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Reconstruction of the Thoracic Esophagus by Means of a Right Colon Transplant
Reconstruction of the Thoracic Esophagus by Means of a Right Colon Transplant From the Division of Surgery, Presbyterian-St. Luke's Hospital, Chicago, Illinois
RICHARD A. TARIZZO, M.D.; ANDRES GABEL, M.D. E. WILSON STAUB, M.D.; STEVEN G. ECONOMOU, M.D., F.A.C.S.
REPLACEMENT of the diseased esophagus from the cervical portion to the stomach by interposition of the right colon is a major operative procedure which is being performed with increasing frequency and safety. This is a description of the operative technique with examples of the role such a procedure may play in the management of esophageal cancer, esophageal stenosis and tracheo-esophageal fistula. HISTORICAL BACKGROUND
SKIN TUBES. Pedicle Grafts. A subcutaneous skin tube to bypass the obstructed esophagus from its cervical portion to the stomach was first proposed and utilized in 1894 by Bircher. A number of modifications have been used; however, cicatrization of the skin tube and the development of stubborn gastrocutaneous fistulas with painful and debilitating dermatitis discourage its use. Free Skin Grafts. In 1917 Esser described two cases in which Thiersch grafts were placed on stents and used in subcutaneous tunnels. Others have used skin grafts supported by tantalum mesh to bridge esophageal defects. JEJUNAL TRANSPLANTS. Jejunal transplants were first used successfully in 1907 by Roux and by Herzen. 7 • 12 Modifications were made with and without skin tubes connecting the cervical esophagus to the jejunal transplant. Attempts to mobilize long segments of the jejunum with an adequate vascular supply met with a high incidence of failures in this respect. There was also a high incidence of jejunal ulceration when the transplant was anastomosed to the stomach. By 1944 Yudin,12 who had 11
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the widest experience with esophagojejunostomies, reported on the difficulty, risk and sometimes impossibility of performing total esophagoplasty. In a review of jejunal transplants by Mes 8 in 1948 he stated that more jejunal transplants failed than succeeded. STOMACH TUBES. Experimental use of the stomach and tubes formed from the stomach and transplanted subcutaneously was described in 1905 by Beck and Carrell. 2 There were subsequent modifications and human applications. Adams and Phemister, l in 1938, first reported the intrathoracic placement of such an esophageal substitute in a patient with carcinoma of the lower one-third of the esophagus. Since that time the level of the esophagogastric anastomosis rose higher into the neck until in 1948 Garlock' described gastropharyngeal anastomosis. The main disadvantages of using the stomach are the difficulty in carrying the stomach up into the neck and regurgitation of the gastric juices with resulting esophagitis. INERT TUBES. Inert tubes to bridge short gaps of esophageal obstruction were first used by Berman. 3 The results were in a manner encouraging but actually the tubes have not worked well for two reasons, namely the migration of the tube down the esophagus and the development of fistula at the suture line. These complications have occurred particularly when the patient has survived sufficiently long from his cancer for them to become apparent. Also, the method is rarely applicable in curative resections for cancer. HETEROLOGOUS GRAFTS. Javid5 used fresh and preserved homologous aorta as replacement with initially good results. However, the grafts used in seven patients with cancer of the esophagus developed cicatricial stenosis at their midportion by the time the patients died of their cancer. COLON. The colon was first used in esophageal reconstruction in 1911 when Kelling and Vulliet independently anastomosed one end of the transverse colon to the stomach and brought the other end subcutaneously to the level of the breast. l l A second operation was later performed and the cervical esophagus was anastomosed to the subcutaneous colon by a skin tube. However, such procedures were infrequently used because of the generally poor results. To some degree the lack of ancillary supportive measures such as antibiotics, transfusions and improved anesthesia may have added to the general failure of such procedures. Intense interest was renewed when a number of authors including Orsoni and Toupetl° in 1950 and Kergin 6 in 1953 reported on subcutaneous and endothoracic colon transplants. There followed increasing use and development of this procedure in the therapy of malignant and benign esophageal diseases. PATHOPHYSIOLOGIC CONSIDERATIONS
There were a number of factors which made natural if not mandatory the development of the use of colon as an esophageal substitute. When
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Ochsner9 analyzed 1025 autopsied cases of carcinoma of the esophagus, it was found that 41 per cent of the lesions had not extended outside the esophagus. It was also shown by Scanlonll that, in 79 cases of esophagectomy for cancer, 45 per cent were inadequately resected as determined by the intramural spread of the cancer. In only 20 per cent of the esophagectomies had adequate resection been performed. It became obvious that segmental resection of the esophagus for carcinoma was generally inadequate. It is natural that the surgeon, fearful of being unable to reconstruct the esophagus, will tend either to perform inadequate resections or to abandon surgery for such a disease. Appropriately, the search was directed to methods of replacing the esophagus. The colon makes a desirable substitute because, with few exceptions, the surgeon can develop from it a sufficiently vascular transplant long enough to reach from the stomach to the neck. Because the colon has large vascular arcades with the marginal arteries close to the bowel, any increase in the length of the vascular arcades, by dividing the right colic artery from the superior mesenteric artery, results in an equal increase in the length of the colon. PREOPERATIVE EVALUATION AND PREPARATION
A complete history and physical examination are essential, and any cQexisting medical problems must be evaluated and corrected as necessary and if possible. The laboratory determinations are those necessary before any major operation. In addition, a barium enema is necessary to assure the surgeon that a normal colon is present. Esophagoscopy and a barium swallow will have been done and, except in the presence of a stricture, bronchoscopy should also be performed. The food intake of patients requiring esophageal reconstructive procedures frequently is inadequate, with the consequent loss of a considerable amount of weight. Therefore, assessment of nutritional status is of great importance. A feeding gastrostomy or jejunostomy will have been performed in those cases of esophageal carcinoma treated by thoracic esophagectomy with colon transplant planned for a second stage. If the disease is benign and the patient is in poor nutritional state, gastrostomy should be performed and reconstructive surgery delayed until the patient's nutritional state is restored by high protein, high caloric gastrostomy feedings. Prior to surgery the patient is placed on a bowel sterilization regimen consisting of one of the nonabsorbable sulfa compounds and/or neomycin, low residue diet, enemas and cathartics. For 48 hours prior to operation the patient takes only a liquid diet. Showers with a medicated soap twice daily are encouraged. The patient is instructed in breathing exercises which enable him to more readily perform this important function postoperatively.
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ANESTHESIA, POSITIONING, AND THE INCISIONS
Endotracheal anesthesia is mandatory because of the occasional accidental entry into the pleural cavity while developing the retrosternal tunnel and because of the draping of the head for the cervical procedures. The patient is placed in the supine position with a small sandbag beneath the right scapula. The skin is prepared in the preferred manner from the face to the midthighs. A desirable draping is one of an adhesive plastic which covers the entire field from face to midthighs. Head drapes are placed in the usual fashion and the operative field is then blocked off by towels so that only one side of the neck and a 4-inch wide strip of plastic-covered skin is exposed from sternal notch to just above the pubis. The preferred abdominal incision is the midline, extending from the xiphoid to 2 or 3 inches below the umbilicus (Fig. 1). Such an incision is rapidly made, provides adequate exposure and is easily closed. The cervical incision will depend on whether or not the patient has had a previous thoracic esophagectomy with cervical esophagostomy. In the former instance, a J-shaped incision along the anterior border of the sternocleidomastoid muscle is preferred for ease in exposure, but a transverse incision may be employed for better cosmetic result. In the presence of a previous esophagostomy the old scar is excised, elliptically surrounding the esophagostoma (Fig. 6). OPERATIVE PROCEDURE
Mobilization of the Right Colon and Treatment of Its Vessels
The abdomen is thoroughly explored following its entry, with particular attention to the condition of the colon and, in the case of esophageal carcinoma, the presence or absence of metastasis to the liver and left gastric and celiac nodes. If exploration is satisfactory, the first important step of right colon mobilization is undertaken. This is performed in the same manner as for a right hemicolectomy, with particular attention paid to preservation of the colonic vasculature, especially the more vulnerable venous system (Fig. 1). The hepatocolic ligament is divided and the right half of the omentum removed from the colon and stomach to a site distal to the middle colic artery. While mobilizing the ascending and transverse colon and reflecting it medially, one must be careful not to injure: (a) the right ureter which is uncovered, (b) the retroperitoneal duodenum, and (c) the middle colic vessels during the division and ligation of the hepatocolic and gastrocolic ligaments. The arterial supply to the proximal half of the colon is identified and studied. This may be facilitated by transillumination of the right colon as it is held up (Fig. 2). The most common pattern is for the middle,
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rCi
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Fig. 1. A, Depicts the preferred midline abdominal incision and the hockey-stick cervical incision. B, The darkened area represents the length of the intestine to be mobilized. The colon mobilization is begun as for a right hemicolectomy (C) and carried to the midtransverse colon (D).
right and ileocolic arteries to arise separately from the superior mesenteric artery. In this situation it is possible to preserve both the middle and right colic vessels. More common variations include the origin of the right colic from either the ileocolic or middle colic artery. In any case the ileocolic vessels must be sacrificed near their origin, but the effect of their occlusion should be determined prior to final ligation and division. The ileocolic vessels are isolated near their origin and occluded in continuity by two "bulldog" clamps (Fig. 2). A period of 10 to 15 minutes should elapse before color and viability of the cecum is determined. During this waiting period the surgeon may perform several short procedures which mayor may not be required in each case, such as vagotomy, gastrostomy, appendectomy or he may begin the neck dissection. If after this period the viability of the cecum is found to be satisfactory, the ligation and division of the ileocolic vessels are carried out
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Fig. 2. By lifting the right colon and making use of transillumination the vasculature to the right colon can be determined. Provisional "bulldog" clamps are placed on the ileocolic vessels. Insert depicts the most common anatomic location of_middle colic, right colic and ileocolic vessels
and mobilization of the right colon is completed by dividing the mesentery along the superior mesenteric artery to the origin to the right or middle colic artery, depending upon the anatomic situation encountered (Fig. 3). Determination of Colon Length
Crushing clamps are placed across the terminal ileum which is transected. The distal segment of ileum is tied with cord tape and covered with a rubber dam to minimize contamination. This segment of terminal ileum is used as a tractor for the colon transplant as it is pulled retrosternally. If the colon transplant is too short, then the right colic artery will have to be transected for additional length, after again testing for viability.
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Fig. 3. Demonstrates the appearance of the mobilized right colon with transection of the ileum and of the transverse colon distal to the middle colic artery.
The colon segment may be passed posterior to the stomach to obtain the greatest length of the vascular pedicle. This is performed by making an opening in the lower portion of the gastrohepatic ligament and pulling the colon through this opening. It is next necessary to determine the site of transection of the transverse colon, always distal to the midcolic artery. The exact site is selected by retracting the stomach into a dependent position or the position it
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will have following a gastrostomy. Then by holding the cecum at the level of the neck the length of colon needed for an anastomosis to the anterior surface of the antrum or body of the stomach can be determined. If the middle or right colic artery compresses the prepyloric area to any degree as it crosses it antNiorly it is advisable to bring the transplant posterior to the stomach. This was done in one case in order to save the right colic artery which branched from the superior mesenteric artery and compressed the prepyloric area. The ileocolostomy may be performed at this stage while a second team begins the cervical dissection (Fig. 4). We prefer to use interrupted 3-0 silk for the seromuscular layers and continuous 3-0 chromic catgut for the mucosa. The mesenteries of the ileum and transverse colon are reapproximated with interrupted or continuous sutures. Cervical Dissection
The previously mentioned hockey-stick incision or a transverse thyroidectomy incision is made and the skin flaps are developed deep to the platysma (Fig. 5). The superficial cervical fascia is incised and the sternocleidomastoid muscle and carotid sheath are retracted laterally and the thyroid and trachea medially. The middle thyroid vein and inferior thyroid artery and vein are divided and the esophagus is freed by blunt finger dissection, taking care not to injure the right recurrent laryngeal nerve. Transection of the lower cervical esophagus is performed by placing two lateral sutures to avoid retraction into the chest. The esophagus is then transected and one or two layers of interrupted silk sutures are used to close the lumen. An esophagocutaneous stoma may easily be constructed at this stage by suturiu,g the esophagus to the skin with 3-0 catgut. .' , If an esophagectomy has been performed previously, the skin incision is made to encompass the esophag~al E!toma. The upper cervical esophagus is mobilized by sharp technique" (Fig. 6). The Retrosternal Tunnel
As depicted in Figure 6, there is a potential space posterior to the sternum and anterior to the pericardium, pleural cavities and the great vessels. We prefer to begin the development of this space from the abdominal side because of the real danger of damaging the innominate veins should the wrong tissue plane be entered from the cervical side. The xiphoid may be safely excised if necessary. The retrosternal space is entered from the abdominal side by gently spreading the blades of the scissors in the plane just beneath the periosteum of the sternum. The remainder of the dissection is performed by the surgeon's index finger and hand. Continuing the substernal dissection in this manner, it is possible to remain superficial to the middle cervical fascia which continues from
e t s e s e e d e m
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Fig. 4. A-E, The end-to-end ileotransverse colostomy may be performed in any desired manner. We use continuous silk for the posterior seromuscular layer, continuous catgut for the mucosa and submucosa and interrupted silk for the anterior seromuscular layers.
the neck to blend with endothoracic fascia of the chest and the fibrous pericardium. The dissection is continued until the index finger protrudes above the sternal notch. To accomplish this the surgeon's entire hand must pass under the sternum. This is assurance that the tunnel will be of adequate size and will accept the colon transplant with ease. It is also important to avoid constriction of the colon at the thoracic inlet. To
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Fig. 5. The neck incision preferred is one along the anterior border of the sternocleidomastoid muscle (center). This muscle is exposed (A), retracted laterally with the carotid sheath (B) and the middle thyroid vein and inferior thyroid artery and vein divided (C). Finger dissection (D) is a safe way to mobilize the esophagus which is then divided (E). If this is a preliminary esophagostomy the distal end is closed with one or two layers of interrupted silk (F).
minimize this risk the anterior cervical fascia at the thoracic inlet is enlarged to admit three fingers, at the same time protecting the great vessels posterior to the endothoracic fascia with the hand in the retrosternal position.
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Fig. 6. Where there has been a pre-existing esophagostomy the skin incision encompasses the esophagostoma (A) and the proximal esophagus dissected by sharp technique (B). The retrosternal tunnel can more safely be started from the abdominal side (C) with a finger protecting the innominate vein (D) during the upp('r dissel'tion. The sagittal view (E) depicts this anatomy. To insure an adequate retrosternal tunnel the surgeon's entire hand must pass up from below (F) and a 2 to 3 finger opening be present from above.
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Fig. 7. With the cecum in the neck (A) the ileum is transected (B) and closed in two layers with continuous catgut for the mucosa (C) and interrupted silk for the seromuscular layer (D). The most convenient site is chosen for the esophagocolostomy and often this is at the site of appendiceal resection (E). The esophageal stoma is freshened and the anastomosis performed with interrupted catgut for the inner layer and with the knots facing inwardly. The outer layer is with interrupted silk (F, G, H). The wound may be left open for inspection of cecal viability for the first few postoperative days.
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One of the pleural cavities may be entered during this dissection, hence it is always advisable to obtain a portable chest roentgenogram at the conclusion of the operative procedure. Should pneumothorax be present, the usual underwater drainage is instituted for 24 to 48 hours postoperatively. The right colon is now brought through the retrosternal tunnel by applying gentle traction on the long cord tape tied to the ileal stump and passed through the tunnel. It is usually also necessary to assist the passage of the colon from below. Careful attention should be made to assure there is no twisting of the vascular pedicle. Preparation of the Cecum and the Esophagocolostomy
With the cecum in the neck, the ileum is excised flush with the cecal wall, employing a two-layer closure of catgut for the mucosa and submucosa, and 3-0 silk for the seromuscular layers (Fig. 7). The site for the esophagocolic anastomosis is now selected. Frequently it may be tailored to an opening formed by excising a button of cecum when the appendix is removed, which is done in any case. The anastomosis is carried out in two layers, again employing a mucosal and submucosal layer of interrupted 3-0 chromic catgut with the knots so tied as to reside inside the lumen, and an outer layer of interrupted 3-0 silk. The cecum is "rolled" over the anastomosis by taking wider bites in it than in the esophagus, assuring a more adequate lumen. The cecum is "tacked" to the cervical fascia to lessen tension on the anastomosis. A soft Penrose drain is brought through a stab wound lateral to the sternocleidomastoid muscle. The platysma and skin are closed as depicted, leaving two or three sutures untied to allow for inspection of the anastomosis and the viability of the cecum on the second and third postoperative days. If these are satisfactory the sutures may then be tied. These precautions also minimize the accumulation of seromas around the anastomosis. Cologastrostomy, Gastrostomy and Abdominal Closure If two teams are involved in this procedure, these steps are performed simultaneously with the work in the neck. The distal end of the colon transplant is anastomosed to a convenient site on the anterior surface of the stomach above the antrum (Fig. 8). The exact site is unimportant but it should be placed so that the colon makes a straight alignment with the stomach. If the anastomosis is located too high, an S-shaped loop of colon may form and subsequently impede food passage by gravity. Again, 3-0 chromic catgut is employed for the mucosal-submucosal layer, and 3-0 silk for the seromuscular layer. A gastrostomy is performed if it has not been previously done. This is to provide decompression during the early postoperative period and may be used later for providing nutrition before the patient is allowed a full diet. We prefer to use a large Foley catheter brought out through a left upper quadrant stab wound,
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Fig. 8. The cologastrostomy will have been performed at the same time as the cervical surgery and (A) depicts the method of swinging up the colon. The swing may be lateral or ventral, whichever least compromises the vascular pedicle. The site of cologastric anastomosis (B) is not too important as long as there is a straight alignment of these structures to allow for easy gravitational fall of food. The anastomotic technique (C-F) is the same as for the ileotransverse colostomy but may be done in a number of satisfactory ways.
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Fig. 9. Diagram showing the completed operation.
suturing the stomach to the anterior abdominal wall around the gastrostomy opening. The ileocolostomy andcologastrostomy sites are drained, usually through stab wounds. The midline abdominal incision is closed, usually employing retention sutures of wire or heavy nylon as well as sutures of 2-0 silk on heavy chromic catgut to reapproximate the linea alba. Figure 9 illustrates diagrammatically the completed operation. POSTOPERATIVE CARE
As mentioned above, a portable chest roentgenogram is taken in the operating room at the conclusion of the operation and immediately developed. If a pneumothorax is present-ahnost always due to tearing the pleura while developing the retrosternal tunnel-closed chest underwater drainage is instituted and continued until there is no more escape of air and the lung is fully expanded, usually 24 to 48 hours postoperatively. Intravenous fluids are given until peristalsis returns at which time high protein, high caloric, high vitamin gastrostomy feedings are begun. Antibiotics are employed ahnost routinely.
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On the second and third day the esophagocolic anastomosis is inspected, and if color and continuity are satisfactory the remaining few skin sutures are tied. Anastomotic integrity is checked by fluoroscopic observation of a swallow of thin barium or Gastrografin between the fifth to seventh day, following which a gradually progressive diet is begun. Postoperative cinefluorography has revealed the passage of barium into the stomach to be dependent upon gravity, colonic peristalsis playing little or no role. RESULTS
Although our series is not large, it should be valuable to illustrate the three major indications for the use of a right colon transplant, namely, reconstruction following thoracic esophagectomy for neoplasm, for esophageal stricture, and for tracheo-esophageal fistula. Esophageal Carcinoma
Mrs. G.C., a 65 year old woman, was admitted in October, 1961 with the complaints of progressive dysphagia, prandial retrosternal distress, and a 15 pound weight loss in the previous nine months. Barium swallow demonstrated an intraluminal mass just below the aortic arch (Fig. 10, A). This was confirmed on esophagoscopy, at which time a biopsy was taken which revealed epidermoid carcinoma. The patient received cobalt-60 teletherapy to the tumor area to a dose of 4500 r in a period of four weeks (Fig. 10, B). Five weeks after completion of therapy she was readmitted for gastrostomy, pyloroplasty and thoracic esophagectomy with cervical esophagostomy. The postoperative course was uneventful and she was discharged on high caloric, high protein, high vitamin gastrostomy feedings. She was again readmitted on February, 1962 for esophageal reconstruction using a right colon transplant. Figure 10, C, demonstrates the result in this patient. Esophageal Stricture
Mrs. G.N., a 30 year old woman, was admitted in January, 1962 with a long esophageal stricture extending distally from the aortic arch (Fig. 11, A). She had lost 75 pounds from a weight of 225 pounds. The stricture proved to be refractory to mercury dilatations. A right colon transplant was substituted for the esophagus, leaving the latter in place. Figure 11, B, demonstrates the postoperative barium swallow. Tracheo-esophageal Fistula
By far the least common of the three indicationE described here is the tracheo-esophageal fistula which is not due to inoperable esophageal
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Fig. 10 (Patient G.C. ). Esophageal cancer. A, The presence of an esophageal carcinoma is confirmed by esophagoscopy. B , Appearance following cobalt-60 teletherapy. This was followed by an esophagectomy and reconst:urtion using a right colon transplant, with the result shown in C.
carcinoma. Mrs. M.S., a 31 year old woman, had received treatment for Hodgkin's disease for nine years, which included steroids and two courses of deep roentgen therapy to the mediastinum. In October, 1961, the patient suddenly coughed up a large amount of foul-smelling thick material, following which ingestion of liquids consistently provoked a cough. A barium swallow (Fig. 12, A) demonstrated a large mediastinal abscess communicating with both the right main bronchus and esopha-
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Fig. 11 (Patient G.N.). Esophageal stricture. A, The stricture is seen extending distally from the aortic arch. It was extremely refractory to mercury dilatations. B, An adequate esophageal substitute using the right colon has been installed.
Fig. 12 (Patient M.S.). Tracheo-esophageal fistula. A, Dramatic view of an esophagobronchial fistula following intensive mediastinal x-ray therapy for Hodgkin's disease. B, The Hodgkin's disease appeared quiescent so a subcutaneous reconstruction using a right colon transplant was performed.
gus. The abscess was drained through a posterior approach and a gastrostomy was performed to provide adequate nutrition. Over the next few months the abscess decreased very little in size and the fistulous openings became even larger until aspiration of her own saliva became a serious problem. The Hodgkin's disease seemed to be
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quiescent. On January 23, 1962 a reconstruction using a right colon transplant was performed. Because of the extensive x-ray treatment to the mediastinum we anticipated difficulty and increased operative risk with the retrosternal dissection. We therefore chose subcutaneous placement of the transposed colon (Fig. 12, B). A tube of gastric fundus was brought out to the skin to allow for continued drainage of the mediastinal abscess and to prevent esophageal reflux which she had experienced preoperatively. The postoperative course was Etormy because of her previous bouts of pulmonary infections and the development of steroid-induced bleeding from gastric ulcers. Although the transplant functioned satisfactorily, the patient ultimately succumbed to bronchopneumonia three months postoperatively. Postmortem examination revealed extensive radiation necrosis of the right lower lobe and right main bronchus, a healed fistulous tract from the esophagus to the mediastinal abscess, a newer tracheo-esophageal fistula and extensive bilateral bronchopneumonia. SUMMARY AND CONCLUSIONS
1. The history of esophageal replacement is briefly outlined, tracing its development through the use of skin tubes, jejunal transplants, gastric tubes, inert tubes, homologous grafts, and colon transplants, the last of which we now favor. 2. The procedure for use of a right colon transplant for esophageal disorders is described and illustrated, with particular attention to technical detail. Our routine for preoperative and postoperative care is outlined. 3. Three of our recent cases are presented as examples of the use of a right colon transplant in esophageal malignancy, stricture and tracheoesophageal fistula. REFERENCES 1. Adams, W. E. and Phemister, D. B.: Carcinoma of lower thoracic esophagus:
2. 3. 4. 5. 6. 7. 8.
Report of successful resection and esophagogastrostomy. J. Thoracic Surg. 7: 621, 1938. Beck, C. and Carrell, A.: Demonstration of specimens illustrating a method of formation of a prethoracic esophagus. Illinois M.J. 7: 463, 1905. Berman, E. F.: Plastic prosthesis in carcinoma of the esophagus. S. CLIN. NORTH AMERICA 36: 883, 1956. Garlock, J. H.: Resection of thoracic esophagus for cancer located above arch of aorta. Cervical esophagogastrostomy. Surgery 24: 1, 1948. Javid, H.: Bridging of esophageal defects with fresh and preserved aortic grafts. Surgical Forum 3: 82, 1952. Kcrgin, F. G.: Esophageal obstruction due to paraffinoma of mediastinum: Reconstruction by intrathoracic colon graft. Ann. Surg. 137: 91, 1953. Mahoney, E. B. and Sherman, C. D.: Total esophagoplasty using intrathoracic right colon. Surgery 35: 937, 1954. Mes, G. M.: New method of esophagoplasty. J. Internat. Coli. Surgeons 11: 270, 1948.
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9. Ochsner, A. and DeBakey, M.: Surgical aspects of cancer of the esophagus. J. Thoracic Surg. 10: 401, 1941. 10. Orsoni, P. and Toupet, A.: Use of the descending colon and left part of the transverse colon for prethoracic esophagoplasty. Presse med. 58: 804, 1950. 11. Scanlon, E. F., Morton, D. R., Walker, J. M. and Watson, W. L.: The case against segmental resection for esophageal carcinoma. Surg. Gynec. & Obst. 101: 290, 1955. 12. Yudin, S. S.: Surgical construction of 80 cases of artificial esophagus. Surg. Gynec. & Obst. 78: 561, 1944. 1753 West Congress Parkway Chicago 12, Illinois (Dr. Economou)
RICHARD A. TARIZZO, M.D.; ANDRES GABEL, M.D. E. WILSON STAUB, M.D.; STEVEN G. ECONOMOU, M.D., F.A.C.S.
REPLACEMENT of the diseased esophagus from the cervical portion to the stomach by interposition of the right colon is a major operative procedure which is being performed with increasing frequency and safety. This is a description of the operative technique with examples of the role such a procedure may play in the management of esophageal cancer, esophageal stenosis and tracheo-esophageal fistula. HISTORICAL BACKGROUND
SKIN TUBES. Pedicle Grafts. A subcutaneous skin tube to bypass the obstructed esophagus from its cervical portion to the stomach was first proposed and utilized in 1894 by Bircher. A number of modifications have been used; however, cicatrization of the skin tube and the development of stubborn gastrocutaneous fistulas with painful and debilitating dermatitis discourage its use. Free Skin Grafts. In 1917 Esser described two cases in which Thiersch grafts were placed on stents and used in subcutaneous tunnels. Others have used skin grafts supported by tantalum mesh to bridge esophageal defects. JEJUNAL TRANSPLANTS. Jejunal transplants were first used successfully in 1907 by Roux and by Herzen. 7 • 12 Modifications were made with and without skin tubes connecting the cervical esophagus to the jejunal transplant. Attempts to mobilize long segments of the jejunum with an adequate vascular supply met with a high incidence of failures in this respect. There was also a high incidence of jejunal ulceration when the transplant was anastomosed to the stomach. By 1944 Yudin,12 who had 11
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the widest experience with esophagojejunostomies, reported on the difficulty, risk and sometimes impossibility of performing total esophagoplasty. In a review of jejunal transplants by Mes 8 in 1948 he stated that more jejunal transplants failed than succeeded. STOMACH TUBES. Experimental use of the stomach and tubes formed from the stomach and transplanted subcutaneously was described in 1905 by Beck and Carrell. 2 There were subsequent modifications and human applications. Adams and Phemister, l in 1938, first reported the intrathoracic placement of such an esophageal substitute in a patient with carcinoma of the lower one-third of the esophagus. Since that time the level of the esophagogastric anastomosis rose higher into the neck until in 1948 Garlock' described gastropharyngeal anastomosis. The main disadvantages of using the stomach are the difficulty in carrying the stomach up into the neck and regurgitation of the gastric juices with resulting esophagitis. INERT TUBES. Inert tubes to bridge short gaps of esophageal obstruction were first used by Berman. 3 The results were in a manner encouraging but actually the tubes have not worked well for two reasons, namely the migration of the tube down the esophagus and the development of fistula at the suture line. These complications have occurred particularly when the patient has survived sufficiently long from his cancer for them to become apparent. Also, the method is rarely applicable in curative resections for cancer. HETEROLOGOUS GRAFTS. Javid5 used fresh and preserved homologous aorta as replacement with initially good results. However, the grafts used in seven patients with cancer of the esophagus developed cicatricial stenosis at their midportion by the time the patients died of their cancer. COLON. The colon was first used in esophageal reconstruction in 1911 when Kelling and Vulliet independently anastomosed one end of the transverse colon to the stomach and brought the other end subcutaneously to the level of the breast. l l A second operation was later performed and the cervical esophagus was anastomosed to the subcutaneous colon by a skin tube. However, such procedures were infrequently used because of the generally poor results. To some degree the lack of ancillary supportive measures such as antibiotics, transfusions and improved anesthesia may have added to the general failure of such procedures. Intense interest was renewed when a number of authors including Orsoni and Toupetl° in 1950 and Kergin 6 in 1953 reported on subcutaneous and endothoracic colon transplants. There followed increasing use and development of this procedure in the therapy of malignant and benign esophageal diseases. PATHOPHYSIOLOGIC CONSIDERATIONS
There were a number of factors which made natural if not mandatory the development of the use of colon as an esophageal substitute. When
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Ochsner9 analyzed 1025 autopsied cases of carcinoma of the esophagus, it was found that 41 per cent of the lesions had not extended outside the esophagus. It was also shown by Scanlonll that, in 79 cases of esophagectomy for cancer, 45 per cent were inadequately resected as determined by the intramural spread of the cancer. In only 20 per cent of the esophagectomies had adequate resection been performed. It became obvious that segmental resection of the esophagus for carcinoma was generally inadequate. It is natural that the surgeon, fearful of being unable to reconstruct the esophagus, will tend either to perform inadequate resections or to abandon surgery for such a disease. Appropriately, the search was directed to methods of replacing the esophagus. The colon makes a desirable substitute because, with few exceptions, the surgeon can develop from it a sufficiently vascular transplant long enough to reach from the stomach to the neck. Because the colon has large vascular arcades with the marginal arteries close to the bowel, any increase in the length of the vascular arcades, by dividing the right colic artery from the superior mesenteric artery, results in an equal increase in the length of the colon. PREOPERATIVE EVALUATION AND PREPARATION
A complete history and physical examination are essential, and any cQexisting medical problems must be evaluated and corrected as necessary and if possible. The laboratory determinations are those necessary before any major operation. In addition, a barium enema is necessary to assure the surgeon that a normal colon is present. Esophagoscopy and a barium swallow will have been done and, except in the presence of a stricture, bronchoscopy should also be performed. The food intake of patients requiring esophageal reconstructive procedures frequently is inadequate, with the consequent loss of a considerable amount of weight. Therefore, assessment of nutritional status is of great importance. A feeding gastrostomy or jejunostomy will have been performed in those cases of esophageal carcinoma treated by thoracic esophagectomy with colon transplant planned for a second stage. If the disease is benign and the patient is in poor nutritional state, gastrostomy should be performed and reconstructive surgery delayed until the patient's nutritional state is restored by high protein, high caloric gastrostomy feedings. Prior to surgery the patient is placed on a bowel sterilization regimen consisting of one of the nonabsorbable sulfa compounds and/or neomycin, low residue diet, enemas and cathartics. For 48 hours prior to operation the patient takes only a liquid diet. Showers with a medicated soap twice daily are encouraged. The patient is instructed in breathing exercises which enable him to more readily perform this important function postoperatively.
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ANESTHESIA, POSITIONING, AND THE INCISIONS
Endotracheal anesthesia is mandatory because of the occasional accidental entry into the pleural cavity while developing the retrosternal tunnel and because of the draping of the head for the cervical procedures. The patient is placed in the supine position with a small sandbag beneath the right scapula. The skin is prepared in the preferred manner from the face to the midthighs. A desirable draping is one of an adhesive plastic which covers the entire field from face to midthighs. Head drapes are placed in the usual fashion and the operative field is then blocked off by towels so that only one side of the neck and a 4-inch wide strip of plastic-covered skin is exposed from sternal notch to just above the pubis. The preferred abdominal incision is the midline, extending from the xiphoid to 2 or 3 inches below the umbilicus (Fig. 1). Such an incision is rapidly made, provides adequate exposure and is easily closed. The cervical incision will depend on whether or not the patient has had a previous thoracic esophagectomy with cervical esophagostomy. In the former instance, a J-shaped incision along the anterior border of the sternocleidomastoid muscle is preferred for ease in exposure, but a transverse incision may be employed for better cosmetic result. In the presence of a previous esophagostomy the old scar is excised, elliptically surrounding the esophagostoma (Fig. 6). OPERATIVE PROCEDURE
Mobilization of the Right Colon and Treatment of Its Vessels
The abdomen is thoroughly explored following its entry, with particular attention to the condition of the colon and, in the case of esophageal carcinoma, the presence or absence of metastasis to the liver and left gastric and celiac nodes. If exploration is satisfactory, the first important step of right colon mobilization is undertaken. This is performed in the same manner as for a right hemicolectomy, with particular attention paid to preservation of the colonic vasculature, especially the more vulnerable venous system (Fig. 1). The hepatocolic ligament is divided and the right half of the omentum removed from the colon and stomach to a site distal to the middle colic artery. While mobilizing the ascending and transverse colon and reflecting it medially, one must be careful not to injure: (a) the right ureter which is uncovered, (b) the retroperitoneal duodenum, and (c) the middle colic vessels during the division and ligation of the hepatocolic and gastrocolic ligaments. The arterial supply to the proximal half of the colon is identified and studied. This may be facilitated by transillumination of the right colon as it is held up (Fig. 2). The most common pattern is for the middle,
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..
rCi
•
Fig. 1. A, Depicts the preferred midline abdominal incision and the hockey-stick cervical incision. B, The darkened area represents the length of the intestine to be mobilized. The colon mobilization is begun as for a right hemicolectomy (C) and carried to the midtransverse colon (D).
right and ileocolic arteries to arise separately from the superior mesenteric artery. In this situation it is possible to preserve both the middle and right colic vessels. More common variations include the origin of the right colic from either the ileocolic or middle colic artery. In any case the ileocolic vessels must be sacrificed near their origin, but the effect of their occlusion should be determined prior to final ligation and division. The ileocolic vessels are isolated near their origin and occluded in continuity by two "bulldog" clamps (Fig. 2). A period of 10 to 15 minutes should elapse before color and viability of the cecum is determined. During this waiting period the surgeon may perform several short procedures which mayor may not be required in each case, such as vagotomy, gastrostomy, appendectomy or he may begin the neck dissection. If after this period the viability of the cecum is found to be satisfactory, the ligation and division of the ileocolic vessels are carried out
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Fig. 2. By lifting the right colon and making use of transillumination the vasculature to the right colon can be determined. Provisional "bulldog" clamps are placed on the ileocolic vessels. Insert depicts the most common anatomic location of_middle colic, right colic and ileocolic vessels
and mobilization of the right colon is completed by dividing the mesentery along the superior mesenteric artery to the origin to the right or middle colic artery, depending upon the anatomic situation encountered (Fig. 3). Determination of Colon Length
Crushing clamps are placed across the terminal ileum which is transected. The distal segment of ileum is tied with cord tape and covered with a rubber dam to minimize contamination. This segment of terminal ileum is used as a tractor for the colon transplant as it is pulled retrosternally. If the colon transplant is too short, then the right colic artery will have to be transected for additional length, after again testing for viability.
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Fig. 3. Demonstrates the appearance of the mobilized right colon with transection of the ileum and of the transverse colon distal to the middle colic artery.
The colon segment may be passed posterior to the stomach to obtain the greatest length of the vascular pedicle. This is performed by making an opening in the lower portion of the gastrohepatic ligament and pulling the colon through this opening. It is next necessary to determine the site of transection of the transverse colon, always distal to the midcolic artery. The exact site is selected by retracting the stomach into a dependent position or the position it
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will have following a gastrostomy. Then by holding the cecum at the level of the neck the length of colon needed for an anastomosis to the anterior surface of the antrum or body of the stomach can be determined. If the middle or right colic artery compresses the prepyloric area to any degree as it crosses it antNiorly it is advisable to bring the transplant posterior to the stomach. This was done in one case in order to save the right colic artery which branched from the superior mesenteric artery and compressed the prepyloric area. The ileocolostomy may be performed at this stage while a second team begins the cervical dissection (Fig. 4). We prefer to use interrupted 3-0 silk for the seromuscular layers and continuous 3-0 chromic catgut for the mucosa. The mesenteries of the ileum and transverse colon are reapproximated with interrupted or continuous sutures. Cervical Dissection
The previously mentioned hockey-stick incision or a transverse thyroidectomy incision is made and the skin flaps are developed deep to the platysma (Fig. 5). The superficial cervical fascia is incised and the sternocleidomastoid muscle and carotid sheath are retracted laterally and the thyroid and trachea medially. The middle thyroid vein and inferior thyroid artery and vein are divided and the esophagus is freed by blunt finger dissection, taking care not to injure the right recurrent laryngeal nerve. Transection of the lower cervical esophagus is performed by placing two lateral sutures to avoid retraction into the chest. The esophagus is then transected and one or two layers of interrupted silk sutures are used to close the lumen. An esophagocutaneous stoma may easily be constructed at this stage by suturiu,g the esophagus to the skin with 3-0 catgut. .' , If an esophagectomy has been performed previously, the skin incision is made to encompass the esophag~al E!toma. The upper cervical esophagus is mobilized by sharp technique" (Fig. 6). The Retrosternal Tunnel
As depicted in Figure 6, there is a potential space posterior to the sternum and anterior to the pericardium, pleural cavities and the great vessels. We prefer to begin the development of this space from the abdominal side because of the real danger of damaging the innominate veins should the wrong tissue plane be entered from the cervical side. The xiphoid may be safely excised if necessary. The retrosternal space is entered from the abdominal side by gently spreading the blades of the scissors in the plane just beneath the periosteum of the sternum. The remainder of the dissection is performed by the surgeon's index finger and hand. Continuing the substernal dissection in this manner, it is possible to remain superficial to the middle cervical fascia which continues from
e t s e s e e d e m
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Fig. 4. A-E, The end-to-end ileotransverse colostomy may be performed in any desired manner. We use continuous silk for the posterior seromuscular layer, continuous catgut for the mucosa and submucosa and interrupted silk for the anterior seromuscular layers.
the neck to blend with endothoracic fascia of the chest and the fibrous pericardium. The dissection is continued until the index finger protrudes above the sternal notch. To accomplish this the surgeon's entire hand must pass under the sternum. This is assurance that the tunnel will be of adequate size and will accept the colon transplant with ease. It is also important to avoid constriction of the colon at the thoracic inlet. To
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Fig. 5. The neck incision preferred is one along the anterior border of the sternocleidomastoid muscle (center). This muscle is exposed (A), retracted laterally with the carotid sheath (B) and the middle thyroid vein and inferior thyroid artery and vein divided (C). Finger dissection (D) is a safe way to mobilize the esophagus which is then divided (E). If this is a preliminary esophagostomy the distal end is closed with one or two layers of interrupted silk (F).
minimize this risk the anterior cervical fascia at the thoracic inlet is enlarged to admit three fingers, at the same time protecting the great vessels posterior to the endothoracic fascia with the hand in the retrosternal position.
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Fig. 6. Where there has been a pre-existing esophagostomy the skin incision encompasses the esophagostoma (A) and the proximal esophagus dissected by sharp technique (B). The retrosternal tunnel can more safely be started from the abdominal side (C) with a finger protecting the innominate vein (D) during the upp('r dissel'tion. The sagittal view (E) depicts this anatomy. To insure an adequate retrosternal tunnel the surgeon's entire hand must pass up from below (F) and a 2 to 3 finger opening be present from above.
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Fig. 7. With the cecum in the neck (A) the ileum is transected (B) and closed in two layers with continuous catgut for the mucosa (C) and interrupted silk for the seromuscular layer (D). The most convenient site is chosen for the esophagocolostomy and often this is at the site of appendiceal resection (E). The esophageal stoma is freshened and the anastomosis performed with interrupted catgut for the inner layer and with the knots facing inwardly. The outer layer is with interrupted silk (F, G, H). The wound may be left open for inspection of cecal viability for the first few postoperative days.
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One of the pleural cavities may be entered during this dissection, hence it is always advisable to obtain a portable chest roentgenogram at the conclusion of the operative procedure. Should pneumothorax be present, the usual underwater drainage is instituted for 24 to 48 hours postoperatively. The right colon is now brought through the retrosternal tunnel by applying gentle traction on the long cord tape tied to the ileal stump and passed through the tunnel. It is usually also necessary to assist the passage of the colon from below. Careful attention should be made to assure there is no twisting of the vascular pedicle. Preparation of the Cecum and the Esophagocolostomy
With the cecum in the neck, the ileum is excised flush with the cecal wall, employing a two-layer closure of catgut for the mucosa and submucosa, and 3-0 silk for the seromuscular layers (Fig. 7). The site for the esophagocolic anastomosis is now selected. Frequently it may be tailored to an opening formed by excising a button of cecum when the appendix is removed, which is done in any case. The anastomosis is carried out in two layers, again employing a mucosal and submucosal layer of interrupted 3-0 chromic catgut with the knots so tied as to reside inside the lumen, and an outer layer of interrupted 3-0 silk. The cecum is "rolled" over the anastomosis by taking wider bites in it than in the esophagus, assuring a more adequate lumen. The cecum is "tacked" to the cervical fascia to lessen tension on the anastomosis. A soft Penrose drain is brought through a stab wound lateral to the sternocleidomastoid muscle. The platysma and skin are closed as depicted, leaving two or three sutures untied to allow for inspection of the anastomosis and the viability of the cecum on the second and third postoperative days. If these are satisfactory the sutures may then be tied. These precautions also minimize the accumulation of seromas around the anastomosis. Cologastrostomy, Gastrostomy and Abdominal Closure If two teams are involved in this procedure, these steps are performed simultaneously with the work in the neck. The distal end of the colon transplant is anastomosed to a convenient site on the anterior surface of the stomach above the antrum (Fig. 8). The exact site is unimportant but it should be placed so that the colon makes a straight alignment with the stomach. If the anastomosis is located too high, an S-shaped loop of colon may form and subsequently impede food passage by gravity. Again, 3-0 chromic catgut is employed for the mucosal-submucosal layer, and 3-0 silk for the seromuscular layer. A gastrostomy is performed if it has not been previously done. This is to provide decompression during the early postoperative period and may be used later for providing nutrition before the patient is allowed a full diet. We prefer to use a large Foley catheter brought out through a left upper quadrant stab wound,
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Fig. 8. The cologastrostomy will have been performed at the same time as the cervical surgery and (A) depicts the method of swinging up the colon. The swing may be lateral or ventral, whichever least compromises the vascular pedicle. The site of cologastric anastomosis (B) is not too important as long as there is a straight alignment of these structures to allow for easy gravitational fall of food. The anastomotic technique (C-F) is the same as for the ileotransverse colostomy but may be done in a number of satisfactory ways.
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Fig. 9. Diagram showing the completed operation.
suturing the stomach to the anterior abdominal wall around the gastrostomy opening. The ileocolostomy andcologastrostomy sites are drained, usually through stab wounds. The midline abdominal incision is closed, usually employing retention sutures of wire or heavy nylon as well as sutures of 2-0 silk on heavy chromic catgut to reapproximate the linea alba. Figure 9 illustrates diagrammatically the completed operation. POSTOPERATIVE CARE
As mentioned above, a portable chest roentgenogram is taken in the operating room at the conclusion of the operation and immediately developed. If a pneumothorax is present-ahnost always due to tearing the pleura while developing the retrosternal tunnel-closed chest underwater drainage is instituted and continued until there is no more escape of air and the lung is fully expanded, usually 24 to 48 hours postoperatively. Intravenous fluids are given until peristalsis returns at which time high protein, high caloric, high vitamin gastrostomy feedings are begun. Antibiotics are employed ahnost routinely.
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On the second and third day the esophagocolic anastomosis is inspected, and if color and continuity are satisfactory the remaining few skin sutures are tied. Anastomotic integrity is checked by fluoroscopic observation of a swallow of thin barium or Gastrografin between the fifth to seventh day, following which a gradually progressive diet is begun. Postoperative cinefluorography has revealed the passage of barium into the stomach to be dependent upon gravity, colonic peristalsis playing little or no role. RESULTS
Although our series is not large, it should be valuable to illustrate the three major indications for the use of a right colon transplant, namely, reconstruction following thoracic esophagectomy for neoplasm, for esophageal stricture, and for tracheo-esophageal fistula. Esophageal Carcinoma
Mrs. G.C., a 65 year old woman, was admitted in October, 1961 with the complaints of progressive dysphagia, prandial retrosternal distress, and a 15 pound weight loss in the previous nine months. Barium swallow demonstrated an intraluminal mass just below the aortic arch (Fig. 10, A). This was confirmed on esophagoscopy, at which time a biopsy was taken which revealed epidermoid carcinoma. The patient received cobalt-60 teletherapy to the tumor area to a dose of 4500 r in a period of four weeks (Fig. 10, B). Five weeks after completion of therapy she was readmitted for gastrostomy, pyloroplasty and thoracic esophagectomy with cervical esophagostomy. The postoperative course was uneventful and she was discharged on high caloric, high protein, high vitamin gastrostomy feedings. She was again readmitted on February, 1962 for esophageal reconstruction using a right colon transplant. Figure 10, C, demonstrates the result in this patient. Esophageal Stricture
Mrs. G.N., a 30 year old woman, was admitted in January, 1962 with a long esophageal stricture extending distally from the aortic arch (Fig. 11, A). She had lost 75 pounds from a weight of 225 pounds. The stricture proved to be refractory to mercury dilatations. A right colon transplant was substituted for the esophagus, leaving the latter in place. Figure 11, B, demonstrates the postoperative barium swallow. Tracheo-esophageal Fistula
By far the least common of the three indicationE described here is the tracheo-esophageal fistula which is not due to inoperable esophageal
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Fig. 10 (Patient G.C. ). Esophageal cancer. A, The presence of an esophageal carcinoma is confirmed by esophagoscopy. B , Appearance following cobalt-60 teletherapy. This was followed by an esophagectomy and reconst:urtion using a right colon transplant, with the result shown in C.
carcinoma. Mrs. M.S., a 31 year old woman, had received treatment for Hodgkin's disease for nine years, which included steroids and two courses of deep roentgen therapy to the mediastinum. In October, 1961, the patient suddenly coughed up a large amount of foul-smelling thick material, following which ingestion of liquids consistently provoked a cough. A barium swallow (Fig. 12, A) demonstrated a large mediastinal abscess communicating with both the right main bronchus and esopha-
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Fig. 11 (Patient G.N.). Esophageal stricture. A, The stricture is seen extending distally from the aortic arch. It was extremely refractory to mercury dilatations. B, An adequate esophageal substitute using the right colon has been installed.
Fig. 12 (Patient M.S.). Tracheo-esophageal fistula. A, Dramatic view of an esophagobronchial fistula following intensive mediastinal x-ray therapy for Hodgkin's disease. B, The Hodgkin's disease appeared quiescent so a subcutaneous reconstruction using a right colon transplant was performed.
gus. The abscess was drained through a posterior approach and a gastrostomy was performed to provide adequate nutrition. Over the next few months the abscess decreased very little in size and the fistulous openings became even larger until aspiration of her own saliva became a serious problem. The Hodgkin's disease seemed to be
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quiescent. On January 23, 1962 a reconstruction using a right colon transplant was performed. Because of the extensive x-ray treatment to the mediastinum we anticipated difficulty and increased operative risk with the retrosternal dissection. We therefore chose subcutaneous placement of the transposed colon (Fig. 12, B). A tube of gastric fundus was brought out to the skin to allow for continued drainage of the mediastinal abscess and to prevent esophageal reflux which she had experienced preoperatively. The postoperative course was Etormy because of her previous bouts of pulmonary infections and the development of steroid-induced bleeding from gastric ulcers. Although the transplant functioned satisfactorily, the patient ultimately succumbed to bronchopneumonia three months postoperatively. Postmortem examination revealed extensive radiation necrosis of the right lower lobe and right main bronchus, a healed fistulous tract from the esophagus to the mediastinal abscess, a newer tracheo-esophageal fistula and extensive bilateral bronchopneumonia. SUMMARY AND CONCLUSIONS
1. The history of esophageal replacement is briefly outlined, tracing its development through the use of skin tubes, jejunal transplants, gastric tubes, inert tubes, homologous grafts, and colon transplants, the last of which we now favor. 2. The procedure for use of a right colon transplant for esophageal disorders is described and illustrated, with particular attention to technical detail. Our routine for preoperative and postoperative care is outlined. 3. Three of our recent cases are presented as examples of the use of a right colon transplant in esophageal malignancy, stricture and tracheoesophageal fistula. REFERENCES 1. Adams, W. E. and Phemister, D. B.: Carcinoma of lower thoracic esophagus:
2. 3. 4. 5. 6. 7. 8.
Report of successful resection and esophagogastrostomy. J. Thoracic Surg. 7: 621, 1938. Beck, C. and Carrell, A.: Demonstration of specimens illustrating a method of formation of a prethoracic esophagus. Illinois M.J. 7: 463, 1905. Berman, E. F.: Plastic prosthesis in carcinoma of the esophagus. S. CLIN. NORTH AMERICA 36: 883, 1956. Garlock, J. H.: Resection of thoracic esophagus for cancer located above arch of aorta. Cervical esophagogastrostomy. Surgery 24: 1, 1948. Javid, H.: Bridging of esophageal defects with fresh and preserved aortic grafts. Surgical Forum 3: 82, 1952. Kcrgin, F. G.: Esophageal obstruction due to paraffinoma of mediastinum: Reconstruction by intrathoracic colon graft. Ann. Surg. 137: 91, 1953. Mahoney, E. B. and Sherman, C. D.: Total esophagoplasty using intrathoracic right colon. Surgery 35: 937, 1954. Mes, G. M.: New method of esophagoplasty. J. Internat. Coli. Surgeons 11: 270, 1948.
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9. Ochsner, A. and DeBakey, M.: Surgical aspects of cancer of the esophagus. J. Thoracic Surg. 10: 401, 1941. 10. Orsoni, P. and Toupet, A.: Use of the descending colon and left part of the transverse colon for prethoracic esophagoplasty. Presse med. 58: 804, 1950. 11. Scanlon, E. F., Morton, D. R., Walker, J. M. and Watson, W. L.: The case against segmental resection for esophageal carcinoma. Surg. Gynec. & Obst. 101: 290, 1955. 12. Yudin, S. S.: Surgical construction of 80 cases of artificial esophagus. Surg. Gynec. & Obst. 78: 561, 1944. 1753 West Congress Parkway Chicago 12, Illinois (Dr. Economou)