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Surgical Lesions of the Esophagus
Surgical Lesions of the Esophagus CHARLES B. PUESTOW, M.D., PH.D., F.A.C.S. * WILLIAM J. GILLESBY, M.D., F.A.C.S. **
THE esophagus has been quite inaccessible to major surgery until the past one to two decades. Advancements in anesthesiology, greater knowledge of nutrition and methods of improving or maintaining it, ready availability of whole blood, and the control of infection by antibiotie agents have given the surgeon free access to this organ. The primary function of the esophagus is to convey foods and fluids from the pharynx to the stomach. Sensation in the esophagus is rather limited, and pain originating in it is usually due to overdistention, generally occurring above a constriction or obstruction, or by invasion or penetration of surrounding tissues by tumor or inflammation. The most common symptoms of esophageal disease are difficulty in swallowing and substernal discomfort. These symptoms first accompany efforts to swallow solid foods, and later may accompany the swallowing of liquids or even saliva. A normal person secretes from 1200 to 1800 cc. of saliva in 24 hours. We all swallow saliva without any sensation or conscious realization of such an act. In esophageal obstruction, the inability to swallow food is serious, but the inability to swallow saliva is even more serious because the quantity of saliva throughout the 24 hours must be expectorated, or drooling will occur. During sleep the saliva tends to accumulate in the throat and passes into the tracheobronchial passages, producing coughing. We have noticed that patients with complete esophageal obstruction have a miserable existence during sleep. They may sleep for one and one-half to two hours, and then awaken with violent coughing in an effort to expectorate the saliva that has run down the tracheobronchial tree. If they do not have this problem they have probably learned to sleep on the face with the head * Chief, Surgical Service, Veterans Administration Hospital, Hines, Illinois; Clinical Professor of Surgery, University of Illinois College of Medicine, and Chief Surgeon, Henrotin Hospital, Chicago.
** Assistant Chief, Surgical Service, Veterans Administration Hospital, Hines, Illinois. From the Surgical Service, Veterans Administration Hospital, Hines, Illinois, and Department of Surgery, University of Illinois College of Medicine, Chicago.
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over the edge of the bed, so that the saliva can drool from the mouth. This problem exists in benign as well as malignant lesions of the esophagus, and it is not uncommon to see these patients with frequent episodes of pneumonitis, lung abscess and other pulmonary complications (Fig 18). The restoration of nutrition to these patients is very important, and gastrostomy or jejunostomy feedings may have to be resorted to in advanced lesions. However, the aspiration of saliva is not prevented by these procedures and more heroic methods are essential for the comfort and health of these patients, whether the disability be due to benign or malignant disease. This clinic will not deal with all surgical lesions of the esophagus. A
Fig. 18. Roentgenogram showing high esophageal obstruction and spilling of barium into bronchial tree.
few diseases will be mentioned in generalities, while the surgical management of some diseases will be discussed in more detail. CARDIOSPASM
Cardiospasm, or achalasia, is a disease of unknown etiology producing a spasm or constriction in the distal end of the esophagus, preventing the free passage of food into the stomach. The esophagus becomes increasingly dilated above the obstruction, and may distend to occupy a large part of the right chest, displacing various amounts of the right lung. A dilated esophagus rarely extends to the left side. In our experience, cardiospasm usually responds to dilatation of the constricted area. A single dilatation may produce a permanent cure. Occasionally the procedure must be repeated at regular intervals. Of the surgical procedures that have been advised where dilatation failed, we believe the Heller
Surgical Lesions of the Esophagus
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operation, an extramucosal myotomy made in a longitudinal direction, is the most satisfactory operation. Various techniques for the establishment of an esophagogastrostomy frequently have been followed by a recurrence of the stenosis. ESOPHAGEAL ULCERS
Peptic ulcers of the esophagus are more common than are generally recognized. They are frequently associated with ulcers of the stomach and duodenum, and probably result from regurgitation of gastric juice into the esophagus. This may be due to inadequate sphincter action at the gastroesophageal juncture, or an insufficient sphincter function of
Fig. 19. A, Roentgenogram !showing esophageal peptic ulcer. B, Roentgenogram showing esophageal stricture secondary to ulcer. C, Postoperative roentgenogram following Wendel reconstruction.
the diaphragmatic muscles. Uncomplicated esophageal ulcers should be treated by medical management. The diagnosis should be ascertained by roentgenograms (Fig. 19, A) and by esophagoscopic biopsies, to differentiate a benign lesion from a possible early malignant growth. The healing of esophageal peptic ulcers may be followed by fibrosis, with varying degrees of stenosis. If obstruction results (Fig. 19, B), surgical intervention is indicated. The lesion should be approached through the left chest, through the bed of the eighth rib, or through the eighth interspace. If the lesion is extensive, it may be necessary to resect the distal esophagus and perform an esophagogastrostomy. A narrow obstruction may be relieved by a Wendel type of plastic reconstruction (Fig. 19, C). If active inflammation is present, suggesting activity of the ulcer, a complete vagotomy should be performed in addition to the reconstructive' procedure. This operation is frequently followed by spasm of
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Charles B. Puestow, William J. Gillesby
the pylorus and gastric retention. This may be avoided by incising the diaphragm to expose the pylorus and performing a pyloromyotomy or a gastrojejunostomy. If a partial esophagectomy is decided upon, and the ulcer is active, the proximal portion of the stomach may be resected to remove a large amount of acid-producing tissue. CAUSTIC STRICTURES OF THE ESOPHAGUS
The accidental or intentional ingestion of corrosive substances is one of the most common causes of benign strictures of the esophagus. Lye is the most frequent etiologic agent. These lesions may occur at any age but are most frequent in children, where they almost invariably result from accidents. In white adults, caustics are usually ingested with suicidal intent during periods of depression. In our experience Negro adults
Fig. 20. Roentgenogram showing strictured areas following ingestion of lye.
have ingested lye which they have erroneously thought to be gin. Caustic substances produce strictures throughout the esophagus with most extensive damage at points of normal constriction (Fig. 20). The immediate management of caustic strictures of the esophagus has been well described by Holinger1 , 2 and others. Weak antidotes are administered. Dilatation of the esophagus with soft mercury bougies is started within 24 hours of the ingestion of the caustic agent. Daily dilatations are carried out, first with small bougies, the size being gradually increased as tolerated. The frequency of dilatations is gradually diminished, but periodic treatment must be continued for many years or for life. If treatment is not instituted early, fibrosis and stenosis develop and require more drastic treatment. Attempted dilatation is the treatment of choice whenever possible. If this cannot be accomplished from above, a gastrostomy and retrograde dilatation may be employed. Only when dilatation cannot be accomplished and complete obstruction has resulted, should more radical surgery be contemplated. .
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When the esophagus is completely stenosed and cannot be dilated, esophagectomy and elevation of the stomach into the chest with a high gastroesophagostomy is indicated. This procedure has been described by the senior author.3 Because most of the esophagus is usually involved, the highest strictures are well above the arch of the aorta and almost the entire esophagus must be removed. We prefer to approach the esophagus through the bed of the left seventh rib. Because of the marked fibrosis in the periesophageal tissues, it may be difficult to remove all scar tissue. It is not essential to do this, but all functioning mucosa should be excised and the resection must extend beyond the highest level at which there is marked narrowing or destruction of the mucosa. It may be necessary to extend the resection into the cervical esophagus and to the pharynx. The stomach is mobilized and brought high into the chest to be anastomosed to the esophageal stump or pharynx. If the scarring involves the stomach, this organ may be contracted down and difficult to elevate into the apex of the pleural cavity. Occasionally it is necessary to mobilize the duodenum to permit such an anastomosis. Where the pylorus is also stenosed, a pyloromyotomy or gastrojejunostomy may be required as an additional procedure. If the upper portion of the esophagus is stenosed, it may be necessary to substitute plastic tubes, aortic or cutis grafts for the cervical segment. The technique of these procedures is described under the treatment of malignant lesions of the esophagus. These problems require a great deal of planning and may necessitate multiple stage operations. ESOPHAGEAL VARICES
Symptoms of esophageal varices are an exception to the rules-mentioned in the first part of this article, namely, there is. no:pain, there is usually no dysphagia, and the only symptom presenting is that of violent bleeding. There may, however, be other evidences of the primary disease, portal hypertension, which is usually secondary to biliary cirrhosis. The diagnosis can be established in most patients by esophagoscopic studies and roentgenograms taken during a barium swallow (Fig. 21, A). The immediate treatment consists of esophageal tamponade by the use of a Sengstaken tube, or a similar multilumen tube with multiple balloons. If the hemorrhage is controlled, efforts may be made to diminish portal hypertension by the use of vascular anastomoses between the portal and systemic venous systems. This is not always possible, and does not always control the bleeding. Under such circumstances, the varices themselves must be attacked. We prefer to approach esophageal varices through the left chest by an incision in the eighth interspace or the bed of the eighth rib. The lower end of the esophagus is mobilized. A longitudinal incision is made in the esophagus close to the diaphragm. Three large varices are usually encountered. These may be occluded by oversewing each of the veins
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Charles B. Puestow, William J. Gillesby
with continuous intestinal catgut sutures beginning near the diaphragm and extending upward for several inches. This can be done through a small incision, as the veins can be pulled down with the sutures (Fig. 22). This method, which has been described by Crile4 • 6 and others, has proved
Fig. 21. .4, Roen tgenogram demonstrating esophageal varices. B , PosLoperaLive roentgenogram of esophagogastrostomy for varices.
Fig. 22. Method of suture of esophageal varices through left thoracotomy approach.
satisfactory in our hands. Where the varices are extensive, it may be necessary to resect the lower esophagus and perform an esophagogastrostomy as first described by Phemister.6 Figure 21, B, is a roentgenogram of the postoperative results of such a procedure. RUPTURE OF THE ESOPHAGUS
In either spontaneous or instrumental rupture of the esophagus, the treatment should consist of immediate operation with exposure and
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suture of the rupture. The approach may be through either the right or left chest, depending upon which side fluid appears in the pleural cavity. Suture of the esophagus is comparatively simple, and we believe should be accomplished over an intraluminal tube. Postoperative drainage of the chest must be effective to prevent the development of empyema. BENIGN TUMORS OF THE ESOPHAGUS
Benign tumors of the esophagus are rare, but are seen sufficiently often to require comment. I eiomyomas of the esophagus are the most common tumors and may produce obstructive symptoms, or be symptomless. They are frequently discovered by routine chest x-rays, there being an
Fig. 23. Roentgenogram showing abnormal density in mediastinum produced by a leiomyoma of the esophagus.
abnormal density in the mediastinum on x-ray film (Fig. 23). These tumors are benign and are easily removed. Some may be enucleated without any difficulty; and if the mucosa of the esophagus remains intact, complications are minimal. Occasionally the leiomyoma may encircle the esophagus, and in such a circumstance esophageal resection with esophagogastrostomy is the procedure of choice. CARCINOMA OF THE ESOPHAGUS
We are encountering carcinoma of the esophagus with half the frequency of carcinoma of the stomach. The early symptoms of this disease consist of anorexia and difficulty in swallowing solid food, often accompanied by mild substernal distress. These symptoms precede weight loss by weeks or months. It is unfortunate that they are not recognized early and that the diagnosis usually is not made until the disease is far ad-
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Charles B. Puestow , William J. Gillesby
vanced. This delay not only permits the disease to advance to an ineurable stage, but also increases the danger of operation by impairing the nutrition of the patient. Early diagnosis can be established in most instances by radiographic studies and by esophagoscopy and biopsy. Resection of the Tumor and Establishment of a Gastroesophagostomy
The treatment of choice for carcinoma of the esophagus is complete excision of the lesion and several centimeters of esophagus on each end. This should be accomplished wherever possible, even though local or distant metastases exist. The distress produced by an obstructing lesion of the esophagus and its resultant starvation is far greater than the terminal stage of this disease produced by metaiiltases. Every effort should be made to re-establish continuity of the alimentary tract, so that the patient is able to swallow his food and saliva. Resection of the tumor and the establishment of a gastroesophagostomy is the most satisfactory of palliative, as well as curative, procedures. Left-Sided Approach. We prefer to approach the esophagus through the left chest, and the stomach through the left diaphragm. This approach gives adequate access to the entire intrathoracic esophagus and permits mobilization of the stomach with a minimum amount of surgery. Lesions of the lower esophagus are approached through the bed of the left eighth rib. Almost the entire rib should be removed to permit adequate access to the stomach and the esophagus. If there is any doubt in the operator's mind as to whether esophagogastric anastomosis can be done below the aortic arch, it should not be attempted. The esophagus should be mobilized from behind the aorta, and an esophagogastric anastomosis performed above the aortic arch. Ther@ can be no compromise with a firm stand on this point. Lesions of the upper thoracic esophagus can be mobilized with greater ease through the bed of the seventh rib. If greater exposure is needed the left sixth, and sometimes fifth, ribs may be divided close to the spine. Carcinomas which extend into the cervical esophagus can be approached by neck incision in addition to the transthoracic approach. The technique of surgical removal of carcinomas of the esophagus and the establishment of a gastroesophagostomy through the left chest has been previously described in detail in this j ournal,7 Right-Sided Approach. Some surgeons prefer to approach the esophagus through the right chest. This approach has the advantage of providing easier access to that portion of the esophagus lying behind the arch of the aorta. It has the disadvantage of requiring an additional abdominal incision for mobilization of the stomach. The technique of the rightsided approach is as follows. The patient should be positioned on the operating table in such a
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manner that both the thoracic and abdominal procedures can be performed without a change of position. We prefer to have the patient on his back, with a 30 degree tilt to the left. A right anterior thoracotomy is performed through the fourth interspace, with a resection of small segments of the fourth, third and second costal cartilages (Fig. 24). A flap of chest wall is elevated. The right lung is retracted to expose the
Fig. 24. A, Incision for right-sided approach. B, Line of incision for chest wall Hap.
Fig. 25. A, Incision for mobilization of stomach. B, Mobilization of stomach and pyloromyotomy.
azygos vein, which must be ligated and divided to expose the esophagus. The esophagus is completely mobilized from the diaphragm to a point well above the upper limits of the tumor. The thoracotomy wound is temporarily closed with towel clips. An abdominal incision is made for mobilization of the stomach (Fig. 25, A). The gastrohepatic and gastrocolic ligaments are divided at a sufficient distance from the stomach to preserve the vascular arcades. This dissection should extend from the esophageal hiatus to the duodenum. We believe a pyloromyotomy should be performed to minimize subsequent pylorospasm (Fig. 25, B). Abdominal and diaphragmatic portions of the esophagus are freed by
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Charles B. Puesww, William J. Gillesby
finger dissection. If the hiatus is somewhat snug, it should be enlarged by dilatation or incision. This can be done either from below or above the diaphragm. The abdominal wound is closed and the thoracic wound reopened. The stomach is pulled into the thoracic cavity as far as possible. It is placed posterior to the root of the right lung. If the tumor is well above the cardiac end of the stomach, the esophagus is separated from the stomach and the opening into the stomach closed. If the tumor is close to the gastroesophageal juncture, varying amounts of stomach may be resected. A gastroesophagostomy is established between the fundus of the stomach and a point on the esophagus at least 4 cm. above the tumor. We prefer a two-row technique using an inner row of continuous catgut and an outer row of interrupted cotton. If there is a redundance of stomach it is well to tack the serosa of the stomach to the esophagus 0.5 to 1 cm. above the line of anastomosis, to protect the suture line. This telescopes a short segment of the esophagus into the stomach. To avoid traction on the suture line the stomach should be sutured to the parietal pleura by a few interrupted cotton sutures. The right pleural space is drained by catheter, with water seal control, and the chest wall closed. Palliative Managenlent
In certain patients in whom resection of the tumor cannot be performed because of extensive invasion of aorta or hilus of lung, palliative procedures are justifiable. Palliation may be accomplished by a side-to-side anastomosis of the stomach to the esophagus above the lesion (Fig. 26, A). This procedure has been described in the French literature,s and we have been employing it with good results. It is possible by this procedure, to leave the tumor attached to the aortic arch or surrounding tissues and short-circuit the esophageal contents to the stomach by by-passing the obstructed region (Fig. 27). Some advanced carcinomas of the esophagus with extension of the disease which will preclude a cure can be resected through a right thoracic incision and a prosthesis substituted for the missing portion of esophagus. This method involves far less surgical trauma than utilization of the stomach. Berman9 has described a plastic tube which, in his hands, has been satisfactory (Fig. 26, B). Our results with this tube have been discouraging. Aortic transplants have been used as substitutes for segments of esophagus. Immediate or delayed leakage at the suture line has been encountered in this procedure. The Macklerlo tube has been used, and in nonresectable situations has been of value in restoring continuity of the esophageal lumen. The tumor is exposed from either the right or left side and an estimate is made of its resectability. If inoperability is evident the esophagus is mobilized above or below the tumor, depending upon which is the most
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Surgical Lesions of the Esophagus
accessible area, and a longitudinal incision is made into the esophagus. The esophageal lumen is then dilated by the use of Bakes common duct dilators to the extent necessary, dilating through the tumor. After
B
Berm~n tube
Fig. 26. A, Palliative supra -ao rtic anastomosis for nonresectable cancer of the middle t hird of the esophagus. B, Method of inse rt ing Berman tube with peri esop hageal cuffs. C, Esophageal incision and placing of Mackler plastic tube through esophageal c :~ncer.
Fig. 27. Roentgenogram showing supra-aortic anastomosis: a, esophagus ; b, carcinoma; c, esophagogastrostomy; d, aorta; !e, stomach.
a sufficient lumen has been made, a Mackler tube, which is a plastic tube with a flange at one end, is inserted into the esophageal lumen and forced through the opening in the tumor so that the lumen will carry food and saliva. This is shown in Fig. 26, C. A circumesophageal suture is placed above or below the flange of the plastic tube so that the tube will remain in position.
Charles B. Puestow, William J. Gillesby
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Curative surgery is to be attempted if at all possible, but in many cases it is impossible to expect any curative results because of extension of the tumor to paravascular areas, to the lung, to mediastinal nodes that are unresectable, or to the lesser curvature of the stomach in patien ts with lower esophageal carcinoma, or to the neck in upper esophageal carcinoma. The use of gastrostomy and jejunostomy is so unsatisfactory that a more major procedure is justifiable in order to give the patient comfort for his remaining months or years. It has been gratifying to see patients so treated who are able to go back to work for months or even years, alth(mgh the prognosis is dismal. It is important to warn patients regarding postoperative management, even when healing has been complete. Those with esophagogastrostomies do not have a competent cardiac valve and may develop regurgitation, which in turn may produce peptic esophagitis in the remaining esophagus. It is also possible that regurgitated material will enter the lung during sleep, and pati€nts should be warned not to drink fiuid51 before lying down. They learn from experience that they are more comfortable if they sleep in a semireclining position. In the case of plastic tube replacements of the esophagus, it is important to warn the patient not to eat poorly chewed foods. The diet must be carefully outlined so that foods can pass any anastomosis or prosthetic lumen. SUMMARY
A number of diseases of the esophagus which are amenable to surgical therapy have been presented. Early symptomatology, especially of malignant lesions, has been emphasized. Techniques of curative and palliative surgical procedures have been described. Safeguards, which minimize the risk of operation as well as postoperative complications, have been discussed. The field of esophageal surgery is relatively new, and is expanding rapidly. It has much to offer in the eradication of disease and in improving the comfort of the patient. Its safety can be greatly augmented by thorough preoperative and postoperative care, meticulous operative technique, and early recognition of disease. REFERENCES 1. Holinger, P. H. and Johnston, K. C.: Benign Strictures of the Esophagus. S. CLIN. NORTH AMERICA 31: 135-152 (Feb.) 1951. 2. Holinger, P. H., Tamari, M. J. and Bear, S. H.: Corrosive Esophagitis Due to Nitric Acid. Laryngoscope 63 (9): 789-807 (Sept.) 1953. 3. Puestow, B. and Chess, S. J.: Resecti@n of the Esophagus for Persistent Stricture. Arch. Surg. 56: 34-37 (.Jan.) 1948. 4. Crile, George, Jr.: Transesophageal Ligation of Bleeding Esophll,glilal Varices. Arch. Surg. 61: 654-660 (Oct.) 1950. 5. Crile, George, Jr.: Personal communication.
e.
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6. Phemister, D. B. and Humphreys, E. M.: Gastroesophageal Resection and Total Gastrectomy in Treatment of Bleeding Varicose Veins in Banti's Syndrome. Ann. Surg. 126 (4): 397-410 (Oct.) 1947. 7. Puestow, C!. B. and Cross, J. H.: Carcinoma of the Esophagus. S. CLIN. NORTH AMERICA 31 (1): 153-171 (Feb.) 1951. 8. Renan, C., Le Bihan, R. and Gaguet, A.: Study Apropos of Palliative Supraaortic Anastomosis for Inoperable Cancer of Middle Third of Thoracic Esophagus. Mem. Acad. de chir. 77: 684-685 (June 20-July 4) 1951. 9. Berman, E. F.: A Plastic Prosthesis for Resected Esophagus. Arch. Surg. 65: 916 (Dec.) 1952. 10. Mackler, S. A.: Personal communication. 25 E. Washington Street Chicago 2, Illinois (Dr. Puestow)
THE esophagus has been quite inaccessible to major surgery until the past one to two decades. Advancements in anesthesiology, greater knowledge of nutrition and methods of improving or maintaining it, ready availability of whole blood, and the control of infection by antibiotie agents have given the surgeon free access to this organ. The primary function of the esophagus is to convey foods and fluids from the pharynx to the stomach. Sensation in the esophagus is rather limited, and pain originating in it is usually due to overdistention, generally occurring above a constriction or obstruction, or by invasion or penetration of surrounding tissues by tumor or inflammation. The most common symptoms of esophageal disease are difficulty in swallowing and substernal discomfort. These symptoms first accompany efforts to swallow solid foods, and later may accompany the swallowing of liquids or even saliva. A normal person secretes from 1200 to 1800 cc. of saliva in 24 hours. We all swallow saliva without any sensation or conscious realization of such an act. In esophageal obstruction, the inability to swallow food is serious, but the inability to swallow saliva is even more serious because the quantity of saliva throughout the 24 hours must be expectorated, or drooling will occur. During sleep the saliva tends to accumulate in the throat and passes into the tracheobronchial passages, producing coughing. We have noticed that patients with complete esophageal obstruction have a miserable existence during sleep. They may sleep for one and one-half to two hours, and then awaken with violent coughing in an effort to expectorate the saliva that has run down the tracheobronchial tree. If they do not have this problem they have probably learned to sleep on the face with the head * Chief, Surgical Service, Veterans Administration Hospital, Hines, Illinois; Clinical Professor of Surgery, University of Illinois College of Medicine, and Chief Surgeon, Henrotin Hospital, Chicago.
** Assistant Chief, Surgical Service, Veterans Administration Hospital, Hines, Illinois. From the Surgical Service, Veterans Administration Hospital, Hines, Illinois, and Department of Surgery, University of Illinois College of Medicine, Chicago.
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Charles B. Puesiow, William J. Gillesby
over the edge of the bed, so that the saliva can drool from the mouth. This problem exists in benign as well as malignant lesions of the esophagus, and it is not uncommon to see these patients with frequent episodes of pneumonitis, lung abscess and other pulmonary complications (Fig 18). The restoration of nutrition to these patients is very important, and gastrostomy or jejunostomy feedings may have to be resorted to in advanced lesions. However, the aspiration of saliva is not prevented by these procedures and more heroic methods are essential for the comfort and health of these patients, whether the disability be due to benign or malignant disease. This clinic will not deal with all surgical lesions of the esophagus. A
Fig. 18. Roentgenogram showing high esophageal obstruction and spilling of barium into bronchial tree.
few diseases will be mentioned in generalities, while the surgical management of some diseases will be discussed in more detail. CARDIOSPASM
Cardiospasm, or achalasia, is a disease of unknown etiology producing a spasm or constriction in the distal end of the esophagus, preventing the free passage of food into the stomach. The esophagus becomes increasingly dilated above the obstruction, and may distend to occupy a large part of the right chest, displacing various amounts of the right lung. A dilated esophagus rarely extends to the left side. In our experience, cardiospasm usually responds to dilatation of the constricted area. A single dilatation may produce a permanent cure. Occasionally the procedure must be repeated at regular intervals. Of the surgical procedures that have been advised where dilatation failed, we believe the Heller
Surgical Lesions of the Esophagus
69
operation, an extramucosal myotomy made in a longitudinal direction, is the most satisfactory operation. Various techniques for the establishment of an esophagogastrostomy frequently have been followed by a recurrence of the stenosis. ESOPHAGEAL ULCERS
Peptic ulcers of the esophagus are more common than are generally recognized. They are frequently associated with ulcers of the stomach and duodenum, and probably result from regurgitation of gastric juice into the esophagus. This may be due to inadequate sphincter action at the gastroesophageal juncture, or an insufficient sphincter function of
Fig. 19. A, Roentgenogram !showing esophageal peptic ulcer. B, Roentgenogram showing esophageal stricture secondary to ulcer. C, Postoperative roentgenogram following Wendel reconstruction.
the diaphragmatic muscles. Uncomplicated esophageal ulcers should be treated by medical management. The diagnosis should be ascertained by roentgenograms (Fig. 19, A) and by esophagoscopic biopsies, to differentiate a benign lesion from a possible early malignant growth. The healing of esophageal peptic ulcers may be followed by fibrosis, with varying degrees of stenosis. If obstruction results (Fig. 19, B), surgical intervention is indicated. The lesion should be approached through the left chest, through the bed of the eighth rib, or through the eighth interspace. If the lesion is extensive, it may be necessary to resect the distal esophagus and perform an esophagogastrostomy. A narrow obstruction may be relieved by a Wendel type of plastic reconstruction (Fig. 19, C). If active inflammation is present, suggesting activity of the ulcer, a complete vagotomy should be performed in addition to the reconstructive' procedure. This operation is frequently followed by spasm of
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Charles B. Puestow, William J. Gillesby
the pylorus and gastric retention. This may be avoided by incising the diaphragm to expose the pylorus and performing a pyloromyotomy or a gastrojejunostomy. If a partial esophagectomy is decided upon, and the ulcer is active, the proximal portion of the stomach may be resected to remove a large amount of acid-producing tissue. CAUSTIC STRICTURES OF THE ESOPHAGUS
The accidental or intentional ingestion of corrosive substances is one of the most common causes of benign strictures of the esophagus. Lye is the most frequent etiologic agent. These lesions may occur at any age but are most frequent in children, where they almost invariably result from accidents. In white adults, caustics are usually ingested with suicidal intent during periods of depression. In our experience Negro adults
Fig. 20. Roentgenogram showing strictured areas following ingestion of lye.
have ingested lye which they have erroneously thought to be gin. Caustic substances produce strictures throughout the esophagus with most extensive damage at points of normal constriction (Fig. 20). The immediate management of caustic strictures of the esophagus has been well described by Holinger1 , 2 and others. Weak antidotes are administered. Dilatation of the esophagus with soft mercury bougies is started within 24 hours of the ingestion of the caustic agent. Daily dilatations are carried out, first with small bougies, the size being gradually increased as tolerated. The frequency of dilatations is gradually diminished, but periodic treatment must be continued for many years or for life. If treatment is not instituted early, fibrosis and stenosis develop and require more drastic treatment. Attempted dilatation is the treatment of choice whenever possible. If this cannot be accomplished from above, a gastrostomy and retrograde dilatation may be employed. Only when dilatation cannot be accomplished and complete obstruction has resulted, should more radical surgery be contemplated. .
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When the esophagus is completely stenosed and cannot be dilated, esophagectomy and elevation of the stomach into the chest with a high gastroesophagostomy is indicated. This procedure has been described by the senior author.3 Because most of the esophagus is usually involved, the highest strictures are well above the arch of the aorta and almost the entire esophagus must be removed. We prefer to approach the esophagus through the bed of the left seventh rib. Because of the marked fibrosis in the periesophageal tissues, it may be difficult to remove all scar tissue. It is not essential to do this, but all functioning mucosa should be excised and the resection must extend beyond the highest level at which there is marked narrowing or destruction of the mucosa. It may be necessary to extend the resection into the cervical esophagus and to the pharynx. The stomach is mobilized and brought high into the chest to be anastomosed to the esophageal stump or pharynx. If the scarring involves the stomach, this organ may be contracted down and difficult to elevate into the apex of the pleural cavity. Occasionally it is necessary to mobilize the duodenum to permit such an anastomosis. Where the pylorus is also stenosed, a pyloromyotomy or gastrojejunostomy may be required as an additional procedure. If the upper portion of the esophagus is stenosed, it may be necessary to substitute plastic tubes, aortic or cutis grafts for the cervical segment. The technique of these procedures is described under the treatment of malignant lesions of the esophagus. These problems require a great deal of planning and may necessitate multiple stage operations. ESOPHAGEAL VARICES
Symptoms of esophageal varices are an exception to the rules-mentioned in the first part of this article, namely, there is. no:pain, there is usually no dysphagia, and the only symptom presenting is that of violent bleeding. There may, however, be other evidences of the primary disease, portal hypertension, which is usually secondary to biliary cirrhosis. The diagnosis can be established in most patients by esophagoscopic studies and roentgenograms taken during a barium swallow (Fig. 21, A). The immediate treatment consists of esophageal tamponade by the use of a Sengstaken tube, or a similar multilumen tube with multiple balloons. If the hemorrhage is controlled, efforts may be made to diminish portal hypertension by the use of vascular anastomoses between the portal and systemic venous systems. This is not always possible, and does not always control the bleeding. Under such circumstances, the varices themselves must be attacked. We prefer to approach esophageal varices through the left chest by an incision in the eighth interspace or the bed of the eighth rib. The lower end of the esophagus is mobilized. A longitudinal incision is made in the esophagus close to the diaphragm. Three large varices are usually encountered. These may be occluded by oversewing each of the veins
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Charles B. Puestow, William J. Gillesby
with continuous intestinal catgut sutures beginning near the diaphragm and extending upward for several inches. This can be done through a small incision, as the veins can be pulled down with the sutures (Fig. 22). This method, which has been described by Crile4 • 6 and others, has proved
Fig. 21. .4, Roen tgenogram demonstrating esophageal varices. B , PosLoperaLive roentgenogram of esophagogastrostomy for varices.
Fig. 22. Method of suture of esophageal varices through left thoracotomy approach.
satisfactory in our hands. Where the varices are extensive, it may be necessary to resect the lower esophagus and perform an esophagogastrostomy as first described by Phemister.6 Figure 21, B, is a roentgenogram of the postoperative results of such a procedure. RUPTURE OF THE ESOPHAGUS
In either spontaneous or instrumental rupture of the esophagus, the treatment should consist of immediate operation with exposure and
Surgical Lesions of the Esophagus
73
suture of the rupture. The approach may be through either the right or left chest, depending upon which side fluid appears in the pleural cavity. Suture of the esophagus is comparatively simple, and we believe should be accomplished over an intraluminal tube. Postoperative drainage of the chest must be effective to prevent the development of empyema. BENIGN TUMORS OF THE ESOPHAGUS
Benign tumors of the esophagus are rare, but are seen sufficiently often to require comment. I eiomyomas of the esophagus are the most common tumors and may produce obstructive symptoms, or be symptomless. They are frequently discovered by routine chest x-rays, there being an
Fig. 23. Roentgenogram showing abnormal density in mediastinum produced by a leiomyoma of the esophagus.
abnormal density in the mediastinum on x-ray film (Fig. 23). These tumors are benign and are easily removed. Some may be enucleated without any difficulty; and if the mucosa of the esophagus remains intact, complications are minimal. Occasionally the leiomyoma may encircle the esophagus, and in such a circumstance esophageal resection with esophagogastrostomy is the procedure of choice. CARCINOMA OF THE ESOPHAGUS
We are encountering carcinoma of the esophagus with half the frequency of carcinoma of the stomach. The early symptoms of this disease consist of anorexia and difficulty in swallowing solid food, often accompanied by mild substernal distress. These symptoms precede weight loss by weeks or months. It is unfortunate that they are not recognized early and that the diagnosis usually is not made until the disease is far ad-
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Charles B. Puestow , William J. Gillesby
vanced. This delay not only permits the disease to advance to an ineurable stage, but also increases the danger of operation by impairing the nutrition of the patient. Early diagnosis can be established in most instances by radiographic studies and by esophagoscopy and biopsy. Resection of the Tumor and Establishment of a Gastroesophagostomy
The treatment of choice for carcinoma of the esophagus is complete excision of the lesion and several centimeters of esophagus on each end. This should be accomplished wherever possible, even though local or distant metastases exist. The distress produced by an obstructing lesion of the esophagus and its resultant starvation is far greater than the terminal stage of this disease produced by metaiiltases. Every effort should be made to re-establish continuity of the alimentary tract, so that the patient is able to swallow his food and saliva. Resection of the tumor and the establishment of a gastroesophagostomy is the most satisfactory of palliative, as well as curative, procedures. Left-Sided Approach. We prefer to approach the esophagus through the left chest, and the stomach through the left diaphragm. This approach gives adequate access to the entire intrathoracic esophagus and permits mobilization of the stomach with a minimum amount of surgery. Lesions of the lower esophagus are approached through the bed of the left eighth rib. Almost the entire rib should be removed to permit adequate access to the stomach and the esophagus. If there is any doubt in the operator's mind as to whether esophagogastric anastomosis can be done below the aortic arch, it should not be attempted. The esophagus should be mobilized from behind the aorta, and an esophagogastric anastomosis performed above the aortic arch. Ther@ can be no compromise with a firm stand on this point. Lesions of the upper thoracic esophagus can be mobilized with greater ease through the bed of the seventh rib. If greater exposure is needed the left sixth, and sometimes fifth, ribs may be divided close to the spine. Carcinomas which extend into the cervical esophagus can be approached by neck incision in addition to the transthoracic approach. The technique of surgical removal of carcinomas of the esophagus and the establishment of a gastroesophagostomy through the left chest has been previously described in detail in this j ournal,7 Right-Sided Approach. Some surgeons prefer to approach the esophagus through the right chest. This approach has the advantage of providing easier access to that portion of the esophagus lying behind the arch of the aorta. It has the disadvantage of requiring an additional abdominal incision for mobilization of the stomach. The technique of the rightsided approach is as follows. The patient should be positioned on the operating table in such a
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manner that both the thoracic and abdominal procedures can be performed without a change of position. We prefer to have the patient on his back, with a 30 degree tilt to the left. A right anterior thoracotomy is performed through the fourth interspace, with a resection of small segments of the fourth, third and second costal cartilages (Fig. 24). A flap of chest wall is elevated. The right lung is retracted to expose the
Fig. 24. A, Incision for right-sided approach. B, Line of incision for chest wall Hap.
Fig. 25. A, Incision for mobilization of stomach. B, Mobilization of stomach and pyloromyotomy.
azygos vein, which must be ligated and divided to expose the esophagus. The esophagus is completely mobilized from the diaphragm to a point well above the upper limits of the tumor. The thoracotomy wound is temporarily closed with towel clips. An abdominal incision is made for mobilization of the stomach (Fig. 25, A). The gastrohepatic and gastrocolic ligaments are divided at a sufficient distance from the stomach to preserve the vascular arcades. This dissection should extend from the esophageal hiatus to the duodenum. We believe a pyloromyotomy should be performed to minimize subsequent pylorospasm (Fig. 25, B). Abdominal and diaphragmatic portions of the esophagus are freed by
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Charles B. Puesww, William J. Gillesby
finger dissection. If the hiatus is somewhat snug, it should be enlarged by dilatation or incision. This can be done either from below or above the diaphragm. The abdominal wound is closed and the thoracic wound reopened. The stomach is pulled into the thoracic cavity as far as possible. It is placed posterior to the root of the right lung. If the tumor is well above the cardiac end of the stomach, the esophagus is separated from the stomach and the opening into the stomach closed. If the tumor is close to the gastroesophageal juncture, varying amounts of stomach may be resected. A gastroesophagostomy is established between the fundus of the stomach and a point on the esophagus at least 4 cm. above the tumor. We prefer a two-row technique using an inner row of continuous catgut and an outer row of interrupted cotton. If there is a redundance of stomach it is well to tack the serosa of the stomach to the esophagus 0.5 to 1 cm. above the line of anastomosis, to protect the suture line. This telescopes a short segment of the esophagus into the stomach. To avoid traction on the suture line the stomach should be sutured to the parietal pleura by a few interrupted cotton sutures. The right pleural space is drained by catheter, with water seal control, and the chest wall closed. Palliative Managenlent
In certain patients in whom resection of the tumor cannot be performed because of extensive invasion of aorta or hilus of lung, palliative procedures are justifiable. Palliation may be accomplished by a side-to-side anastomosis of the stomach to the esophagus above the lesion (Fig. 26, A). This procedure has been described in the French literature,s and we have been employing it with good results. It is possible by this procedure, to leave the tumor attached to the aortic arch or surrounding tissues and short-circuit the esophageal contents to the stomach by by-passing the obstructed region (Fig. 27). Some advanced carcinomas of the esophagus with extension of the disease which will preclude a cure can be resected through a right thoracic incision and a prosthesis substituted for the missing portion of esophagus. This method involves far less surgical trauma than utilization of the stomach. Berman9 has described a plastic tube which, in his hands, has been satisfactory (Fig. 26, B). Our results with this tube have been discouraging. Aortic transplants have been used as substitutes for segments of esophagus. Immediate or delayed leakage at the suture line has been encountered in this procedure. The Macklerlo tube has been used, and in nonresectable situations has been of value in restoring continuity of the esophageal lumen. The tumor is exposed from either the right or left side and an estimate is made of its resectability. If inoperability is evident the esophagus is mobilized above or below the tumor, depending upon which is the most
77
Surgical Lesions of the Esophagus
accessible area, and a longitudinal incision is made into the esophagus. The esophageal lumen is then dilated by the use of Bakes common duct dilators to the extent necessary, dilating through the tumor. After
B
Berm~n tube
Fig. 26. A, Palliative supra -ao rtic anastomosis for nonresectable cancer of the middle t hird of the esophagus. B, Method of inse rt ing Berman tube with peri esop hageal cuffs. C, Esophageal incision and placing of Mackler plastic tube through esophageal c :~ncer.
Fig. 27. Roentgenogram showing supra-aortic anastomosis: a, esophagus ; b, carcinoma; c, esophagogastrostomy; d, aorta; !e, stomach.
a sufficient lumen has been made, a Mackler tube, which is a plastic tube with a flange at one end, is inserted into the esophageal lumen and forced through the opening in the tumor so that the lumen will carry food and saliva. This is shown in Fig. 26, C. A circumesophageal suture is placed above or below the flange of the plastic tube so that the tube will remain in position.
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78
Curative surgery is to be attempted if at all possible, but in many cases it is impossible to expect any curative results because of extension of the tumor to paravascular areas, to the lung, to mediastinal nodes that are unresectable, or to the lesser curvature of the stomach in patien ts with lower esophageal carcinoma, or to the neck in upper esophageal carcinoma. The use of gastrostomy and jejunostomy is so unsatisfactory that a more major procedure is justifiable in order to give the patient comfort for his remaining months or years. It has been gratifying to see patients so treated who are able to go back to work for months or even years, alth(mgh the prognosis is dismal. It is important to warn patients regarding postoperative management, even when healing has been complete. Those with esophagogastrostomies do not have a competent cardiac valve and may develop regurgitation, which in turn may produce peptic esophagitis in the remaining esophagus. It is also possible that regurgitated material will enter the lung during sleep, and pati€nts should be warned not to drink fiuid51 before lying down. They learn from experience that they are more comfortable if they sleep in a semireclining position. In the case of plastic tube replacements of the esophagus, it is important to warn the patient not to eat poorly chewed foods. The diet must be carefully outlined so that foods can pass any anastomosis or prosthetic lumen. SUMMARY
A number of diseases of the esophagus which are amenable to surgical therapy have been presented. Early symptomatology, especially of malignant lesions, has been emphasized. Techniques of curative and palliative surgical procedures have been described. Safeguards, which minimize the risk of operation as well as postoperative complications, have been discussed. The field of esophageal surgery is relatively new, and is expanding rapidly. It has much to offer in the eradication of disease and in improving the comfort of the patient. Its safety can be greatly augmented by thorough preoperative and postoperative care, meticulous operative technique, and early recognition of disease. REFERENCES 1. Holinger, P. H. and Johnston, K. C.: Benign Strictures of the Esophagus. S. CLIN. NORTH AMERICA 31: 135-152 (Feb.) 1951. 2. Holinger, P. H., Tamari, M. J. and Bear, S. H.: Corrosive Esophagitis Due to Nitric Acid. Laryngoscope 63 (9): 789-807 (Sept.) 1953. 3. Puestow, B. and Chess, S. J.: Resecti@n of the Esophagus for Persistent Stricture. Arch. Surg. 56: 34-37 (.Jan.) 1948. 4. Crile, George, Jr.: Transesophageal Ligation of Bleeding Esophll,glilal Varices. Arch. Surg. 61: 654-660 (Oct.) 1950. 5. Crile, George, Jr.: Personal communication.
e.
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6. Phemister, D. B. and Humphreys, E. M.: Gastroesophageal Resection and Total Gastrectomy in Treatment of Bleeding Varicose Veins in Banti's Syndrome. Ann. Surg. 126 (4): 397-410 (Oct.) 1947. 7. Puestow, C!. B. and Cross, J. H.: Carcinoma of the Esophagus. S. CLIN. NORTH AMERICA 31 (1): 153-171 (Feb.) 1951. 8. Renan, C., Le Bihan, R. and Gaguet, A.: Study Apropos of Palliative Supraaortic Anastomosis for Inoperable Cancer of Middle Third of Thoracic Esophagus. Mem. Acad. de chir. 77: 684-685 (June 20-July 4) 1951. 9. Berman, E. F.: A Plastic Prosthesis for Resected Esophagus. Arch. Surg. 65: 916 (Dec.) 1952. 10. Mackler, S. A.: Personal communication. 25 E. Washington Street Chicago 2, Illinois (Dr. Puestow)