotomy at about the level of the 5th rib. This operation is facilitated by performing it on a table which can be rotated on its long axis. The patient is fixed on the table with the right side of his body propped up at an angle of about 45 degrees. Rotation of the table to the right brings the abdominal wall horizontal for the l~parotomy; rotation to the left brings the patient into an almost true lateral position for the thoracotomy. After mobilization of the
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oesophagus the stomach is elevated through the hiatus, which may need to be enlarged, either by stretching, or by division of a portion of the right crus. The oesophagus is severed at the cardia and the lower stump turned in. The stomach is fastened in its new position and oesophago-gastrostomy performed in the usual manner. . If the tumour proves unresectable it may be possible to anastomose stomach to oesophagus above the site of obstruction as advised by Chamberlain.17
All these operations which result in a high intrathoracic oesophagogastrostomy are open to the objection that the patient may SUbsequently be plagued by uncomfortable postprandial fullness in the chest, and regurgitation, particularly when lying down, while reflux oesophagitis may lead to pain, haemorrhage, or stricture formation. Many surgeons have, therefore, sought to develop alternative methods which might avoid these difficulties. The following procedures have all been successfully accomplished, but it is as yet much too soon to render any final judgment as to their value: 2. Intrathoracic Oesophago-jejunostomy
This operation depends upon the preparation of a long Roux loop of proximal jejunum. It may be of value to give a brief description of the technique. Through an upper abdominal incision the first portion of the jejunum is picked up and the vascular pattern of its mesentery carefully studied with the aid of a silhouetting spotlight. Usually the fourth or fifth main radial branch of the superior mesenteric artery is of generous size and an adequate pattern of marginal anastomosis can be traced to the upper end of the jejunum. Before dividing any vessels, the peritoneum is carefully stripped from both sides of the mesentery in that area. This greatly facilitates precise dissection of the blood vessels and allows them to straighten out so that increased length is obtained. Beginning at the upper end, .the main branches of the superior mesenteric artery are then divided and ligated proximal to their points of bifurcation. It is of great importance to ligate veins and arteries separately and to include no extraneous tissue in the ligature. All tissue in the base of the mesentery is trimmed away to within ),i inch of the marginal vessels. After two or three main vessels have been divided, it is wise to examine the length of the jejunal loop which has been mobilized. The limiting factor is the marginal vessels,and it is their straightened out length which must be measured with a piece of surgical tape. It may be possible to obtain increased length by dividing one or more secondary branches of the parent artery. If length is still insufficient, the feasibility of dividing another main artery can be tested by digital compression of the vessel in question. Slight duskiness of the proximal portion of jejunum and violent uncoordinated peristaltic reaction can be safely countenanced-all but one of our loops have survived in spite of these ominous signs. The bowel is then divided 2 or 3 inches distal to the ligament of Treitz and the proximal end of the Roux loop is closed. Intestinal continuity is restored by end-to-side anastomosis at a level well below the origin of the mobilized loop in order to avoid restricting its upward movement.
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Implantation of the lower end of the Roux loop into stomach is interdicted by the probable development of "stomal" ulceration. 18 ,19
This operation can most conveniently be done through separate upper abdominal and right thoracotomy incisions. The oesophagus is transected just above the diaphragm and the lower end carefully closed. The mobilized bowel is brought up through transverse mesocolon, lesser omentum, and a conveniently placed opening in the diaphragm. The reconstructive anastomosis is best done between the end of the oesophagus and the side of the jejunal loop close to its upper extremity (Fig. 252, C). 3. Colonic Oesophagoplasty
The use of a transplanted loop of transverse colon to replace the oesophagus seems to present some definite advantages. 2o Its blood supply depends on a marginal vessel which has few main arteries supplying it; thus division of one or two vessels will often produce a viable loop of considerable length (Fig. 252, D). The continuity of the large bowel is readily restored by end-to-end anastomosis, and the mobilized loop is transplanted in an isoperistaltic manner. It is believed inadvisable, because of the danger of peptic ulceration, to implant the distal end of the loop into the stomach. Depending upon individual circumstances it may be implanted into either lower end of oesophagus or proximal end of jejunum (Fig. 252, E). For lesions of the. midthoracic oesophagus the colonic transplant is probably best accomplished by the use of separate incisions in the upper abdomen and right chest. ' 4. Plastic Tube Reconstruction
Berman 21 has described the ·use of a polythene tube to replace the thoracic oesophagus in experimental animals, and, in a recent publication,22 this method is reported as having been carried out in over 70 human patients (Fig. 253, A) .. It appears to be a relatively simple operation which results in the restoration of swallowing in a high percentage of cases. It has the great advantage of being equally applicable whether or not the tumour can be completely removed. On theoretical grounds one would anticipate difficulties in patients who survive long periods of time, either from development of stricture, or ulceration of adjacent structures by pressure of the tube. Further reports on this procedure are awaited with interest. 5. Extrathoracic Oesophagoplasty
By a variety of methods it is possible to construct a substitute oesophagus which do~s not pass through the chest cavity. Thus the ability to swallow is restored regardless of whether or not the primary tumour can
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Fig. 253. Methods of circumventing obstruction of mid thoracic eosophagus. A, Oesophagoplasty by polythene tube. B, Antethoracic oesophago-jejunostomy. C, The Robertson operation-substernal oesophago-jejunostomy. D, Stricture of midthoracic oesophagus. E, Jejunal by-pass of oesophageal stricture.
be subsequently resected. Having provided excellent palliation, the surgeon may, in suitable cases, enter the chest at a later operation and excise the oesophagus in a manner unrestricted by the need for coincident reconstruction. There are several methods of extrathoracic oesophagoplasty: a.
ANTETHORACIC SUBCUTANEOUS OESOPHAGO-JEJUNOSTOMY
This was one of the earliest methods of by-passing the thoracic oesophagus.23 Its feasibility was first impressed upon the surgical world by Prof.
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Yudin of Moscow in 1944.18 A Roux loop of jejunum is elevated through a subcutaneous tunnel on the anterior chest wall to whatever level can be attained. Frequently it will reach to the base of the neck where it is brought out to the skin. At a second operation the cervical oesophagus is transected and anastomosed to the upper end of the transplanted loop. If the loop should fail to reach the neck area, it can be connected to the lower end of cervical oesophagus by a skin tube (Fig. 253, B). Should a portion of the upper end of the Roux loop fail to survive, the patient will not likely suffer any serious effects, and the resulting gap can be bridged by a skin tube. Dr. Mark Ravitch of Mount Sinai Hospital, New York City, has recently revived interest in this type of operative procedure.19
b.
SUBSTERNAL OESOPHAGO-JEJUNOSTOMY
This ingenious operation was devised by Robertson and Sarjeant of Vancouver, Canada.ll A Roux loop of jejunum is brought up through a tunnel which is constructed immediately deep to the sternum by blunt dissection from separate cervical and abdominal incisions. This is the shortest route from abdomen to neck, and it is possible in the majority of patients to pass through it·a viable Roux loop for anastomosis with the transected cervical oesophagus (Fig. 253, C). In the Toronto General Hospital this operation has been attempted 6 times with complete success in 5 cases. Our original skepticism was considerably modified when it was observed that these patients were able to eat a full diet with little difficulty and without complications such as diarrhoea and cramps. This operation is beautifully conceived and, usually, brilliantly successful. It must be recognized, however, that the probable price of failure, i.e., gangrene at the upper end of the transplanted loop, is death of the patient. Orsoni and Lemaire20 have recommended that the colon be utilized in place of jejunum for transplantation through a substernal tunnel. This is an attractive possibility whose advantages and limitations remain to be explored.
These extrathoracic reconstructions have the disadvantage that, if one plans to deal with the primary tumour, a second major operation is required. In many cases, of course, the neoplasm is clearly inoperable, either on clinical grounds or as a result of the findings at abdominal exploration. Moreover, it could be argued that, in view of the almost negligible cure rate following oesophagectomy for carcinoma of the mid and upper thoracic oesophagus, there is no justification for excising the tumour once palliative reconstruction has been successfully accomplished. At present this seems the most logical opinion for all cases except those few in which the growth appears to be either very early or very - limited. Now that cobalt beam therapy is available, we propose to radiate the primary tumour following extrathoracic reconstruction of the oesophagus. Benign Lesions of Midthoracic Oesophagus
When dealing with a stricture of the midthoracic oesophagus it is felt that the ideal objective is to restore continuity without disturbance of
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gastric function. Elevation of stomach into the chest is considered to be contraindicated by the likelihood of reflux oesophagitis, while Roux-loop reconstruction is undesirable since the stomach is thereby excluded. It should be kept in mind that in the occasional case with a very short stricture it may be possible to excise the damaged area and do an endto-end anastomosis. 24 • 25 With longer strictures the ideal objective may be attained by bringing up into the chest a mobilized loop of either jejunum or colon and utilizing it to by-pass the obstructed segment of oesophagus. Using jejunum this procedure has been successfully accomplished in 1 patient, who had, however, not a stricture, but a small localized carcinoma of the oesophagus. This patient, nevertheless, had an excellent functional result-he is able to eat full meals without difficulty and is back doing hard manual labour a year and a half following his operation. It is our impression that this procedure would be much simpler in the case of a benign stricture, because it would then be unnecessary to excise a segment of the oesophagus; the transplanted loop could merely be anastomosed to the side of the oesophagus above and below the stricture (Fig. 253, D, E). In those patients with a favourable arrangement of blood supply to the transverse colon, one would favour use of a section of that structure, since it is somewhat easier than jejunum to prepare for transplantation. REPLACEMENT OF UPPER THORACIC OESOPHAGUS
In this section are considered those cases in which the inferior limit of excision is too low to permit a cervical operation, while the upper limit is too high to be accomplished through the thorax. These lesions, therefore, require separate incisions in chest and neck. In regard to malignant lesions of the upper thoracic oesophagus, it should be pointed out that it is virtually impossible by surgical means to cure cancer in that area. Early invasion of the trachea or great vessels, and development of inaccessible lymph node metastases, render practically every case incurable at the time of diagnosis. For this reason all operations for carcinoma here may be considered to have palliation as' their sole objective. If this be true, it would appear unreasonable to subject these unfortunate patients to the surgical tour-de-force required to transplant the stomach through the chest cavity for anastomosis with the oesophagus in the neck. Should the patient withstand this massive procedure, his brief period of survival may very likely be marred by frequent episodes of bitter and bilious regurgitation. As a simpler procedure giving more effective palliation it would appear preferable to use the substernal oesophago-jejunostomy of Robertson and Sarjeant, or the subcutaneous oesophagoplasty of Yudin and Ravitch. In selected cases this palliative operation would be supple-
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mented by treatment to the primary tumour with supervoltage radiation therapy. With benign strictures of the upper thoracic oesophagus the objectives should be the same as those indicated for similar lesions of the midthoracic oesophagus. Thus one would favour some method of by-passing the obstruction by interposing a loop of small or large bowel anastomosed to the oesophagus above and below the narrowed area. This would, of necessity, require three incisions, one in the abdomen for preparation of the loop, one in the thorax for anastomosis below the stricture, and one in the neck for anastomosis above the stricture. The author was privileged to assist his senior colleague, Dr. F. G. Kergin, in an operation of this type. The patient had a long intractable stricture of the upper thoracic oesophagus which was by-passed by a loop of transverse colon anastomosed to the side of the oesophagus above and below the lesion. This case, as reported elsewhere,26 has been a brilliant success and encourages us to attempt it in future problems of a similar nature. In performing these operations, the laparotomy should, of course, be performed first, and the vascular arrangement in the mesentery of jejunum and colon carefully studied. If it appears unlikely that a loop of sufficient length can be obtained to reach easily through the chest into the neck, the best alternative is to mobilize the proximal jejunum as far as possible for transplantation through an antethoracic subcutaneous tunnel. If this fails to reach the neck, it can at a subsequent operation be connected by a skin tube to the end of the cervical oesophagus as advised by Yudin.Is Although prolonged and tiresome, this type of operation has, in relation to benign lesions, the great advantage that it involves little risk to the patient's life. CONCLUSION
During the past two decades most surgeons on this Continent concerned with oesophageal replacement have concentrated on developing techniques for elevating the stomach to higher and higher levels in the chest. Growing awareness of the functional imperfections associated with oesophago-gastric anastomoses is responsible for the present tendency to explore other methods of reconstruction involving the use of jejunum, colon, and plastic tubes. These alternative procedures have been described because it is felt they merit extensive trial. It must, however, be emphasized that there has not yet been accumulated sufficient experience with the newer methods of oesophagoplasty to indicate with assurance the extent of their applicability or the degree of risk associated with them. It is clear that, in regard to oesophageal reconstruction, one must keep an open mind, continue to seek improved methods, and submit each to the unbiased judgment of the passing years.
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REFERENCES 1. Fallis, L. S. and Barron, J.: Gastric and Jejunal Alimentation with Fine Polythene Tubes. A.M.A. Arch. Surg. 65: 373, 1952. 2. Wookey, H.: The Surgical Treatment of Carcinoma of the Pharynx and Upper Esophagus. Surg., Gynec. & Obst. 75: 499, 1942. 3. Wookey, H.: The Surgical Treatment of Carcinoma of the Hypopharynx and the Oesophagus. Brit. J. Surg. 249: 1948. 4. Grimes, O. F. and Stephens, H. B.: The Surgical Treatment of Carcinoma of the Hypopharynx, Larynx, and Upper Esophagus. J. Thorac. Surg. 24: 246, 1952. 5. Raven, R. W.: Discussion on Surgical Treatment of Carcinoma of the Pharynx. Proc. Roy. Soc. Med. 46: 770, 1953. 6. Negus, V. E.: Problem of Hypopharyngeal Carcinoma. Proc. Roy. Soc. Med. 43: 168, 1950. 7. Reidy, J. P.: Discussion on Surgical Treatment of Carcinoma of the Pharynx. Proc. Roy. Soc. Med. 46: 776, 1953. 8. Cade, Sir Stanford: Discussion on Surgical Treatment of Carcinoma of the Pharynx. Proc. Roy. Soc. Med. 46: 769,1953. 9. Edgerton, M. T.: One-Stage Reconstruction of Cervical Esophagus or Trachea. Surgery 31: 239, 1952. 10. Allison, P. R.: Oesophago-Jejunostomy for Irremovable Carcinoma of the Cardia. Thorax 1: 239,1946. 11. Robertson, R. and Sarjeant, T. R.: Reconstruction of Esophagus. J. Thorac. Surg. 20: 689, 1950. 12. Barnes, W. A. and McElwee, R. S.: Surgical Treatment of Non-neoplastic Lesions at the Esophago-gastric Junction. Ann. Surg. 137: 523, 1953. 13. Allison, P. R. and DaSilva, L. T.: The Roux Loop. Brit. J. Surg. 41: 173, 1953. 14. Allison, P. R.: Personal communication, Dec. 1953. 15. Lewis, Ivor: The Surgical Treatment of Carcinoma of the Oesophagus With Special Reference to a New Operation for Growths of the Middle Third. Brit. J. Surg. 34: 18, 1946. 16. MacManus, J. E.: Combined Left Abdominal and Right Thoracic Approach to Resection of Esophageal Neoplasms. Surgery 24: 9,1948. 17. Chamberlain, J. M.: Discussion of Paper by Kent and Harrison, "Combined Abdominal and Right Thoracic Approach to Lesions of the Middle and Upper Thirds of the Esophagus." J. Thorac. Surg. 19: 569, 1950. 18. Yudin, S.: The Surgical Construction of 80 Cases of Artificial Esophagus. Surg., Gynec. & Obst. 78: 561, 1944. 19. Ravitch. M. M., Robinson, H. T. and Johns, T. N. P.: Carcinoma of the Oesophagus. J. Thorac. Surg. 24: 256, 1952. 20. Orsoni, P. and Lemaire, M.: Oesophagoplasties by Means of Transverse and Descending Colon. J. de chir. 67: 491, 1951. 21. Berman, E. F.: The Experimental Replacement of Portions of The Esophagus by a Plastic Tube. Ann. Surg. 135: 337,1952. 22. Shackelford, R. T. and Sparkuhl, K.: Palliative Resection of the Esophagus with Use of a Plastic Tube: A Case Report with Autopsy Findings. Ann. Surg. 138: 791, 1953. 23. Roux, C.: L'oesophago-Jejuno-Gastrostomose Nouvelle Operation Pour Retrecissement Infranchissable de l'oesophage. Semaine med., Paris, 27: 37,1907. 24. Tuttle, W. M. and Day, J. C.: The Treatment of Short Esophageal Strictures by Resection and End-To-End Anastomosis. J. Thorac. Surg. 19: 534, 1950. 25. Parker, E. F. and Rockington, W. S.: Esophageal Resection with End-to-End Anastomosis. Ann. Surg. 129: 588, 1949. 26. Kergin, F. G.: Esophageal Obstruction due to Paraffinoma of Mediastinum: Reconstruction by Intrathoracic Colon Graft. Ann. Surg. 137: 91, 1953. 280 Bloor Street, W., Toronto, Ontario, Canada.
THE past fifteen years have witnessed tremendous improvements in oesophageal surgery. Oesophagectomy with replacement has advanced from being a surgical adventure rarely successful to its present status as a well established surgical technique with a preponderance of successful results. Improvements in anaesthesia, the advent of antibiotics, increased availability of blood transfusion, and improved knowledge of postoperative management have enabled many ingenious extensions of surgical technique to be carried to a successful conclusion. The surgeon's problem now is not a vital decision as to the feasibility of any operation whatever, but rather the difficulty of selecting the best procedure for each particular case. There are now many methods of replacing all or part of the oesophagus. Transplanted stomach, small bowel, and colon have proven their worth; skin tubes have been used for many years; plastic tubes and sections of preserved aorta hold promise for the future. In this field ideas are rapidly changing; techniques have not become "established"; individual experience and personal preference guide each surgeon to his separate conclusion. In this paper an attempt will be made to describe briefly the various methods of oesophageal reconstruction and to indicate the special advantages of each in relation to the site and nature of the obstructing lesion. PREOPERATIVE PREPARATION
Most patients requiring oesophageal replacement are in a state of malnutrition, the extent of which is indicated by the amount of weight loss and the degree of weakness. Before operating on these people an attempt should be made to restore the nutritional balance. As long as the patient can swallow he should be encouraged to take large quantities of high protein, high calorie, liquid feedings with generous supplements of ascorbic acid and vitamin B complex. Where swallowing is difficult it will often be found possible to pass into the stomach a small rubber or
* Surgeon, Toronto General Hospital,· Consulting Surgeon, Ontario Institute of Radiotherapy; Clinical Teacher, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. 979
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Robert A . Mustard
plastic tube through which twenty-four-hour constant drip feedings may be administered. Frequently the passage of this tube can be accomplished by the oesophagoscopist when he is examining the lesion. In our experience the most satisfactory preparations for tube feedings are mixtures of normal diet homogenized in a Waring Blender as described by Fallis and Barron. l • It is generally wise to avoid, if possible, preliminary gastrostomy or jejunostomy, unless one is certain that neither stomach nor small bowel will be required for reconstruction of the oesophagus. For patients with marked anaemia or for those whose extensive weight loss suggests a contracted blood volume, preoperative transfusion of 1000 to 2000 cc. of blood should be given during the few days immediately preceding operation. RECONSTRUCTION OF CERVICAL OESOPHAGUS
Stricture of the cervical oesophagus is quite rare, while carcinoma is distressingly common. When dealing with malignant lesions it is frequently necessary to include the larynx in the excised bloc because of the likelihood of its invasion by direct spread from the primary growth. 1. W ookey Two-Stage Operation As a method of reconstruction of the cervical oesophagus the W ookey operation 2 , 3 is as yet unsurpassed. The author has been privileged to learn this procedure from its distinguished originator. The details of the method are depicted in the diagram (Fig. 249). At the first operation a rectangular, full-thickness skin flap is utilized to construct a deep skin~lined groove connecting the pharynx above and oesophagus below. A period of 4 to 8 weeks is required for complete 'healing of all incisions and of the grafted area, and for the skin flap to pick up an adequate blood supply from its new bed. During this interval the patient is fed by a tube introduced into the stomach through the lower segment of the oesophagus. At the second operation a carefully placed circumferential incision around the pharyngostome allows its margins to be turned in and approximated with a double row of fine sutures. Direct closure of the resulting skin defect has, in our experience, always been possible. When healing seems complete the patient is allowed to drink. Swallowing is usually performed without difficulty and a full diet can soon be taken. Fistulae are uncommon except in patients who have undergone preoperative radiation, or who have previous operative scars in the neck. In those cases in which the larynx is excised, care should be taken that the tracheotomy is at least 17~ inches away from the lower margin of the pharyngostome, and separated from it by viable, full-thickness skin. This can usually be accomplished by bringing the cut end of the trachea out a separate stab wound low down in the suprasternal notch. If the two orifices are not separated in this way, the second operation may be very difficult. In those few cases which do not require sacrifice of larynx, the Wookey
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operation is much more easily accomplished, and the final result, from the patient's standpoint, much happier. Care must be taken, however, to preserve the recurrent laryngeal nerves.
The outstanding defect of this procedure, as originally described, was the frequency with which cervical metastases brought the patient to an RE CONSTRUCTION OF CERVICAL OESOPHAGUS [-WOOKEY OPERATION]
of lncislon Tor closure
Fig. 249. The Wookey method of reconstruction of cervical oesophagus. A, Rectangular full thickness skin flap. B, The flap has been tacked down to prevertebral fascia and is now being sutured to pharynx and eosophagus. C, Completion of anastomosis of skin tube to pharynx. D, First stage completed; note tracheotomy brought out stab wound in suprasternal notch; incision for second stage closure of pharyngostome indicated.
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'Ii"
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early recurrence of misfortune. Subsequently, various surgeons4 • 5 have extended the procedure to include a unilateral or bilateral lymph node dissection. However, only a modified dissection of the side of the neck on which the skin flap is based can be performed, since the blood supply to the flap must be protected by preservation of the upper two-thirds of the sternomastoid muscle. Dissection of the opposite side of the neck, moreover, carries with it the disadvantage that it removes the shelf of ti'ssue over which the skin flap is folded to form an anterior wall for the pharyngostome-this leads to the formation of a shallow trough rather than a deep groove connecting pharynx and oesophagus. The conversion of this trough to a tube at the second operation is a hazardous undertaking. It is our opinion, therefore, in regard to this contralateral side, that, unless nodes appear to be invaded, one should carry out only such dissection as is compatible with preservation of the sternomastoid muscle. Moreover, we believe that both internal jugular veins should not be sacrificed at the same operation. A further difficulty with the skin flap reconstruction of the cervical oesophagus is the problem in male patients of hair growth in the skin tube. No completely satisfactory solution to this problem has yet been offered. Frequently, of course, it is possible to plan the skin flap so that most of its lies below the hair-bearing area of the neck. When it appears that hair growth may lead to eventual difficulty, radiation therapy may be cautiously applied to the pharyngostome between the two stages of operation in a dosage of about 1500 r over a ten-day period. This will produce temporary epilation so that the final operation can be successfully carried out. Scanty regrowth of hair will occur but will be troublesome only in an occasional case. Finally, it must be clear that, under ordinary circumstances, the lowest level of transection of the oesophagus permitted by the W ookey operation is about % inch below the sternal notch. By basing the skin flap somewhat more caudally, and excising the inner end of the clavicle, a slight gain may be obtained in the length of oesophagus which can be removed. However, not infrequently, with lesions in the lower portion of the cervical oesophagus, the skin flap operation is not feasible, and, instead, one of the procedures designed for lesions of the upper thoracic oesophagus must be attempted. 2. One-Stage-Operation
In recent years a one-stage operation has been devised in an attempt to avoid the prolonged hospitalization required for the two-stage skin flap reconstruction. Mr. V. E. Negus6 of University College Hospital, London, England, proposed in 1950 the replacement of cervical eosophagus by a polythene tube covered with split-skin graft. Reidy 7 has recently described the method (Fig. 250):
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The polythene tube is a 10 inch long funnel ovoid at its upper end with a 272 inch transverse diameter tapering to a circular cross-section 1 inch in diameter at the half-way mark and narrowing further to 72 inch distally; it is trimmed to the appropriate length at the time of operation. The graft on its tubular mold is stitched with plain catgut to the margins of the oesophagus and to the mucosa of the oral pharynx. Three heavy nonabsorbable sutures are introduced transversely through skin, sternomastoid muscles, and polythene tube, and fixed in such a way as to prevent the tube from sliding down into the mediastinum. A firm dressing is maintained in position for three weeks in order to compress the skin flaps onto the underlying graft, and further, to provide a degree of immobility of the head and neck during the healing period. The tube is removed after about three weeks and the patient encouraged to take fluids and food by mouth. RECONSTRUCTION
"tube
graft
Fig. 250. Reconstruction of cervical oesophagus by skin graft on plastic prosthesis.
The main defect of this operation is freely admitted by Mr. Reidy, confirmed by Sir Stanford Cade8 ; stricture develops not infrequently within a relatively few weeks at either end of the grafted area or throughout the whole length of the skin graft segment. Such strictures are seldom amenable to bouginage, and thus it may become necessary to excise the whole area and reconstruct the oesophagus by pedicle skin flaps. Milton Edgerton 9 has recently described a modification of this onestage operation in which he has successfully utilized a framework of tantalum gauze or stainless steel mesh to support the skin graft. This new method of reconstruction merits careful trial in selected
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cases. For the time being, however, it would appear that the Wookey procedure is a somewhat more certain, though more tedious, solution to the problem. REPLACEMENT OF LOWER THORACIC OESOPHAGUS
In this category are included all cases in which the reconstructive anastomosis can be performed below the level of the aortic arch. The method utilized depends to a considerable extent on the nature of the primary obstructing lesion. Malignant Lesions of Lower Thoracic Oesophagus
When dealing with carcinoma in this area, the surgeon's chief concern is to perform a wide excision of oesophagus, upper stomach, and adjacent lymphatic tissues (Fig. 251, A, B).
Oesophago-gastrostomy It is generally agreed that the most favourable approach is by a left thoracoabdominal incision entering the chest along the line of the 8th or the 9th rib and running obliquely downwards and to the right across the recti. The abdominal incision is usually made first, since exploration of the subdiaphragmatic area and liver may determine resectability and curability of the lesion. When these observations are completed the chest is opened and the diaphragm split down to the oesophageal hiatus. The lower oesophagus is now mobilized along with the tumour to as high a level as is considered necessary. When resectability of the tumour has thus been finally verified, the stomach is prepared for transplantation; the gastrosplenic attachments are divided and the greater omentum incised at a distance from the greater curvature so as to preserve the vascular arch of the gastro-epiploic vessels; the gastrohepatic ligament is opened and the left gastric artery divided. The blood supply to the stomach will be found adequately maintained by the right gastric and gastro-epiploic vessels. The lower level of resection is now determined according to the location and extent of the tumour. Frequently it is necessary to sacrifice a portion of the lesser curvature and cardiac end of the stomach. The remaining portion of the stomach is carefully closed; this produces, usually, a tubular organ which can readily be elevated to the required level in the chest. If at this point it appears necessary, mobility of the stomach may be substantially increased by cutting the peritoneal reflection along the right border of the duodenum and developing the readily opened plane behind that structure and the enclosed head of the pancreas. It is important to suspend the stomach in its new location by tacking it to the parietal and mediastinal pleura. The apex of the transplanted stomach should be about 2 inches above the anticipated level of oesophago-gastrostomy. In performing this important anastomosis great care must be taken not to prejudice the blood supply to the upper end of the stomach by carelessly placed sutures. There should be no tension on the suture line, the integrity of which is further protected by careful inversion into the stomach and fixation there by interrupted nonabsorbable sutures.
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It has been our practice, thus far observed without ill effect, to introduce a duodenal tube through the anastomosis into the stomach so that, by the application of suction, postoperative distention of the transplanted stomach may be avoided. LO\IITER
THORACIC
OESOPHAGUS
[ CARCINOMA]
B
[STRICTURE]
D
Fig. 251. Operations for replacement of lower thoracic oesophagus. A, Extent of excision for carcinoma. B, Reconstruction by oesophago-gastrostomy. C, Roux loop of jejunum anastomosed to oesophagus above an irremovable carcinoma. D, Limits of excision for benign stricture of lower oesophagus. E, Reconstruction by oesophago-jejunostomy designed to avoid reflux oesophagitis.
If the neoplasm is judged unresectable, a palliative operation should, whenever possible, be performed, in order to restore and maintain the ability to swallow. This is best accomplished by utilizing a Roux-en-Y loop of the proximal jejunum for anastomosis to the oesophagus above the obstructing tumour. Depending upon circumstances and the sur-
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Robert A . Mustard
geon's inclination this may be accomplished either intrathoracically, as advised by Allison10 (Fig. 251, C), or substernally, according to the method of Robertson and Sarjeant,ll which is described below (Fig. 253, C). Benign Lesions of Lower Oesophagus
It should be recognized that, while oesophago-gastrostomy is certainly the most expeditious method of dealing with carcinoma of the lower oesophagus, those who survive face the hazards of a surgical hiatus hernia-regurgitation and substernal distention after eating, and reflux oesophagi tis with its consequent heartburn, haemorrhage, and stricture. These complications are most likely to develop in young persons with an active gastric secretion and in whom little or none of the stomach has been resected. It appears, therefore, that oesophago-gastrostbmy is not an ideal method of treatment for benign strictures of lower oesophagus. As an alternative procedure, resection of the lower oesophagus and upper stomach is advised, with re-establishment of gastrointestinal continuity by means of a Roux-en-Y loop of jejunum according to the method originally proposed by Allison and recently advocated by Barnes and McElwee12 (Fig. 251, D, E). Two theoretical objections may be cited in regard to this procedure. First is the anticipated difficulty of such patients in eating full meals and maintaining a normal state of nutrition. Actually, our limited experience with patients whose stomachs have been excluded by an oesophago-jejunal anastomosis, has suggested that they eat and maintain their nutrition about as well as those who have undergone a radical subtotal gastrectomy for peptic ulceration. Allison13 has recently stated that, of 25 patients who have survived this type of operation for benign lesions, 19 eat slightly small but otherwise normal meals and maintain their weight; only 2 have anaemia; 1 has a "dumping syndrome"; and 3 have occasional diarrhoea and postprandial discomfort. In a personal communication14 he advises that, in addition to eating frequent small meals, all patients with oesophago-jejunostomies should be given liver therapy including vitamin B 12 . As suggested by Barnes and McElwee,12 it may be that the distal segment of stomach, although excluded from the passage of food, protects against the ill effects which seem so often to follow total gastrectomy. The other fear which is expressed in regard to this type of reconstruction is that peptic ulceration may occur in the isolated stomach. This complication has apparently not yet been reported and, indeed, it would seem rather unlikely, since a considerable portion of the acid-bearing area of the stomach is removed and, in addition, a complete vagotomy is performed. As with many other aspects of oesophageal surgery, the final answer to these problems must await the slow verdict of time and experience.
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RECONSTRUCTION OF MIDTHORACIC OESOPHAGUS
In this category will be considered those cases in which the upper level of excision is at or just above the arch of the aorta. Here again the selection of a method of reconstruction is influenced by the nature of the primary oesophageal lesion. Malignant Lesions of Midthoracic Oesophagus
Many methods have been devised for dealing with carcinoma in this area but none, as yet, has attained general approval. 1. Oesophago-gastrostomy
The procedure most widely used is elevation of the stomach into the chest with performance of oesophago-gastrostomy above the level of the neoplasm. This operation is generally quite feasible, its successful accomplishment depending largely on care in mobilizing the stomach and oesophagus so as to ensure an adequate blood supply to the line of anastomosis. There is seldom difficulty in obtaining sufficient length of stomach since none of it is sacrificed. The oesophagus is transected at the cardia and the lower stump carefully closed. The anastomosis is performed between the end of the oesophagus and a short transverse opening made in the anterior aspect of the cardiac portion of stomach. This operation has most frequently been done through a left thoracotomy, entering the chest at about the level of the 5th or 6th rib. It is usually necessary to mobilize the tumour behind the arch of the aorta, transect the oesophagus at a lower level, and then to withdraw the oesophagus from behind the aortic arch for anastomosis superficial to that structure (Fig. 252, A, B). The stomach is mobilized through an incision in the diaphragm, and for this portion of the procedure the surgeon is at somewhat of a disadvantage. By utilizing a left thoraco-abdominal incision the stomach can be managed with increased facility, but the anastomosis high in the chest becomes, of necessity, more difficult. An approach to the mid thoracic oesophagus through the right chest has the advantage that the tumour is no longer hidden behind the aortic arch, but is crossed only by the vena azygos major which may readily be divided. The danger of tearing either aorta or vein is thereby largely circumvented. A right thoraco-abdominal incision may be successfully used but the chest opening is generally too low to permit the anastomosis being done with ease. The author's personal preference is for separate abdominal and right thoracic incisions as first suggested by I vor Lewis I5 and modified by MacManus. 16 This method gives optimal exposure for both abdominal and thoracic procedures while avoiding the interference with postopera-
Robert A . Mustard
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tive respiratory function which results from phrenicotomy, division of the diaphragm, and section of the chest margin. MID -THORACIC OESOPHAGUS [CARCINOMA]
(~ '~ ','
B
A
c
D
E
Fig, 252. Operations for carcinoma of midthoracic oesophagus. A, Limits of excision. B, Oesophago-gastrostomy lateral to aortic arch. C, Long Roux loop of jejunum elevated into right upper chest for anastomosis with oesophagus. D, Preparation of colonic transplant. E, Loop of colon brought up through right chest to join oesophagus and jejunum.
The stomach is mobilized through a left upper paramedian incision, while the oesophagectomy and reconstruction are accomplished through a right thoracotomy at about the level of the 5th rib. This operation is facilitated by performing it on a table which can be rotated on its long axis. The patient is fixed on the table with the right side of his body propped up at an angle of about 45 degrees. Rotation of the table to the right brings the abdominal wall horizontal for the l~parotomy; rotation to the left brings the patient into an almost true lateral position for the thoracotomy. After mobilization of the
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oesophagus the stomach is elevated through the hiatus, which may need to be enlarged, either by stretching, or by division of a portion of the right crus. The oesophagus is severed at the cardia and the lower stump turned in. The stomach is fastened in its new position and oesophago-gastrostomy performed in the usual manner. . If the tumour proves unresectable it may be possible to anastomose stomach to oesophagus above the site of obstruction as advised by Chamberlain.17
All these operations which result in a high intrathoracic oesophagogastrostomy are open to the objection that the patient may SUbsequently be plagued by uncomfortable postprandial fullness in the chest, and regurgitation, particularly when lying down, while reflux oesophagitis may lead to pain, haemorrhage, or stricture formation. Many surgeons have, therefore, sought to develop alternative methods which might avoid these difficulties. The following procedures have all been successfully accomplished, but it is as yet much too soon to render any final judgment as to their value: 2. Intrathoracic Oesophago-jejunostomy
This operation depends upon the preparation of a long Roux loop of proximal jejunum. It may be of value to give a brief description of the technique. Through an upper abdominal incision the first portion of the jejunum is picked up and the vascular pattern of its mesentery carefully studied with the aid of a silhouetting spotlight. Usually the fourth or fifth main radial branch of the superior mesenteric artery is of generous size and an adequate pattern of marginal anastomosis can be traced to the upper end of the jejunum. Before dividing any vessels, the peritoneum is carefully stripped from both sides of the mesentery in that area. This greatly facilitates precise dissection of the blood vessels and allows them to straighten out so that increased length is obtained. Beginning at the upper end, .the main branches of the superior mesenteric artery are then divided and ligated proximal to their points of bifurcation. It is of great importance to ligate veins and arteries separately and to include no extraneous tissue in the ligature. All tissue in the base of the mesentery is trimmed away to within ),i inch of the marginal vessels. After two or three main vessels have been divided, it is wise to examine the length of the jejunal loop which has been mobilized. The limiting factor is the marginal vessels,and it is their straightened out length which must be measured with a piece of surgical tape. It may be possible to obtain increased length by dividing one or more secondary branches of the parent artery. If length is still insufficient, the feasibility of dividing another main artery can be tested by digital compression of the vessel in question. Slight duskiness of the proximal portion of jejunum and violent uncoordinated peristaltic reaction can be safely countenanced-all but one of our loops have survived in spite of these ominous signs. The bowel is then divided 2 or 3 inches distal to the ligament of Treitz and the proximal end of the Roux loop is closed. Intestinal continuity is restored by end-to-side anastomosis at a level well below the origin of the mobilized loop in order to avoid restricting its upward movement.
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Implantation of the lower end of the Roux loop into stomach is interdicted by the probable development of "stomal" ulceration. 18 ,19
This operation can most conveniently be done through separate upper abdominal and right thoracotomy incisions. The oesophagus is transected just above the diaphragm and the lower end carefully closed. The mobilized bowel is brought up through transverse mesocolon, lesser omentum, and a conveniently placed opening in the diaphragm. The reconstructive anastomosis is best done between the end of the oesophagus and the side of the jejunal loop close to its upper extremity (Fig. 252, C). 3. Colonic Oesophagoplasty
The use of a transplanted loop of transverse colon to replace the oesophagus seems to present some definite advantages. 2o Its blood supply depends on a marginal vessel which has few main arteries supplying it; thus division of one or two vessels will often produce a viable loop of considerable length (Fig. 252, D). The continuity of the large bowel is readily restored by end-to-end anastomosis, and the mobilized loop is transplanted in an isoperistaltic manner. It is believed inadvisable, because of the danger of peptic ulceration, to implant the distal end of the loop into the stomach. Depending upon individual circumstances it may be implanted into either lower end of oesophagus or proximal end of jejunum (Fig. 252, E). For lesions of the. midthoracic oesophagus the colonic transplant is probably best accomplished by the use of separate incisions in the upper abdomen and right chest. ' 4. Plastic Tube Reconstruction
Berman 21 has described the ·use of a polythene tube to replace the thoracic oesophagus in experimental animals, and, in a recent publication,22 this method is reported as having been carried out in over 70 human patients (Fig. 253, A) .. It appears to be a relatively simple operation which results in the restoration of swallowing in a high percentage of cases. It has the great advantage of being equally applicable whether or not the tumour can be completely removed. On theoretical grounds one would anticipate difficulties in patients who survive long periods of time, either from development of stricture, or ulceration of adjacent structures by pressure of the tube. Further reports on this procedure are awaited with interest. 5. Extrathoracic Oesophagoplasty
By a variety of methods it is possible to construct a substitute oesophagus which do~s not pass through the chest cavity. Thus the ability to swallow is restored regardless of whether or not the primary tumour can
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Fig. 253. Methods of circumventing obstruction of mid thoracic eosophagus. A, Oesophagoplasty by polythene tube. B, Antethoracic oesophago-jejunostomy. C, The Robertson operation-substernal oesophago-jejunostomy. D, Stricture of midthoracic oesophagus. E, Jejunal by-pass of oesophageal stricture.
be subsequently resected. Having provided excellent palliation, the surgeon may, in suitable cases, enter the chest at a later operation and excise the oesophagus in a manner unrestricted by the need for coincident reconstruction. There are several methods of extrathoracic oesophagoplasty: a.
ANTETHORACIC SUBCUTANEOUS OESOPHAGO-JEJUNOSTOMY
This was one of the earliest methods of by-passing the thoracic oesophagus.23 Its feasibility was first impressed upon the surgical world by Prof.
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Robert A . Mustard
Yudin of Moscow in 1944.18 A Roux loop of jejunum is elevated through a subcutaneous tunnel on the anterior chest wall to whatever level can be attained. Frequently it will reach to the base of the neck where it is brought out to the skin. At a second operation the cervical oesophagus is transected and anastomosed to the upper end of the transplanted loop. If the loop should fail to reach the neck area, it can be connected to the lower end of cervical oesophagus by a skin tube (Fig. 253, B). Should a portion of the upper end of the Roux loop fail to survive, the patient will not likely suffer any serious effects, and the resulting gap can be bridged by a skin tube. Dr. Mark Ravitch of Mount Sinai Hospital, New York City, has recently revived interest in this type of operative procedure.19
b.
SUBSTERNAL OESOPHAGO-JEJUNOSTOMY
This ingenious operation was devised by Robertson and Sarjeant of Vancouver, Canada.ll A Roux loop of jejunum is brought up through a tunnel which is constructed immediately deep to the sternum by blunt dissection from separate cervical and abdominal incisions. This is the shortest route from abdomen to neck, and it is possible in the majority of patients to pass through it·a viable Roux loop for anastomosis with the transected cervical oesophagus (Fig. 253, C). In the Toronto General Hospital this operation has been attempted 6 times with complete success in 5 cases. Our original skepticism was considerably modified when it was observed that these patients were able to eat a full diet with little difficulty and without complications such as diarrhoea and cramps. This operation is beautifully conceived and, usually, brilliantly successful. It must be recognized, however, that the probable price of failure, i.e., gangrene at the upper end of the transplanted loop, is death of the patient. Orsoni and Lemaire20 have recommended that the colon be utilized in place of jejunum for transplantation through a substernal tunnel. This is an attractive possibility whose advantages and limitations remain to be explored.
These extrathoracic reconstructions have the disadvantage that, if one plans to deal with the primary tumour, a second major operation is required. In many cases, of course, the neoplasm is clearly inoperable, either on clinical grounds or as a result of the findings at abdominal exploration. Moreover, it could be argued that, in view of the almost negligible cure rate following oesophagectomy for carcinoma of the mid and upper thoracic oesophagus, there is no justification for excising the tumour once palliative reconstruction has been successfully accomplished. At present this seems the most logical opinion for all cases except those few in which the growth appears to be either very early or very - limited. Now that cobalt beam therapy is available, we propose to radiate the primary tumour following extrathoracic reconstruction of the oesophagus. Benign Lesions of Midthoracic Oesophagus
When dealing with a stricture of the midthoracic oesophagus it is felt that the ideal objective is to restore continuity without disturbance of
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gastric function. Elevation of stomach into the chest is considered to be contraindicated by the likelihood of reflux oesophagitis, while Roux-loop reconstruction is undesirable since the stomach is thereby excluded. It should be kept in mind that in the occasional case with a very short stricture it may be possible to excise the damaged area and do an endto-end anastomosis. 24 • 25 With longer strictures the ideal objective may be attained by bringing up into the chest a mobilized loop of either jejunum or colon and utilizing it to by-pass the obstructed segment of oesophagus. Using jejunum this procedure has been successfully accomplished in 1 patient, who had, however, not a stricture, but a small localized carcinoma of the oesophagus. This patient, nevertheless, had an excellent functional result-he is able to eat full meals without difficulty and is back doing hard manual labour a year and a half following his operation. It is our impression that this procedure would be much simpler in the case of a benign stricture, because it would then be unnecessary to excise a segment of the oesophagus; the transplanted loop could merely be anastomosed to the side of the oesophagus above and below the stricture (Fig. 253, D, E). In those patients with a favourable arrangement of blood supply to the transverse colon, one would favour use of a section of that structure, since it is somewhat easier than jejunum to prepare for transplantation. REPLACEMENT OF UPPER THORACIC OESOPHAGUS
In this section are considered those cases in which the inferior limit of excision is too low to permit a cervical operation, while the upper limit is too high to be accomplished through the thorax. These lesions, therefore, require separate incisions in chest and neck. In regard to malignant lesions of the upper thoracic oesophagus, it should be pointed out that it is virtually impossible by surgical means to cure cancer in that area. Early invasion of the trachea or great vessels, and development of inaccessible lymph node metastases, render practically every case incurable at the time of diagnosis. For this reason all operations for carcinoma here may be considered to have palliation as' their sole objective. If this be true, it would appear unreasonable to subject these unfortunate patients to the surgical tour-de-force required to transplant the stomach through the chest cavity for anastomosis with the oesophagus in the neck. Should the patient withstand this massive procedure, his brief period of survival may very likely be marred by frequent episodes of bitter and bilious regurgitation. As a simpler procedure giving more effective palliation it would appear preferable to use the substernal oesophago-jejunostomy of Robertson and Sarjeant, or the subcutaneous oesophagoplasty of Yudin and Ravitch. In selected cases this palliative operation would be supple-
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mented by treatment to the primary tumour with supervoltage radiation therapy. With benign strictures of the upper thoracic oesophagus the objectives should be the same as those indicated for similar lesions of the midthoracic oesophagus. Thus one would favour some method of by-passing the obstruction by interposing a loop of small or large bowel anastomosed to the oesophagus above and below the narrowed area. This would, of necessity, require three incisions, one in the abdomen for preparation of the loop, one in the thorax for anastomosis below the stricture, and one in the neck for anastomosis above the stricture. The author was privileged to assist his senior colleague, Dr. F. G. Kergin, in an operation of this type. The patient had a long intractable stricture of the upper thoracic oesophagus which was by-passed by a loop of transverse colon anastomosed to the side of the oesophagus above and below the lesion. This case, as reported elsewhere,26 has been a brilliant success and encourages us to attempt it in future problems of a similar nature. In performing these operations, the laparotomy should, of course, be performed first, and the vascular arrangement in the mesentery of jejunum and colon carefully studied. If it appears unlikely that a loop of sufficient length can be obtained to reach easily through the chest into the neck, the best alternative is to mobilize the proximal jejunum as far as possible for transplantation through an antethoracic subcutaneous tunnel. If this fails to reach the neck, it can at a subsequent operation be connected by a skin tube to the end of the cervical oesophagus as advised by Yudin.Is Although prolonged and tiresome, this type of operation has, in relation to benign lesions, the great advantage that it involves little risk to the patient's life. CONCLUSION
During the past two decades most surgeons on this Continent concerned with oesophageal replacement have concentrated on developing techniques for elevating the stomach to higher and higher levels in the chest. Growing awareness of the functional imperfections associated with oesophago-gastric anastomoses is responsible for the present tendency to explore other methods of reconstruction involving the use of jejunum, colon, and plastic tubes. These alternative procedures have been described because it is felt they merit extensive trial. It must, however, be emphasized that there has not yet been accumulated sufficient experience with the newer methods of oesophagoplasty to indicate with assurance the extent of their applicability or the degree of risk associated with them. It is clear that, in regard to oesophageal reconstruction, one must keep an open mind, continue to seek improved methods, and submit each to the unbiased judgment of the passing years.
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