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Reversed Gastric Tube (RGT) Esophagoplasty for Failure of Colon, Jejunum and prosthetic Interpositions
Abstract
Reversed gastric tube (RGT) esophagoplasty is preferred by the author as the primary procedure for esophageal replacement. Many patients undergoing RGT esophagoplasty, however, have previously had multiple operative procedures. A particularly challenging problem in esophageal reconstruction is the patient who has already had unsuccessful intestinal or prosthetic interposition operations in attempts to reconstruct the esophagus. In such patients, it has been possible to replace the esophagus by means of the RGT operation. Of 67 RGT esophagoplasties, 9 patients (13.4%) had previous interposition operations that had failed. Six had undergone colon interposition; 2 of these had strictured, 1 had partially sloughed leaving a cervical salivary fistula, and in 1 the proximal end was never patent. In each instance, bypass with RGT was performed without resecting the colon transplant. The colon had necrosed and was removed in 2 patients. Of the remaining 3 patients, in 1 a plastic esophageal prothesis had sloughed and two had free jejunal transplants, 1 of which had impaired vascularity and the other had fibrosed. The specific techniques used to reconstruct the esophagus by reversed gastric tube esophagoplasty, as they relate to this particular group of patients, are described.
... At a later date, Heimlich [39] demonstrated his experience with gastric tube of greater anisoperistaltic curvature in cervical derivation in the treatment of esophagoplasties that failed with the use of stomach, colon, jejunum, or even prostheses. A total of 67 patients underwent this procedure with only 3 fatal cases. ...
Although malignant neoplasms of the esophagus remain a very common disease, their diagnosis might often come late, which explains why 50% of patients require palliative treatment. The ideal scenario would be the performance of procedures that provided an adequate quality of life and satisfactorily restored swallowing. This chapter aims to describe the results of palliative methods, discussed with emphasis on the technique of the isoperistaltic greater curvature gastric tube (IGCGT). About 143 patients with unresectable squamous cell carcinoma of the esophagus (T4b) were evaluated at this facility. In the early postoperative evaluation, 64 patients (44.7%) presented systemic complications, with pulmonary infection being the most frequent; 51 patients (35.6%) presented local complications, with cervical esophagogastric anastomosis leak being the most frequent. Thirteen patients (9.1%) died as a result of postoperative complications. Out of 112 patients who were adequately followed up, 91 (81.2%) achieved good palliation with this procedure, as they had adequate restoration of swallowing function, with a median survival of 3 years in 63 patients (69.2%). With these results, it is possible to conclude that despite showing non-negligible morbidity, IGCGT can be performed quickly and safely, offering adequate palliation and survival rate.
... Additionally, the surgical history of every patient needs to be considered and treatment should be tailored 70 . Several surgical approaches have been reported such as colonic conduit revision, colon-gastric disconnection with Roux-en-Y colon-jejunal anastomosis 47,71 , resection and antimesenteric longitudinal tapering of the colonic segment, trans-hiatal colonic mobilization with anti-mesenteric tapering coloplasty, and reverse gastric tube oesophagoplasty 72 . Advantages of reverse gastric oesophagoplasty are the absence of an interposed organ between the oesophagus and stomach, excellent vascularization, and similar outcomes for subcutaneous, retrosternal or intrathoracic approaches. ...
Oesophageal atresia-tracheoesophageal fistula (EA-TEF) is a common congenital digestive disease. Patients with EA-TEF face gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life issues in childhood, adolescence and adulthood. Although consensus guidelines exist for the management of gastrointestinal, nutritional, surgical and respiratory problems in childhood, a systematic approach to the care of these patients in adolescence, during transition to adulthood and in adulthood is currently lacking. The Transition Working Group of the International Network on Oesophageal Atresia (INoEA) was charged with the task of developing uniform evidence-based guidelines for the management of complications through the transition from adolescence into adulthood. Forty-two questions addressing the diagnosis, treatment and prognosis of gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life complications that patients with EA-TEF face during adolescence and after the transition to adulthood were formulated. A systematic literature search was performed based on which recommendations were made. All recommendations were discussed and finalized during consensus meetings, and the group members voted on each recommendation. Expert opinion was used when no randomized controlled trials were available to support the recommendation. The list of the 42 statements, all based on expert opinion, was voted on and agreed upon.
... Conventional reversed gastric tube oesophagoplasty is mainly required to treat oesophageal atresia and caustic oesophageal strictures in infants and children [8]. However, a small amount was applied to failure cases in the treatment of colon, jejunum and prosthetic interpositions [9]. These gastric tubes were made of a part of the greater curvature gastric with gastroepiploic vessels and the lesser curvature gastric. ...
Background
The gastric conduit is the best replacement organ for oesophageal reconstruction, but a reversed gastric conduit (RGC) is rare. Oesophageal reconstruction for oesophageal cancer patients with a previous history of complicated gastrointestinal surgery is rather difficult. Here, we report a case in which oesophageal reconstruction was successfully managed using RGC based solely on the left gastroepiploic artery supply.
Case presentation
A 69-year-old man with oesophageal cancer had a history of endoscopic intestinal polypectomy and pylorus-preserving pancreaticoduodenectomy (PPPD). The right gastroepiploic artery and right gastric artery had been completely severed. The only supply artery that could be used for the gastric conduit was just the left gastroepiploic artery. Because of the complex history of abdominal surgery, we had no choice but to use the RGC to complete the oesophageal reconstruction, in which the gastric conduit was passed reversely through the hiatus to the oesophageal bed and layered end-to-side manual intrathoracic anastomosis with the esophagus. The patient had transient feeding problems with postoperative delayed thoracic stomach emptying but no anastomotic stenosis or thoracic stomach fistula. He was satisfied with his life and had no long-term complications. There was no significant effect on gut physiological function, and RGC could work normally.
Conclusions
Oesophageal reconstruction with RGC is a feasible procedure for complex oesophageal carcinoma that can simplify complicated surgical procedures, has less influence on gut function, is less invasive, and is safe.
... Colon conduit was placed retrosternally in seven and through posterior left thorax in six patients [4,5]. Eleven patients underwent oesophageal reconstruction with Heimlich type reversed gastric tube at the median age of 12 (12)(13)(14) months [6]. Reversed gastric tube reconstruction was performed in two stages by constructing the gastric tube by stapling along the greater curvature of the stomach. ...
Purpose:
Because of an extended gap between esophageal pouches a variety of methods are employed to treat oesophageal atresia (OA) without (type A) or with (type B) proximal tracheooesophageal fistula. This retrospective observational study describes their single centre long-term outcomes from 1947 to 2014.
Methods:
Of 693 patients treated for OA 68 (9.7%) had type A (n=58, 8.3%) or B (n=10, 1.4%). Hospital records were reviewed. Main outcome measures were survival and oral intake.
Results:
Nine (13%) patients had early and 10 (15%) delayed primary anastomosis, 30 (44%) underwent reconstruction including colonic interposition (n=13), reversed gastric tube (n=11) and jejunum interposition (n=6), whereas19 (28%) had died without a definite repair. Median follow up was 35 (interquartile range, 7.4-40) years. Thirty-one (63%) of 49 patients with definitive repair survived long term. Survival was 22% for early and 80% for delayed primary anastomosis, 57% for colon interposition, 82% for gastric tube and 84% for jejunum interposition. Gastrooesophageal reflux was most common after gastric tube (80%), dysphagia after colon interposition (50%), and 3 (60%) of 5 survivors with jejunum interposition had permanent feeding ostomy because of neurological disorder. Endoscopic follow-up disclosed no oesophageal cancer or dysplasia. Repair in the most recent patients from 1985 to 2014 (n=14) included delayed primary anastomosis (n=7), jejunum interposition (n=6) and gastric tube (n=1) with 93% long-term survival.
Conclusion:
Morbidity among long-term survivors of type A or B OA is high. With modern management survival is, however, excellent and patients without neurological disorder achieve full oral intake either after primary anastomosis or reconstruction.
Levels of evidence:
IV.
Although malignant neoplasm of the esophagus is a disease with a high incidence, its diagnosis is often still delayed. This fact combined with excessive weight loss due to dysphagia and the association with car-diopulmonary diseases resulting from excessive tobacco use, makes these patients have a difficult clinical control, which explains that more than 50% of them require palliative treatment. The ideal scenario would be to perform procedures that provide an adequate quality of life and with satisfactory rescue of swallowing, without the need for frequent hospitalizations and with a low rate of complications. Thus, this chapter aims to discredit the indications and results of palliative methods and especially shunt surgeries, discussing the technique of isoperistaltic gastric tube of great healing (GIT). In the Department of Surgery of Hospital PUC Campinas, 143 patients with unresectable esophageal squamous cell carcinoma (T4b) were studied, and all of them had clinical conditions to be submitted to GIT. In the early postoperative evaluation, 64p (44.7%) presented systemic complications, with pulmonary infection being the most frequent; 51p (35.6%) presented local complications, with dehiscence of the cervical esophagogastric anastomosis being the most frequent. 13p (9.1%) died due to postoperative complications. Of the 112 patients who were properly followed, 91 (81.2%) presented good palliation with this procedure, with adequate swallowing rescue. Chemoradiation was performed after the TGI in 82 patients, with a mean survival of 3 years in 63 patients (76.8%). With these results, it is possible to conclude that despite the postoperative morbidity not being negligible, the TGI can be performed safely, especially after the advent of mechanical suture, because it offers adequate palliation and survival. In addition, this procedure has the advantage of simultaneously providing good drainage of the esophagus and stomach, and thus potentially avoiding esophageal mucocele.
Several substitutes, including gastric transposition, colonic interposition, reverse gastric tube (RGT), etc., have been described for esophageal replacement in children and adolescents. However, the search for the ideal esophageal substitute continues due to adverse events associated with these procedures. This report presents our technique for creating an isoperistaltic gastric tube (IGT). We believe that the IGT is a versatile option for esophageal replacement as it is never length-limiting, and additional length can be gained by making minor adjustments.
Abstract Objective: The aim of this study was to investigate the vascular anatomy of the stomach, especially the right gastroepiploic artery for the reconstruction of a gastric tube during esophagectomy. Methods: The vascular anatomy of the stomach was studied in
28 embalmed human specimens provided by the Department of Anatomy, Shanghai Medical College, Fudan University, included 10 female and 18 male specimens.. The length and diameter of gastric vessels were measured. The ratio of the length of the right gastroepiploic artery to the length of the greater curvature was calculated. Anastomosis between the left and right gastroepiploic arteries was also assessed. Results: The mean diameter of the left gastric artery was 3.40 (2.10-6.40) mm, of the right gastric artery was 1.97 (0.68-3.56) mm, of the left gastroepiploic artery was 1.87 (0.80-2.96) mm, and of the right gastroepiploic artery was 2.82 (1.58-4.80). mm The mean lengths of the right gastroepiploic artery and greater curvature were 216.71 (120-318) mm and 356.39 (248-487) mm, respectively, with a ratio of 0.61 (0.45-0.82) mm. Anastomosis between the left and right gastroepiploic arteries was observed in 60.7% (17/28) of the specimens. Conclusion: The length and diameter of gastric vessels were calculated. It was assumed that the right gastroepiploic artery provides an average of 61% of the blood supply for the great curvature. In addition, the anastomotic branch of the right and left gastroepiploic arteries was observed in 60.7% specimens. These anatomical data allow surgeons to estimate the blood supply and to choose an optimal method of gastric tube reconstruction during esophagectomy.
Keywords: esophageal cancer, gastric tube, gastric vessel, right gastroepiploic artery, blood supply, surgery
The laminar structure of the esophageal wall (Fig. 1) follows the same general pattern as the rest of the alimentary tract [21, 27]. In the thoracic part of the esophagus, the entire right side and the upper and lower portions of the left side receive a serous covering from the mediastinal pleura. The abdominal part of the esophagus is covered anteriorly by peritoneum. Interposed between the serosa and underlying muscular coat is the adventitia, a loose layer of connective tissue which is a downward continuation of the pharyngeal fascia and which gives the esophagus its mobility in the neck and posterior mediastinum. The pleural serous coat is lost when the esophagus is surgically exposed.
Using the colon (or jejunum) to replace resected segment of the esophagus permits the surgeon to preserve intact a functioning stomach. Performing the cologastric anastomosis 10 cm down from the gastric cardia will generally minimize gastrocolic reflux. Achieving a sufficient length of viable colon is, with rare exceptions, feasible. One drawback to using the colon as a substitute esophagus is the risk of impairing the venous blood flow either by injuring the veins in the colon mesentery or impairing venous return by leaving an inadequate aperture in the diaphragm or at the apex of the thorax for the colon and its mesentery. Under these conditions venous infarction can occur. Following careful surgery, this complication should be quite rare. Belsey experienced one colon infarct in 92 left colon interposition operations. This complication appears to be more common when the right colon is used as opposed to the left colon (Wilkins).
The esophagus, although well protected by other organs and structures in the posterior mediastinum, is easily accessible to endoscopy through the mouth. The same anatomic factors, however, make surgical approach difficult, necessitating thoracotomy, laparotomy, or both. Each is a major surgical procedure. The dual function of the esophagus as conduit for food and draining path for saliva makes complete removal of this organ impossible. Therefore, to provide a substitute esophagus by means of reconstruction has been the aim of surgeons for decades. New methods and improvement of old procedures are described frequently in surgical publications.
It is well established that there is no better conduit than the native esophagus1 but there are some conditions in which the native esophagus cannot be preserved and needs to be replaced. The main indications for esophageal replacement in the pediatric population are long-gap esophageal atresia (LGEA) and severe esophageal strictures. There are several options for replacement depending on the organ (i.e., stomach, colon, jejunum) and the route used (i.e., subcutaneous, retrosternal, transhiatal).
The geographic high incidence areas of squamous cell carcinoma of the esophagus suggest that a predisposing factor, such as diet or habits of alcohol or tobacco use, may exist. No convincing evidence, however, has evolved as to what this factor might be. The diagnosis is seldom difficult but the natural history of the disease, with invasion or metastases occurring relatively early, makes effective treatment difficult.Other lesions of the esophagus do occur, both benign and malignant-tumors, but proportionately they are less frequent. Mention is made of these.Despite the fact that only 30% of these carcinomas can be resected and the five-year survival of all patients is in the range of 3%, attempts to secure palliation and occasionally complete cure by operation should continue. Most of the described methods of palliation and stated resection have been tried here. In view of this experience, the simplest, most direct, one stage operation is strongly advised in the majority of patients.
There has not been described a uniformly successful method for palliation of inoperable carcinoma of the esophagus, especially malignant tracheoesophageal fistula. A gastric tube formed from the greater curvature of the stomach is being evaluated for these patients. The blood supply is based on the right gastroepiploic vessels. Using a stapler, one can form a gastric tube sufficiently long to reach the hypopharynx. Placed substernally, anastomosis to the cervical esophagus is performed. In 30 patients postoperative mortality has been 13%. No tube necrosis has occurred, but anastomotic leakage has been a problem. In those patients who had esophageal bypass for palliation and were discharged from the hospital, swallowing function has been satisfactory and the average survival has been 5.2 months.
Three patients were encountered who had physical defects that prevented them from swallowing food. They had received nourishment for a long period of time by means of tube feedings, gastrostomy in two cases and nasogastric tube in the third. Following surgical correction of the physical problems, they were still unable to swallow food. It was conceived that they had forgotten how to swallow. A program to enable them to relearn the technique of swallowing was established, similar to that used in premature infants. The three patients were successfully rehabilitated, able to eat a regular diet. The method is being evaluated in stroke patients who have lost the ability to swallow food and saliva.
Total replacement of the cervical esophagus and hypopharynx after pharyngolaryngoesophagectomy for malignant neoplasms was accomplished successfully in two patients with the use of a revascularized isolated intestinal segment. The ileocolic artery was anastomosed to the external carotid artery and the ileocolic vein to the internal jugular vein. In one patient unilateral neck dissection and in the other patient bilateral simultaneous neck dissection was performed. The terminal ileum supplied by the ileocolic vessels appears to be the most suitable segment for transplantation because of the constancy and the size of the vessels. The terminal ileum is preferable to the colon since the small intestine more closely approximates the diameter of the cervical esophagus and pharynx and has a thicker wall and a better blood supply.
Seventeen patients with carcinoma of the hypopharynx and/or cervical esophagus who require total pharyngolaryngectomy-esophagectomy are presented; Twenty-one different reconstructive methods were applied in the seventeen patients. An overall two year survival rate of 35 per cent was attained with effective palliation in 65 per cent of the patients. The Wookey and free jejunal transplantation procedures were unsuccessful as primary means of pharyngoesophageal reconstruction, although the Wookey principle was occasionally useful in salvaging failures of other procedures. The reversed deltopectoral flap was successfully employed in a small number of patients with only minimal extension below the cricopharyngeus but was found to be unfeasible in several other instances because of the extent of esophageal resection required. Transposition of the entire stomach was successfully employed in a number of suitable patients and is an excellent method of esophageal replacement in relatively healthy patients. The reversed gastric tube esophagoplasty was useful in more debilitated patients, with resection and reconstruction performed in separate stages.
A method of reconstructing the entire esophagus by a chain of free forearm flaps connecting pharynx to jejunum is presented. This was indicated because all other means of reconstruction were not possible. It solved a difficult problem with good result, and the patient was satisfied.
This review discusses postoperative gastric ischaemia after detailed consideration of the gastric blood supply and the effects of devascularization. Special consideration is given to gastric remnant necrosis, lesser curve ischaemia after highly selective vagotomy, and gastric ischaemia after other operations.
This paper reports two late complications of oesophageal replacement using the reversed gastric tube described by Gavriliu. One patient developed obstruction of the gastric tube and the other a perforation of a diverticulum within the gastric tube, both occurring more than 10 years after the original operation. The occurrence of such complications should be made known to surgeons who are contemplating using this form of oesophageal replacement.
Benign oesophageal stricture remains a common problem. Following accurate diagnosis, early treatment allows dilatation in the great majority of patients. Resection can frequently be avoided and in fit patients dilatation should be combined with an anti-reflux operation plus gastroplasty where necessary. Frail elderly patients may be managed by continued dilatation and medical means to reduce and combat the effects of reflux. Resection should now be necessary in only about 5 per cent of patients and colonic interposition offers good long-term results. It must be remembered that adenocarcinoma is a small but real risk in patients with reflux stricture.
Manometric studies were performed to evaluate motor activity of several types of esophageal substitutes: total stomach (5 patients), isoperistaltic gastric tube (5 patients), jejunal Roux-en-Y loops (4 patients), and isoperistaltic left colon (15 patients). Motor behavior of substitutes was assessed following dry swallows and following several stimuli: intraluminar injection of 30 ml of water or 0.1N hydrochloric acid and swallowing pills. Following dry swallows, there was no response with either stomach or isoperistaltic gastric tube, jejunum showed a variable response, and a response was infrequent in patients with colon transplants. After dry swallows, transmission of the pressure wave through the anastomosis was not observed in any patient. Total stomach and isoperistaltic gastric tube did not respond to any stimulus. Jejunum responded with progressive waves after water and solid stimuli, and had a hyperkinetic response after acid injection. Colon had a constant (80 to 90%) and homogeneous response with progressive waves after all stimuli. After wet swallows, there was transmission through the anastomosis in 2 patients with colon transplants. Our data indicate that stomach and isoperistaltic gastric tubes do not contribute actively to the onward transmission of food in the digestive tract. Jejunum may contribute actively in digestive transit, but its responses are variable. Having steady and homogeneous responses, colon segments take an active part in transit.
An infected mucocele of an excluded retained esophageal segment is an infrequently reported complication of esophageal bypass surgery. The subtle symptoms of this entity and its management are discussed.
During the period 1972-1982, 84 pharyngoesophageal reconstructions were performed on 82 patients (10 benign lesions and 72 malignant lesions) by the Department of Otolaryngology, Mount Sinai Medical Center, New York. The overall mortality for the series was 10%, with postoperative complications developing in the majority of patients and swallowing accomplished in 61%. The most successful method of reconstruction was stomach transposition (92%), followed by cervical flap repair (68%). The least successful methods were the use of the tubed deltopectoral and pectoralis major myocutaneous flaps, colon interposition, and jejunal autografts (40%-50%). The pertinent literature is reviewed and the reported mortality, morbidity, indications, limitations, and success rates for each method of reconstruction are analyzed and compared with the present series.
A heretofore unreported low-morbidity staged procedure for the cxtrathoracic construction of a neoesophagus employing a combination of cutaneous and myoepithelial flaps is offered as an adjunct or alternative method to the surgeon faced with the problem of restoring the continuity of the upper digestive tract following thoracic esophageal resect ion.
Numerous methods have been employed for esophageal replacement after total pharyngolaryngectomy-esophagectomy. These have included the use of skin, as well as free transplantation or transposition of various abdominal viscera. The history and technical aspects of the procedures that have been used on the author's service are reviewed and results of 32 reconstructive operations are presented. Lower mortality and morbidity rates were obtained and palliation more consistently achieved with visceral transposition procedures than when the esophagus was reconstructed with skin. The 3-year cure rate of patients undergoing resection for cancer was 21%. Gastric transposition after extrathoracic total esophagectomy is the preferred procedure for suitable patients with post-cricoid and cervical esophageal carcinoma. Skin flaps are preferred for high hypopharyngeal tumors and in the poorest risk patients. Reversed gastric tube esophagoplasty and esophagocoloplasty are best employed for secondary rather than primary reconstruction.De nombreuses techniques ont t proposes pour remplacer l'oesophage aprs pharyngo-laryngo-oesophagectomie totale: elles utilisent la peau ou des transpositions de divers viscres abdominaux. L'article revoit l'histoire des techniques utilises dans le service et prsente les rsultats obtenus dans 32 reconstructions. La transposition de viscres donne une mortalit et une morbidit plus faibles et une palliation meilleure que la reconstruction utilisant la peau. La survie 3 ans est de 21% aprs rsection pour cancer. Chez les malades atteints de cancer de l'oesophage sous-cricodien ou cervical, la gastroplastie aprs oesophagectomie totale extrathoracique est la technique de choix, si l'tat du malade le permet. Pour les tumeurs hautes, sous-pharynges, et dans les cas haut risque, nous prfrons les lambeaux cutans. Le tube gastrique invers et la plastie avec le clon sont utiliss pour les reconstructions secondaires plutt que pour les primaires.
Submersion injury is so often lethal because it inflicts severe hypoxia. To prevent hypoxic end-organ damage to the heart and brain, the goals of resuscitation are immediate ventilation and oxygenation. Issue 1: Should submersion victims receive the Heimlich maneuver? The pathophysiologic assumptions for this intervention are that water in the airway is obstructive, thus precluding ventilation, and that aspiration of water is the major injury. Anecdotal case reports describe improved ventilation of some victims who failed prior ventilatory efforts. However, animal and human studies support that aspirated water is rapidly absorbed, does not preclude ventilation and intubation, and is best treated rapidly with positive pressure ventilation. With inadequate data to support benefit from the Heimlich maneuver and concern that the Heimlich maneuver would delay initiation of ventilation, basic life support procedures are recommended in managing the airway of the submersion victim. Issue 2: What is the role of prehospital care? Outcomes of submersion victims treated with rapid, aggressive prehospital care show that the window for medical intervention for the submersion victim is in the prehospital setting, not in the emergency department or intensive care unit. The submersion victim should be provided advanced cardiac life support, including intubation as needed, as soon as possible.
From 1979 to 1996, 19 patients underwent gastric-tube esophagoplasty. There were 10 boys and 9 girls, aged between 1 year 4 months and 4 years 11 months at the time of surgery. In 1 patient the esophagoplasty was performed due to a long stenosis secondary to reflux; 3 others had caustic stenoses; and the remaining patients had esophageal atresia. In 17 cases an isoperistaltic gastric tube was brought up to the neck through the retrosternal space; in 2 an anisoperistaltic gastric tube was used, cervical mobilization being via the posterior mediastinum without a thoracotomy in 1 case and by the left transpleural route in the other. The cervical anastomosis was carried out in one surgical stage in 12 patients and in two stages in 7. In 1 patient the tube was resected due to necrosis of its proximal third; the child later underwent an esophagocoloplasty. Necrosis of the colic graft, mediastinitis, and septicemia occurred, leading to the only death in the series. There were 12 fistulas of the cervical anastomosis (63.3%) and 8 stenoses (42.1%). All fistulas, with 1 exception, closed spontaneously after 8 days to 2 months, and all stenoses were treated by endoscopic dilatation. Another patient developed a fistula of the gastric tube with chronic evolution to a stenosis of the distal third of the tube and communication with the right lower pulmonary lobe. A lobectomy and closure of the fistula were necessary. All patients were followed for a period of 1 to 16 years. At present, all of them swallow solid food normally. The evolution of the nutritional status was normal (eutrophic) in 14 of the 18 patients (77.7%) who survived the operation; 4 showed variable degrees of malnutrition. In 2 of these 4 cases the malnutrition was due to poor socioeconomic conditions, but was not related to the surgery. Redundancy, a problem associated with esophagocoloplasty, was not observed in any of the gastric tubes, which was attributed to the thickness of the gastric wall. The authors prefer the use of an isoperistaltic gastric tube (with proximal base) for esophageal replacement in children and recommend that the operation should be carried out when the child is able to swallow solid foods and walk. As in any other major surgical procedure, a good nutritional state is essential prior to operation.
Malignant lesions of the pharyngoesophagus often require total laryngopharyngectomy and mediastinal dissection. As a result of the current treatment paradigms for advanced laryngopharyngeal cancers, it is common that the surgical field has been previously irradiated or exposed to systemic chemotherapy, resulting in fistula rates as high as 78% and mortality as high as 8%. The free vascularized tubed gastric antrum and the accompanying greater omentum offer a single-staged method of pharyngoesophageal reconstruction, with the added benefit of protection of the great vessels, the tracheal stump, and the mediastinal contents in a high-risk surgical field.
To assess the gastro-omental free flap as a method of pharyngoesophageal reconstruction in patients who have been previously treated with multimodality therapy.
Five consecutive cases of gastro-omental free flap reconstruction after total laryngopharyngectomy were retrospectively reviewed. Each case was assessed for intraoperative, perioperative, and postoperative complications at the primary site of reconstruction and the donor site. Patients were also evaluated for their ability to maintain an oral diet. Patients were followed up for a minimum of 6 months after surgery.
Five patients aged 44 to 70 years (mean, 59 years) underwent gastro-omental free flap reconstruction after total laryngopharyngectomy. Five patients had received previous external beam irradiation, 2 had received systemic chemotherapy, and 4 had undergone previous surgery. There were no fistulae or flap complications. Three patients were successfully treated with esophageal dilation for strictures sustained 2 to 5 months after surgery, and a third patient was successfully treated with conservative management for a partial gastric outlet obstruction sustained 2 months after surgery. One patient died 3 months after surgery of distant metastatic disease. The remaining 4 patients currently tolerate an oral diet.
The tubed gastro-omental free flap offers a safe method of reconstructing the pharyngoesophageal segment in a surgical field compromised by previous multimodality therapy.
A one-stage operation for replacing or by-passing the esophagus has been successfully performed experimentally. This procedure utilized a tube which is created from the greater curvature of the stomach, retaining its attachment to the cardia. The left gastroepiploic vessels are preserved and utilized to maintain the vascularity of the tube. The clinical implications of this operation are: (1) esophagogastric continuity is restored without the intervention of intestine or a plastic material; (2) the residual stomach retains its storage function; (3) the mediastinal structures and lungs are not compressed; (4) it is not necessary to incise or paralyze the diaphragm; (5) the vagus nerves may be preserved; (6) it is hoped that the anastomosis of the nonacid-secreting portion of the antrum to the esophagus will prevent the development of esophagitis.
SYNOPSISThe difficulties in fashioning a replacement for the oesophagus are briefly reviewed and a new technique, based on constructing a tube from the greater curvature of the stomach is described. The method has several obvious advantages and the short-term results are satisfactory.
1.1. Esophageal replacement or by-pass with a tube created from the greater curvature of the stomach has proved successful in 8 children ranging in age from months to 16 years. Four of these replacements were performed for congenital esophageal atresia, three for lye stricture and one for peptic esophagitis.2.2. When possible, the upper anastomosis should be performed at the initial operation if there is no pre-existing cervical esophagostomy. Using this technique we have had no anastomatic leaks. Angulation of the tube in the neck was minimal.3.3. The tube serves as a relatively inert conduit and seems to retain its tone and empty quickly. There has been no problem with stasis.4.4. Reflux can be demonstrated radiographically, but has not caused symptoms. None of the patients regurgitate and all can lie down after eating.5.5. This type of esophagoplasty is ideally suited to the infant with associated colon or anal malformations and to those with a colonic blood supply unsuitable for support of a colon transplant.
Bleeding esophageal varices in children under 10 years of age usually require esophagogastric resection with interposition of a segment of colon. Disadvantages are the magnitude of the operation and the risk of later peptic ulceration in the implant. A 4-year-old child with severely bleeding varices underwent esophagogastric resection and replacement with a reversed gastric tube in 2 stages. Since the operation the child has not bled for 32 months and he eats normally. Advantages of the method are: (1) comparative ease of operation, which can be staged, if desired; (2) close resemblance anatomically and functionally of the "neoesophagus" to its normal counterpart; (3) one gastroesophageal anastomosis in the neck, rather than 3 bowel anastomoses, of which 2 are abdominal; and (41 absence of peptic ulceration. The operation should have great promise in resections for congenital and acquired esophageal lesions in infants and children.
Complications Treated by Total Bypass Without Esophageal Resection Esophagoplasty with Reversed Gastric Tube
- Esophagitis
Esophagitis: Complications Treated by Total Bypass Without Esophageal Resection. Ann. Thorac. Surg., 1970, 10:203, 1970. 6. Esophagoplasty with Reversed Gastric Tube. Am. J. Surg., 123:80, 1972.