Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma

Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma Curative resection is impossible in most patients with carcinoma of the esophagus or malignant tracheoesophageal fistulas, because of local tumor invasion or distant metastases. Optimal palliative therapy in these patients should relieve dysphagia and aspiration and restore the ability to swallow comfortably. This report describes a technique for palliation of carcinoma of the esophagus with a substernal gastric bypass after exclusion of the thoracic esophagus with the GIA surgical stapler. The results of this procedure in 10 patients with advanced malignant disease are discussed. Although postoperative morbidity and mortality rates were high, the quality of life achieved with this method of palliation was gratifying. Substernal gastric bypass of the excluded thoracic esophagus is an effective alternative to feeding tubes, prolonged radiation therapy, esophagogastrectomy; or colon bypass in patients with incurable, malignant esophageal disease.

Mark B. Orringer, M.D. (by invitation), and Herbert Sloan, M.D., Ann Arbor, Mich.

In

over seventy-five per cent of patients with carcinoma of the esophagus, particularly those with malignant tracheoesophageal fistulas, local tumor invasion of distant metastases make a curative resection impossible. 7, 18 Therapy in these patients is palliative and ideally should relieve dysphagia and aspiration while restoring the ability to swallow comfortably. This report describes a technique for palliation of carcinoma of the esophagus with the use of a substernal gastric bypass of the excluded thoracic esophagus. Clinical material

Substernal gastric bypass of the excluded thoracic esophagus has been performed in From the Department of Surgery, Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor, Mich. 48104. Read at the Fifty-fifth Annual Meeting of The American Association for Thoracic Surgery, New York, N. Y., April 14, IS, and 16, 1975. Address for reprints: Mark B. Orringer, M.D., Assistant Professor of Surgery, Section of Thoracic Surgery, The University of Michigan Medical Center, Ann Arbor, Mich. 48104.

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10 patients with surgically incurable esophageal squamous carcinomas (Table I). Seven of these patients had experienced a 20 to 45 pound weight loss. Four patients had tracheoesophageal fistulas. Three had metastases to the celiac axis lymph nodes, and 1 patient had metastases to cervical lymph nodes. Patient 4 had a recurrent upper esophageal malignancy following a course of radiation therapy. Patient 5 had a midesophageal tumor which was found to involve the left main-stem bronchus at bronchoscopy. Patient 6 was severely cachectic, weighing only 60 pounds, and was not believed to be a candidate for esophageal resection. Technique

The operative field includes the entire neck, anterior chest, and abdomen from the level of the mandibles to the pubis. Celiotomy is performed through a midline upper abdominal incision; the gastrocolic ligament, the left gastric artery, gastrohepatic ligament, and left gastroepiploic vessels are

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·, ··,, ,

..

R. gastroepiploic a .

Fig. 1. Mobilization of the stomach for substernal bypass of the excluded esophagus. Note preservation of dual blood supply of the stomach (right gastric and gastroepiploic vessels) . mobilization of the duodenum and head of the pancreas. pyloromyotomy. and the oversewn stapled and divided distal esophagus and cardia.

ligated and divided. The right gastric and gastroepiploic arteries are preserved. All short gastric vessels are ligated and divided, with care taken to avoid injury to the spleen (Fig. 1). Any celiac axis, lesser curvature, or esophagogastric lymph nodes involved with metastatic tumor are dissected away from the stomach to avoid their transfer into the chest. The esophagogastric junction is mobilized and encircled with a Penrose drain. The vagus nerves are divided. With downward traction on the Penrose drain, the distal esophagus is divided at the cardia with the GIA surgical stapler. The esophageal and gastric staple suture lines are oversewn

with running 3-0 Prolene Lembert sutures. A pyloromyotomy or pyloroplasty is performed, and a Kocher maneuver is carried out to gain maximum mobility of the stomach. The stomach is delivered from the peritoneal cavity and placed upon the anterior chest wall, where it can be seen that the gastric fundus, rather than the divided cardia, is that part of the stomach which reaches most superiorly. Next, 2-0 silk sutures are placed in that portion of fundus which reaches most cephalad, and the stomach is returned to the peritoneal cavity. A short oblique incision is made in the neck paralleling the anterior border of the

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Fig. Z. Resection of the medial clavicle, sternoclavicular joint, and upper comer of manubrium (dotted lines). Removal of the posterior prominence of the clavicular head significantly widens the superior opening of the anterior mediastinum and allows more room for the transposed substernal stomach at the anterior thoracic inlet.

Fig. 3. Stapling and division of the low cervical esoph agus with the GIA stapler.

sternocleidomastoid muscle and curving downward from the suprasternal notch onto the manubrium for 2 to 3 em. (Fig. 1, inset). This cervical incision is placed on the side opposite the patient's dominant hand to minimize early postoperative discomfort which may accompany movement of the divided clavicle.

The sternocleidomastoid muscle is divided from its insertion on the clavicle and manubrium with the electrocautery. The clavicle is divided in its midportion with a Gigli saw. The subclavian vessels are protected while a sternal saw is used to resect the medial clavicle, sternoclavicular joint, and adjacent upper corner of manubrium, en bloc (Fig. 2) . By the removal of the posterior prominence of the clavicular head, this maneuver widens the superior opening of the anterior mediastinum and provides greater exposure of the cervical and upper thoracic esophagus (Fig. 2, inset). We carry out this procedure routinely whenever a substernal position is used for any method of esophageal replacement or bypass. The recurrent laryngeal nerve is identified and protected, while the cervical esophagus is mobilized and encircled with a Penrose drain. Finger dissection along the esophagus in the superior mediastinum provides addition cervical esophageal length. With upward traction on the Penrose drain , the esophagus is divided as far distally as possible with the GIA stapler (Fig. 3), and the staple suture line is oversewn with a 3-0 Prolene Lembert stitch. This completes the exclusion of the thoracic esophagus.

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Fig. 4. Transposition of the mobilized stomach through the substernal tunnel and into the cervical incision, Note that it is the gastric fundus, not the divided cardia, which reaches most cephalad, several centimeters above the level of the clavicles,

Following this, a retrosterna! tunnel is created. The peritoneum and the sternal origin of the diaphragm adjacent to the xiphoid process are incised transversely with the electrocautery through the abdominal incision, and a four fingerbreadth substernal tunnel is formed by blunt dissection superiorly and inferiorly. In construction of this tunnel, care is taken to dissect in the midline as close to the posterior aspect of the sternum as possible to avoid injury to either the pleural or pericardia! cavities. The previously placed silk traction sutures in the gastric fundus are passed from the abdominal incision behind the sternum into the cervical wound . With the use of gentle manipulation behind the sternum and trac-

tion from above, the stomach is placed in a substernal position and a length of fundus that reaches 4 to 6 em. above the level of the clavicles is delivered into the neck (Fig. 4). The traction sutures are used to anchor the fundus of the stomach to the cervical prevertebral fascia (Fig. 5A). The abdominal incision is closed to avoid contamination when the cervical esophagus is opened. The esophagogastric anastomosis is performed with two layers of interrupted 4-0 Prolene sutures on the anterior surface of the stomach, 3 to 4 em. below the most superior aspect of the gastric fundus . Suspension of the stomach from the prevertebral fascia avoids direct tension on the suture line, which occurs in standard end-to-

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Fig. 5. Construction of the cervical esophagogastric anastomosis. A, Suspension of the gastric fundus from the anterior cervical prevertebral fascia. B, Placement of first posterior row of sutures on the anterior gastric wall, 3 to 4 ern. below the most superior aspect of the gastric fundus. C, Transverse gastrotomy at the anastomotic site. D, Placement of second posterior row of sutures. E, Completion of anterior half of anastomosis. Note that to permit anastomosis on the anterior gastric wall, the divided cervical esophagus has been cut so that the anterior "lip" is at least 1 to 1.5 ern. longer than the posterior edge.

end esophagogastric anastomoses. Construction of the anastomosis on the anterior surface of the stomach requires that the end of the esophagus be beveled, so that an anterior flap at least 1 em, longer than the posterior half is created (Fig. 5). A lateral pharyngostomy tube is used for

postoperative gastric decompression. It is positioned by inserting of a nasogastric tube into the stomach prior to completion of the anastomosis and withdrawal of the proximal end through a small stab wound in the pharynx. This pharyngostomy tube achieves gastric decompression without the discom-

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Fig. 6. Lateral view of completed substernal gastric bypass of the excluded thoracic esophagus. The gastric fundus is suspended from the cervical prevetebral fascia, the anastomosis is on the anterior gastric wall, and the esophagus, with its unresectable tumor, is excluded in the posterior mediastinum.

fort and interference with pulmonary toilet associated with a nasogastric tube. After completion of the cervical esophagogastric anastomosis (Fig. 6), the mobilized edge of the sternomastoid muscle is sutured to the periosteum of the resected portion of the clavicle, and the cervical incision is closed without drainage. A postoperative chest roentgenogram is taken in

the operating room to determine whether the pleural cavities have been entered. Oral liquids are begun once postoperative ileus has subsided, generally after 48 to 72 hours, and the diet is advanced progressively. The pharyngostomy tube is left in place until a barium swallow is obtained 7 to 10 days following the operation. If an anastomotic disruption has occurred, nutrition is main-

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Table I. Substernal gastric bypass of the excluded thoracic esophagus Patient No. (age,sex) I (62, M)

2 (65, M)

3 (54, M)

4

(55, M)

5

(67, M)

6

(43, F) 7 . (65, M)

8 (57, M) 9 (46, M)

10

(75, M)

Symptoms (duration)

Tumor location (cm.from incisors) and characteristics

I

Postop. complications

Epigastric pain (2 wk.); Mid-esophagus, 27 em.; Anastomotic leak dysphagia (10 da.); TEF with extrinsic anterior compression cough on swallowing (4 da.) Mid-esophagus, 24 em.; Cervical and abdominal Retrosternal pain and increasing dysphagia obstructing, with celiac wound infections, pneumonia (4 yr.); 45 pound weight lymph node metastases loss Dysphagia (I yr.); hoarse- Upper esophagus, 15 em.; None ness (2 mo.); hemoptysis obstructing, with (2 wk.); 30 pound cervical lymph node weight loss metastases and TEF Dysphagia (5 mo.) Upper esophagus, 20 em.; Small bowel obstruction, unrelieved by radiation obstructing pharyngeal incoordinatherapy which induced tion (pre- and postop.) pharyngeal incoordinarequiring feeding tube tion from radiation fibrosis Dysphagia (5 wk.) Mid-esophagus, 25 em.; Respiratory arrest night 7 em. long, obstructing, of operation, myowith compression of cardial infarction, left main-stem bronchus renal failure Dysphagia (4 rno.); 20 Lower esophagus, 35 em. Sudden death in sleep pound weight loss Retrosternal pain (6 mo.); Mid-esophagus, 32 em.; None hemoptysis (5 mo.); TEF, without lumenal cough on swallowing obstruction (I wk.); 30 pound weight loss Retrosternal pain (I yr.); Mid-esophagus, 28 em.; Small bowel obstruction dysphagia (2 mo.) obstructing, with metastases to celiac axis lymph nodes Retrosternal pain (I yr.); Mid-esophagus, 30 em.; None dysphagia (I yr.); 30 partially obstructing, II em. long with pound weight loss metastases to celiac axis lymph nodes Dysphagia (5 mo.); cough Upper esophagus, 19 em.; Pneumonia, sepsis, on swallowing (5 wk.); obstructing, 12 em. sudden death 25 pound weight loss long, with TEF and compression ofleft main-stem bronchus

Survival status 9 mo., dead; hemorrhage from aorta-TEF

II days; dead; sepsis, pneumonia, bilateral subphrenic abscesses 2 '/ 2 mo., dead; hemorrhage from aortabronchoesophageal fistula 21/ 2 mo. dead; progressive cachexia

8 da., dead; cardiac and renal insufficiency

8 da., dead; unexplained 12 mo., alive

2 mo., dead; progressive cachexia and pneumonia 4 mo., lost to follow-up

II da., dead; multiple pulmonary abscess with probable esophageal suture line disruption

Legend: TEF, Malignant tracheoesophageal fistula.

tained with feedings administered through the pharyngostomy tube. Results

Because these patients had advanced malignant disease, postoperative complications were common and the mortality rate was high, four deaths occurring within 11 days of the operation (Table I).

Six patients lived from 2 to 12 months after the operation. The 3 who had no postoperative complications were discharged from the hospital eating regular six equal feeding diets, 12 to 14 days after their bypass procedures. Despite restoration of the ability to swallow in all of those patients, persistent anorexia remained a problem in 2 of them (Nos. 3 and 8). Patient 9, the

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most vigorous patient in this group, gained 7 pounds and returned to his work as a truck driver within 1 month of his operation. He was lost to follow-up after 4 months, at which time he claimed to be eating well with intermittent substernal discomfort relieved with Percodan. The 2 patients to survive longest in this group were those who presented initially with a malignant tracheaesophageal fistula. Patient 1 was the only patient in this group' who experienced an anastomotic disruption; the lesion healed spontaneously while nutrition was maintained through the pharyngostomy tube. He lived for 9 months after the bypass operation. Patient 7 is currently alive 12 months after the bypass operation. Despite subsequent total occlusion of the left main-stem bronchus by tumor, this patient has remained ambulatory, eating a regular diet, although troubled by intermittent chest discomfort. Postoperatively, no patient has had clinicalor radiographic evidence of gastroesophageal reflux, and all have been able to sleep supine without reflux of gastric contents into the pharynx. Postoperative acidreflux testing was performed in 2 of these patients by positioning a pH probe 1 em. distal to the cricopharyngeus sphincter as determined by manometric studies. After introducing 250 c.c, of 0.1 N hydrochloric acid into the stomach, we found that reflux of acid from the intrathoracic stomach into the remaining cervical esophagus could not be induced with various postural maneuvers. This demonstrated that the antireflux mechanism at the cervical esophagogastric anastomosis was effective. Discussion

Since the demonstration of the feasibility of transthoracic esophagectomy-" and the first successful lower esophageal resection with reconstructive esophagogastrostomy,': :H esophageal resection for carcinoma has become an established surgical procedure performed with an operative mortality rate which averages between 15 and 20 per cent. 3, 7, 41, 44 Despite improvements in preoperative

evaluation, anesthetic and operative techniques, and postoperative care, which permit the performance of esophageal resection and reconstruction with greater facility and safety than ever before, the 5 year cure rate for esophageal carcinoma remains dismally low, generally from 5 to 10 per cent or Iess."- 16-18, 25 The necessity of evaluating the results of treatment in this disease in terms of 2 year survival rates rather than the standard 5 year figures reflects the inadequacy of our current approach to a malignancy which at this time is almost invariably fatal. Because of local tumor invasion or widespread metastases, curative resection is impossible in more than three fourths of patients operated upon for carcinoma of the esophagus. Treatment thus becomes a matter of providing the best palliation: restoration of the patient's ability to swallow comfortably in the most simple and expeditious manner possible. It is difficult to rationalize palliation which combines the morbidity and mortality rates of a thoracotomy, celiotomy, and medistinal dissection in a generally debilitated patient. Although supervoltage radiation provides a valuable alternative treatment in many of these patients, it has several important disadvantages: the length of treatment, often representing a major portion of the patient's remaining life span; the potential of esophageal perforation; and, most important, the failure to relieve dysphagia in the majority of patients with annular tumors causing high-grade obstruction." 2,' Furthermore, radiation treatment is contraindicated in patients with malignant communications between the esophagus and tracheobronchial tree, because subsequent necrosis of the tumor may result in enlargement of the fistula. Palliative peroral intubation of esophageal carcinomas effectively re-establishes a passage for saliva. However, this procedure carries an over-all mortality rate of approximately 14 per cent and a complication rate of at least 25 per cent, largely the result of perforation of the esophagus, migration of the tubes, or obstruction of the tubes by

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food or tumor overgrowth." Although the ability of the patient to handle saliva is improved by intubation of the esophageal tumor, oral intake must be restricted to foods of a consistency compatible with passage through the rigid, indwelling esophageal conduits. The concept of palliative internal bypass of incurable malignancies of the gastrointestinal tract has been applied to tumors of the stomach, biliary tract, pancreas, and large and small bowel. Bypass of incurable esophageal carcinomas with long-segment colon interpositions has been advocated as a method of palliation. However, this procedure is of considerable magnitude. Two intra-abdominal gastrointestinal anastomoses are required, and inadequate arterial blood supply to or venous drainage from the colonic graft frequently results in graft failure.v- 32, 40 The mortality rate for colon bypass of esophageal carcinomas is at least 15 to 25 per cent." 12, :16 The use of variously fashioned gastric tubes to bypass the esophagus requires the construction and healing of a long gastric suture line.r'- 22 The T formed at the cervical esophagogastric anastomosis may result in local ischemia and anastomotic disruption. It is an established but often forgotten fact that the gastric fundus will reach to the neck in the majority of patients. Kirschner was the first to describe anastomosis of the mobilized, subcutaneous ante thoracic stomach to the cervical esophagus in a patient with a benign esophageal stricture. He anastomosed the divided cardiac end of the esophagus to a loop of jejunum." Sweet? and Garlock>' both demonstrated that the stomach can be mobilized through the chest to a sufficient extent to permit anastomosis between the cervical esophagus and gastric fundus after resection of carcinomas of the upper thoracic and cervical esophagus. Nakayama" reported on 217 patients who, after esophageal resection, had reconstruction with an antethoracic esophagogastrostomy. Ong 3 3 and LeQuesne and Ranger-:' performed primary pharyngogastric anastomoses after esophagopharyngectomies for

carcinoma of the hypopharynx and cervical esophagus. Akiyama- has recently described a method of retrosternal gastric bypass of the esophagus which is similar to ours. His technique was used with no operative deaths in 11 patients with nonresectable malignancies. This method involves high division of the stomach, passage of the oversewn distal stomach retrosternally into the neck with anastomosis to the divided cervical esophagus, and anastomosis of the proximal end of the divided stomach to the jejunum. Mobilization of the duodenum and head of the pancreas by the Kocher maneuver increases the distance that the stomach will reach. Because the pancreas and duodenum are fixed to the posterior abdominal wall, the shortest distance the stomach must traverse to reach the neck is through the chest in the posterior mediastinum. Postmortem measurements in 10 patients showed that the stomach must reach an additional 2 to 3 ern. in an antethoracic subcutaneous position. The substernal distance lies midway between. An adequate gastric length reaching several centimeters above the level of the clavicles was easily obtained in all of our patients (Fig. 7). During mobilization of the stomach, care should be taken to avoid injury to the spleen. Two patients (Nos. 4 and 8), who required splenectomy during the bypass procedure, developed postoperative small bowel obstructions from a loop of intestine adherent to the splenic bed. After the gastric fundus has been suspended from the prevertebral fascia, the abdominal incision should be closed to avoid contamination associated with opening the esophagus for the cervical esophagogastric anatomosis. In Patient 2, splenectomy and abdominal closure were performed after completion of the anastomosis. He died of sepsis from the cervical and abdominal wound and of bilateral subphrenic abscesses. The method of substernal gastric bypass described in this report is less awesome than other palliative operations involving either esophageal resection and reconstruction or bypass. The reason is that this tech-

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Substernal gastric bypass of esophagus

Fig. 7. A, Oblique view of barium swalIow in a patient with a malignant tracheoesophageal fistula who was treated with substernal gastric bypass . Note anterior angulation of the cervical esophagus as it passes forward to meet the retrosternal stomach. Small arrow represents the site of the esophagogastric anastomosis which is at the level of the clavicles . B, Posteroanterior view in the same patient showing the undilated intrathoracic stomach with the pylorus just below the diaphragmatic hiatus. C, Lateral view in the same patient demonstrating retrosternal position of the stomach in the anterior mediastinum.

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Fig. 8. Barium swallow in patient with a malignant tr acheoesophageal fistula. Note free flow of contrast material into both the left main-stem bronchus and the stomach.

nique is essentially an upper abdominal and cervical procedure which avoids the need for thoracotomy and mediastinal dissection . Patient . 6, whose severe debilitation precluded esophageal resection, survived the bypass operation and was tolerating a liquid diet well when she suddently died on the eighth postoperative day. No cause for her death was found at postmortem examination. The blood supply to the stomach surpasses that of any other portion of the gastrointestinal tract used for esophageal replacement; even after it has been mobilized, the stomach still possesses two arterial arcades , the right gastric and gastroepiploic , with obvious implications for anastomotic healing and viability of the transposed organ. The lack of intra-abdominal or intrathoracic gastrointestinal anastomoses with this technique eliminates one of the greatest problems in these patients , who often suffer from a negative nitrogen balance . The consequences of an esophagogastric anastomotic

Thoracic and Cardiovascular Surgery

disruption in the neck are far less disastrous than when this complication occurs in the chest. Exclusion of the thoracic esophagus with the surgical stapler is achieved with a minimum of tissue trauma and gastrointestinal contamination. The double rows of staggered, stainless steel staples delivered by the GIA stapler and then oversewn with minimally reactive suture material such as Prolene provide a secure closure of the esophagus . It has been shown both experimentally" and clinically" that the excluded thoracic esophagus becomes an asymptomatic mucocele within the posterior mediastinum. Only 1 of our patients , No. 10, an elderly, debilitated man, experienced a disruption of the distal esophageal suture line. Substernal gastric bypass of the excluded thoracic esophagus is ideally suited for the patient with a malignant tracheoesophageal fistula (Fig. 8). Approximately 80 per cent of patients with this condition are dead within 3 months of the onset of fistula formation, and the cause of death in 85 per cent is aspiration pneumonia. " However, because the disease is confined to the chest in 50 per cent of the patients with malignant tracheoesophageal fistulas," prolonged survival might be possible if the morbidity and mortality rates associated with repeated aspiration could be eliminated. Martini and his associates" emphasized the need for total exclusion of the esophagus and prevention of gastric regurgitation through the fistulous site in these patients. Patients with malignant tracheoesophageal fistulas treated with various combinations of cervical esophagostomy, tracheostomy, or gastrostomy are unable to eat and must constantly change cervical dressings saturated with saliva. Adequate palliation has not been achieved in these patients. Palliative intubation of the esophagus in an attempt to occlude a malignant tracheoesophageal fistula has been reported with varying success in about a dozen patients."- 11 , 24, 38 This approach was not feasible in 2 of our patients because of the lack of intraesophageal tumor or obstruc-

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Fig. 9. Sequential views of barium swallow of cervical esophagogastric anastomosis. Small arrows indicate esophagogastric junction; large arrows indicate the most superior aspect of the suspended gastric fundus. A, Oblique view of initiation of swallow. Note acute angle of entry of esophagogastric junction 2 em. below the most superior aspect of the suspended gastric fundus (retouched). B, Posteroanterior view with barium entering the stomach. Note the air-filled stomach is 2 to 3 em. above the level of the clavicles, posterior to the anastomosis. C, Posteroanterior view with barium filling the cervical portion of the gastric bypass.

tion on which to "seat" a peroral tube. The relatively prolonged, comfortable survival of 2 of our patients with malignant tracheoesophageal fistulas for 9 Y2 and 12 months indicates that very effective palliation for this condition is possible with substernal gastric bypass of the excluded thoracic esophagus. Secretions from the excluded esophagus through the fistulous communication were minimal and were readily cleared with a vigorous cough in both patients.

Gastroesophageal reflux following esophagogastrostomy is a major cause of morbidity because of secondary reflux esophagitis and aspiration.s- 19, 20, 39 Consequently, various methods for creating a competent valvular mechanism at the new esophagogastric junction have been employed experimentally- 37 and clinically."! 27, 35 The method of esophagogastric anastomosis described in this report is a variation of the technique utilized by Fisher and his associates'" for intrathoracic anastomoses. Post-

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operatively, the bulging, air-filled gastric fundus can be seen subcutaneously several centimeters above the level of the clavicles. Dilatation of this portion of the gastric fundus posterior to the remaining distal cervical esophagus provides a flap-valve mechanism which, in combination with the acute angle of entry of the esophagus into the stomach, effectively prevents gastroesophageal reflux into the pharynx (Fig. 9). Until advances in tumor immunology allow successful tumor eradication through the combined efforts of the surgeon and the oncologist, the surgeon's role in the treatment of most patients with carcinoma of the esophagus and malignant tracheoesophageal fistula is primarily one of providing palliation. We regard all upper thoracic and most midthoracic esophageal carcinomas as surgically incurable, particularly if metastases to cervical or celiac axis lymph nodes are demonstrated. Patients with such tumors and minimal dysphagia from partial esophageal obstruction may benefit greatly from radiation therapy, which causes regression of the primary lesion. With high-grade esophageal obstruction, however, radiation generally provides neither cure nor palliation, and maintenance of nutrition is dependent upon a feeding tube of some variety. Further, if there is endoscopic evidence of tracheobronchial involvement or an established tracheoesophageal fistula, radiation therapy is contraindicated. In very elderly or debilitated patients with the latter conditions, palliative peroral intubation of the esophageal malignancy may provide at least partial relief from dysphagia and aspiration. In younger patients or those with very long tumors which may not be amenable to intubation, substernal gastric bypass of the excluded thoracic esophagus offers an alternative to radiation therapy, feeding tubes, or colon bypass. This procedure restores the ability to swallow normally and thereby provides as optimal a quality of remaining life as is possible for these patients. There seems little justification for "palliative" esophagogastrectomy, performed to relieve dysphagia

in the presence of metastatic disease, when the same goal can be achieved by substernal gastric bypass of the excluded thoracic esophagus without the added morbidity and mortality rates from thoracotomy, mediastinal dissection, and intrathoracic esophagogastric anastomosis. Although this procedure is a major one for the debilitated patient, the improved quality of life it provides would seem to justify its use in selected patients with incurable esophageal malignancies. REFERENCES

2

3

4

5 6

7 8 9

10 11

12

Adams, W. E., and Phemister, D. B.: Carcinoma of the Lower Thoracic Esophagus: Report of a Successful Resection and Esophagogastrostomy, J. THORAC. SURG. 7: 621, 1938. Adler, R. H., Firme, C. N., and Lanigan, J. M.: Valve Mechanisms to Prevent Gastroesophageal Reflux and Esophagitis, Surgery 44: 63, 1958. Akakura, I., Nakamura, Y., Kakegawa, T., Nakayama, R., Watanabe, H. and Yamashita, H.: Surgery of Carcinoma of the Esophagus With Preoperative Radiation, Chest 57: 47, 1970. Akiyma, H., and Hiyama, M.: A Simple Esophageal Bypass Operation by the High Gastric Division, Surgery 75: 674, 1974. Belsey, R. H.: Reconstruction of the Esophagus With Left Colon, J. THORAC. CARDIOVASCo SURG. 48: 205, 1964. Berger, R. L., and Donato, A. T.: Treatment of Esophageal Disruption by Intubation, Ann. Thorac. Surg. 13: 27, 1972. Buck, B. A., and Fletcher, W. S.: Esophageal Cancer: Results of Therapy in an Indigent Population, J. Surg. Oncol. 5: 101, 1973. Burdette, W. J.: Palliative Operation for Carcinoma of Cervical and Thoracic Esophagus, Ann. Surg. 173: 714, 1971. Clinical Staging for Carcinoma of the Esophagus, Chicago, 1973, The American Joint Committee for Cancer Staging and End Results Reporting. Deaton, W. R., Jr., and Bradshaw, H. H.: The Fate of an Isolated Segment of the Esophagus, J. THoRAe. SURG. 23: 570, 1952. Duvoisin, G. E., Ellis, F. H., and Payne, W. S.: The Value of Palliative Prosthesis in Malignant Lesions of the Esophagus, Surg. Clin. North Am. 47: 827, 1967. El-Domeiri, A., Martini, N., and Beattie, E. J., Jr.: Esophageal Reconstruction by Colon Interposition, Arch. Surg, 100: 358, 1970.

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13 Fisher, R. D., Brawley, R. K., and Kieffer, R. F,: Esophagogastrostomy in the Treatment of Carcinoma of the Distal Two-thirds of the Esophagus, Ann, Thorac. Surg. 14: 658, 1972. 14 Garlock, J. H.: Resection of the Thoracic Esophagus for Carcinoma Located Above the Arch of the Aorta: Cervical Esophagogastrostomy, Surgery 24: I, 1948. 15 Girardet, R. E. Ransdell, H. T., r-, and Wheat, M. W., Jr.: Palliative Intubation in the Management of Esophageal Carcinoma, Ann. Thorac. Surg, 18: 417, 1974. 16 Guinn, G. A., Jordan, P. H., and Steward, C. V.: Appraisal of Therapy for Carcinoma of the Esophagus, Am. J. Surg. 122: 703, 1971. 17 Gunnlaugsson, G. H., Wychulis, A. R., Roland, c., and Ellis, F. H.: Analysis of the Records of 1,657 Patients With Carcinoma of the Esophagus and Cardia of the Stomach, Surg. Gynecol. Obstet. 130: 997, 1970. 18 Hankins, J. R., Cole, F. N., Ward, A., Carter, E. A., Weiner, S., and McLaughlin, J. S.: Carcinoma of the Esophagus, Ann. Thorac. Surg, 14: 189, 1972. 19 Hanna, E. A., Harrison, A. W., and Derrick, J. R.: Comparative Function of Visceral Esophageal Substitutes by Cinefluoroscopy, Ann. Thorac. Surg, 3: 173, 1967. 20 Hanna, E. A., Harrison, A. W., and Derrick, J. R.: Long-Term Results of Visceral Esophageal Substitutes, Ann. Thorac. Surg. 3: 111, 1967. 21 Heimlich, H. J.: Carcinoma of the Cervical Esophagus, J. THORAC. CARDIOVASC. SURG. 59: 309, 1970. 22 Heimlich, H. J.: Elective Replacement of the Esophagus, Br. J. Surg. 53: 913, 1966. 23 Johnson, J., Schwegman, C. W., and Kirby, C. K.: Esophageal Exclusion for Persistent Fistula Following Spontaneous Rupture of the Esophagus, J. THoRAc. SURG. 32: 827, 1956. 24 Judd, D. R., and Codd, J.: Palliation for Malignant Esophagotracheal Fistula, J. THORAC. CARDIOVASC. SURG. 54: 751, 1967. 25 Leon, W., Strug, L. H., and Brickman, I. D.: Carcinoma of the Esophagus-a Disaster, Ann. Thorac. Surg, 11: 583, 1971. 26 LeQuesne, L. P., and Ranger, P.: Pharyngolaryngectomy With Immediate Pharyngogastric Anastomosis, Br. J. Surg. 53: 105, 1966. 27 Lortat-Jacob, J. L., Maillard, J. N., and Fekete, F: Procedure to Prevent Reflux After Esophagogastric Resection: Experience With 17 Patients, Surgery 50: 600, 196 I. 28 Lott, J. S., and Smith, I. H.: Cobalt-60 Beam Therapy in Carcinoma of the Esophagus, Radiology 71: 320, 1958. 29 Martini, N., Goodner, J. T., D'Angio, G. J.,

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and Beattie, E. J., Jr.: Tracheoesophageal Fistula due to Cancer, J. THORAC. CARDIOVASC. SURG. 59: 319, 1970. Nakayama, K.: Statistical Review of 5-Year Survivals After Surgery for Carcinoma of the Esophagus and Cardiac Portion of the Stomach, Surgery 45: 883, 1959. Nicks, R.: Colonic Replacement of the Oesophagus: Some Observations on Infarction and Wound Leakage, Br. J. Surg, 54: 124, 1967, Ong, G. B.: Resection and Reconstruction of the Esophagus, ill Current Problems in Surgery, Chicago, 197 I, Year Book Medical Publishers, Inc. Ong, G. 8., and Lee, T. C.: Pharyngogastric Anastomosis After Oesophago-pharyngectomy for Carcinoma of the Hypopharynx and Cervical Oesophagus, Br. J. Surg. 48: 193, 1960. Oshawa, T. J.: The Surgery of the Esophagus, Arch. Jap. Chir. 10: 605, 1933. Pearson, F. G., Henderson, R. D., and Parrish, M. D.: An Operative Technique for the Control of Reflux Following Esophagogastrostomy, J. THORAc. CARDIOVASC. SURG. 58: 668, 1969. Postlethwait, R. W., Sealy, W. C., Dillon, W. L., and Young, W. G.: Colon Interposition for Esophageal Substitution, Ann. Thorac. Surg. 12: 89, 1971. Redo, S .F., Barnes, W. A., and Oritz della Sierra, A.: Esophagogastrostomy Without Reflux Utilizing a Submuscular Tunnel in the Stomach, Ann. Surg, 151: 37, 1960. Riemer, R. W.: Discussion of Wilson, S. E., Plested, W. G., and Carey, J. S.: Esophagogastrectorny Versus Radiation Therapy, Ann. Thorac. Surg, 10: 195, 1970. Ripley, H. R., Olsen, A. M., and Kirklin, J. W.: Esophagitis After Esophagogastric Anastomosis, Surgery 32: I, 1952. Rooney, B. P.: The Blood Supply of the Colon in Oesophageal Replacement, II'. J. Med. Sci. 8: 301, 1969. Surgical Treatment of Carcinoma of Esophagus and Gastric Cardia, Chin. Med. J. 1: 60, 1975. Sweet. R. H.: The Treatment of Carcinoma of the Esophagus and Cardiac End of the Stomach by Surgical Extirpation-203 Cases of Resection, Surgery 23: 952, 1948. Torek, F.: The First Successful Resection of the Thoracic Portion of the Esophagus for Carcinoma, J. A. M. A. 60: 1533, 1913. Younghusband, 1. D., and Aluwihare, A. P. R.: Carcinoma of the Esophagus: Factors Influencing Survival, Br. J. Surg, 57: 422, 1970.

The Journal of

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Thoracic and Cardiovascular

Orringer and Sloan

45 Yudin, S. S.: The Surgical Construction of 80 Cases of Artificial Esophagus, Surg. Gynecol. Obstet, 78: 561, 1944.

Discussion DR. JOHN W. YARBROUGH Durham, N.

c.

The success of Drs. Orringer and Sloan in palliating unresectable esophageal carcinoma by total exclusion of the esophagus is of great interest to us at the Durham Veterans Administration Hospital, where we have been investigating another approach. Under the direction of Dr. Postlethwait, we have performed an esophageal bypass in 6 patients without occlusion of the distal esophagus. This technique employs the use of a greater curvature gastric tube, the blood supply of which is based on the right gastroepiploic artery, as originally described by Beck. A stapling device facilitates division of the greater curvature. A Kocher maneuver is used to mobilize the duodenum and increase the effective length of the tube, which is placed retrosternally. The end-toend anastomosis is performed at the cervical esophagus. During the past 7 months this procedure has been employed in 6 patients with unresectable tumors: Two had malignant tracheoesophageal 'fistulas and 4 had positive celiac nodes or extension of the tumor to the lesser curvature of the stomach. Small leaks have occurred at the cervical anastomosis in 4 patients, but they have resolved spontaneously in 3. A soft diet has been tolerated postoperatively by all patients, even with a small fistula present. The 2 patients with tracheoesophageal fistulas were relieved of aspiration by occlusion of the cervical esophagus only. Reflux with aspiration has not occurred in these 2 patients postoperatively. We believe that this procedure also warrants further clinical trials in patients with un resectable lesions for the following reasons: 1. It requires only the mobilization of the greater curvature of the stomach without significant dissection about the spleen, pancreas, or esophageal hiatus. 2. It can be accomplished even with extension of the tumor to the lesser curvature of the stomach. 3. Swallowing has been improved and maintained in all patients, and morbidity has been acceptable to this point. DR. AGUSTIN ARBULU Detroit, Mich.

I want to congratulate the authors for bringing to our attention that the name of the game

Surgery

in treatment of cancer of the esophagus is palliation. In the past 12 years, we have seen 354 cases of cancer of the esophagus with only one 11 year survivor after resection and esophagogastrostomy. We are seeing at the present time about 40 cases of cancer of the esophagus a year. Our philosophy of therapy is to palliate this disease in the most effective way. In our latest 42 patients treated during the past 14 months, the preferred method of treatment has been resection and reconstruction by a gastroesophagostomy by means of the inkwell procedure, as suggested by Ellison and Proctor. This operation is performed through a midline laparotomy and a right thoracotomy done in succession, not simultaneously. Essentially, we take care of the abdominal part first and, after closing the abdomen, we turn the patient and resect the esophagus through a right thoracotomy. [Slide] The esophagogastrostomy shown here is the inkwell type of anastomosis. We treated 28 patients with this modality, with only one anastomotic leak that resulted in death, a mortality rate of 4 per cent. Palliation has been adequate in these patients up to 13 months. In 3 additional patients we used a technique similar to the one suggested by the authors. In 1 case there was a leak which resulted in the patient's death, a mortality rate of 33 per cent. In patients with malignant tracheoesophageal fistulas or fistulas of extremely poor condition (and we have encountered 11 patients in this group in the past 14 months), our preference is a pull-through esophageal tube with a double suture technique of abdominal wall fixation. We have prevented the serious complication of migration of the tube in these cases by affixing the tube to the abdominal wall by the method indicated. Palliation was effective in these patients. We should think in terms of palliation in the treatment of cancer of the esophagus, and I congratulate the authors in holding to that philosophy. DR. PAUL 1. P. BOLANOWSKI Newark. N. J.

For many years, Dr. William E. Neville has used an anterior mediastinal ileocolon transplant for palliation in patients with carcinoma of the esophagus in whom resection was not advisable. Because of the length of the procedure and the debility of the patient, the operation occasionally left something to be desired. In the past few years this has changed considerably because of preoperative hyperalimentation and the use of the automatic stapler as advocated by Drs. Ravitch and Steichen. In the past 3 years we have used the stapler for all of the anastomoses and thus have markedly reduced the operative time. The most difficult

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Substernal gastric bypass of esophagus

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November, 1975

anastomosis is the ileoesophageal anastomosis in the neck, performed after the colon has been tunneled through the anterior mediastinum. For this we use the GIA instrument and perform a side-to-side anastomosis between the ileum and the esophagus. We have used this technique in 14 patients and have had only one cervical esophageal fistula. This was in a patient who had a prevous esophagostomy. Even though the use of the stomach as advocated by Drs. Orringer and Sloan is feasible, we favor the ileocolon conduit because of the ease of mobilization of the right colon and the recent advances in surgical technique with the automatic stapler. DR. JAMES B. D. MARK Stanford, Calif.

I found Dr. Orringer's presentation very stimulating, mainly because I disagree with the concept presented. We are dealing with a disease that is lethal in a patient who is often debilitated and cachectic, and I believe that an extensive surgical procedure such as the one proposed is rarely indicated under such circumstances. I was fortunate to be able to spend a year in Tanzania not long ago. In this country, carcinoma of the esophagus is extremely frequent, as frequent as carcinoma of the rectum, and many patients presented with far-advanced disease, including tracheoesophageal fistula. We found the use of the indwelling tube, such as the Celestin tube, to be most successful. We were able to provide excellent palliation at minimum operative risk for these unfortunate patients.

DR. ORRINGER (Closing) I would like to thank the discussers for their comments. Two of the points made by Dr. Bigelow in his Presidential Address seem applicable to this discussion: First, as surgeons we should not be guilty of closed-mindedness in thinking that the ultimate answer to esophageal carcinoma is resection. Hopefully, tumor immunology soon will provide a solution to this problem. Second, if our role in the treatment of this disease is primarily one of providing pailiation, we might better evaluate the adequacy of our results in terms of the quality of life provided rather than the absolute months of survival. Cervical esophagostomy and gastrostomy prolong life but provide miserable palliation. Peroral intubation of esophageal tumors permits the patients to swallow saliva but requires that the diet be altered to a consistency compatible with passage through rigid conduits, which are often obstructed by food or tumor overgrowth. Esophagogastrectomy or colon bypass require mediastinal dissection, thoracotomy, or intra-abdominal or intrathoracic intestinal anastomoses in debilitated patients. Variously fashioned gastric tubes effectively bypass the esophagus but require the healing of a long gastric suture line. Further, the T formed at the junction of the cervical esophagus and the gastric tube results in frequent anastomotic disruptions. We believe that the excellent relief from dysphagia and aspiration afforded by substernal gastric bypass of the excluded thoracic esophagus merits its continued use in patients with incurable esophageal malignancies.