249

Esophageal Reconstruction and Replacements Ivan A. May and Paul C. Samson Ann Thorac Surg 1969;7:249-277 DOI: 10.
1016/S0003-4975(10)66183-8
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The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association. Copyright 1969 by The Society of Thoracic Surgeons. Print ISSN: 0003-4975; eISSN: 1552-6259.
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COLLECTIVE REVIEW
Esophageal Reconstruction and Replacements

Ivan A. May, M.D., and Paul C. Samson, M.D.
zerny [29] first successfully resected cancer of the esophagus in 1877. Since then esophageal replacement or reconstruction has been the surgical challenge. Mikulicz (1886) was the first to reconstruct the esophagus, using skin flaps also for a cervical lesion [951. No method of esophageal replacement is universally preferred since there is no ideal esophageal substitute; patients and their lesions must be individualized. In this review some of the significant contributions to the development of various methods of restoring esophageal continuity are presented. Extensive reviews have been written by Lilienthal, 1921 [78]; Saint, 1929 [141]; Ochsner, 1934 [112] and 1941 [ l l l ] ; Yudin, 1944 [169]; Rapant and Hromada, 1950 [129]; Postlethwait and Sealy, 1961 [126]; Meade, 1961 [go]; and Parker and Gregorie, 1967 [120]. A complete summation of the literature in the present review was not possible, but for those seeking a more detailed knowledge of the historical development, the above articles are strongly recommended.
SKIN
In 1907 Eugene Bircher reported that H. Bircher in 1894 had attempted antethoracic skin-tube bypass of the entire esophagus in 2 patients [ZO]. Von Hacker (1908) reviewed 25 cases of resection of the cervical esophagus and found that there had been a 48% mortality [163]. Skin flaps were used when reconstruction was attempted. Denk (1913) resected the thoracic esophagus from the neck and abdomen by the tunnel method; swallowing was later reestablished by an antethoracic skin tube [32]. In 1917 Payr successfully completed an antethoracic skin
Supported in part by the Professional Fee Fund, Highland General Hospital, and the Alameda Contra-Costa County Medical Society Library, Oakland, Calif. Address reprint requests to Dr. May, 3115 Webster St., Oakland, Calif. 94609.
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tube esophageal reconstruction from the cervical esophagus to the stomach in 1 patient [123]. Lilienthal (1921) resected a carcinoma of the thoracic esophagus from the posterior mediastinal approach, using a preliminary pedicle flap to place the esophagus extrapleurally [78]. After resection of the esophagus this flap was made into a skin tube. Graham and Ballon (1931) described use of the Gluck radical resection of cervical esophagus, trachea, and larynx in 116 patients with esophageal carcinoma; they reported 6 five-year cures [46]. Wookey (1942) presented the surgical treatment of carcinoma of the pharynx and upper esophagus; he advocated the type of skin-lined tubes devised by Mikulicz, Eggers, and Trotter, now usually referred to as the Wookey technique [ 1671. In 1948 Wookey recommended antethoracic skin tubes for thoracic inlet lesions that were too high for primary anastomosis with the stomach [168]. Ladd (1944) used skin tubes in the treatment of esophageal atresia for antethoracic reconstruction [76]. Watson and Converse (1953) presented the development of their radical resection of the cervical esophagus with skin and pedicle flap reconstruction [ 1641. Bricker and Burford (1957) summarized their experience with tube pedicle graft reconstruction following esophageal resection above the aortic arch level in 16 patients [22]. Twelve were for carcinoma, but only 1 of these had a good result; 4 were for lye stricture, and of these there were 2 fair and 2 poor results; there were only 5 survivors. T h e most frequent problem was progressive obstruction. Despite staging and careful technique, the results were poor and the operation was no longer recommended. Morfit, Klopp, and Nieerken (1957) reported 5 1 patients with carcinoma of the larynx and cervical esophagus [97]. Polyethylene stents were used; however, in 11 the tumor was too extensive for a primary repair. Their experience revealed that the operation could be done, but that the cure rate was not worth the morbidity. They concluded that if one cannot resect the tumor and reanastomose the esophagus, salvage cannot be increased by more extensive surgery. T h e trend has been away from skin-lined tubes for esophageal reconstruction because this method requires multiple operations and is often complicated by fistulas, irritation of the skin, and generally unsatisfactory results. At this time skin flap reconstruction is usually used only as a secondary procedure to complete reconstruction when visceral segments are inadequate or have failed in part. When a portion of a visceral segment is lost because of inadequate blood supply, an additional length of conduit can be formed from skin tubes and the reconstructive procedure salvaged.
JEJUNUM
In one patient with stricture, Roux (1907) brought an isolated segment of jejunum high enough under the skin to anastornose to the cervi250
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Esophageal Reconstruction and Replacement
cal esophagus [138]. T h e lower jejunum was anastomosed to the stomach and jejunal continuity was reestablished by side-to-side anastomosis. T h e cervical anastomosis was completed four years later. Lexer (1913) combined the Roux isolated jejunal loop with the Bircher cutaneous skin tube when the jejunum was not long enough to reach the neck [77]. He stated that the descent of food was by the impetus of the pharynx and that no peristalsis was necessary. Saint (1929) reviewed the literature and found that 144 esophageal reconstructions had been started for benign stricture but that only 84 had been completed [141]. Most of them had been constructed with jejunum and skin. Some patients died of other causes, but most of the deaths were from the operation. T h e total morbidity was 20.8%. Ochsner and Owens (1934) reviewed the literature on antethoracic esophageal reconstruction for benign stricture [112]. At that time, 240 operations had been performed. Of these 240, approximately 41% were jejunodermatoesophageal plasties of the Wullstein-Lexer type; 13%were skin-lined antethoracic tubes; 15% were jejunal segments; 8% were colon segments; 10% were stomach tubes; and 10% were of the entire stomach. T h e remainder consisted of miscellaneous operations. They reported the management of a patient in which an isolated jejunal segment anastomosed to the stomach and brought subcutaneously to the upper chest was used. T h e remainder was reconstructed with skin flaps (Lexers technique) [77]. This was probably the first successful esophageal reconstruction in the United States. Yudin (1944) reviewed the methods of esophageal replacement and reported the surgical construction of an artificial esophagus in 80 cases [169]. Antethoracic skin-lined tubes were often complicated by stricture. T h e most acceptable operations were the Roux-Y jejunal transplant or, if the blood supply was not adequate, a Lexer jejunodermatoplasty. Yudin presented the technique of his operation, which was performed in two stages. He no longer felt it was necessary to anastomose the small bowel to the stomach as he had done earlier when he used the Roux-YHerzen. His reasons were that the jejunogastrostomy was hard to do in the original or second operation and that the anastomosis functioned poorly and was probably useless anyway. He found no change in metabolism, growth, or development in children whose stomach was bypassed. Allison (1946) reported Roux-Y bypass of the stomach for reflux esophagitis [5] and with Da Silva (1953) he reported the use of this method for 28 patients who had benign lesions and 61 who had carcinomas, 17 of which were not resected [6]. Reinhoff (1946) performed the first intrathoracic esophagojejunostomy for three lesions in the upper third of the esophagus-arcinoma, stricture, and achalasia [ 1301. He recommended the shorter intrathoracic route and felt that the jejunum was long enough to reach the neck. Longmire (1947) reported a jejunal Roux-Y reconstruction of an esophagus for a lye stricture in which the
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blood supply at the upper end of the jejunum appeared inadequate [SO]. In the first stage, the internal mammary artery was anastomosed to the mesenteric artery of the jejunum at the second rib level for additional blood supply. At the second stage, the cervical esophagostomy was done. At the third, these were anastomosed. Van Prohaska and Sloan (1947) found that if the blood supply of the jejunum was inadequate, a stricture invariably resulted, and also that by staging operations to delay sacrifice of the jejunal vessels the blood supply was improved [161]. The jejunum was used antethoracically only when the stomach would not reach high enough for esophagogastric anastomosis. Mes (1948), in discussing operations using jejunal loops, stated that more patients probably died than lived [92]. Reynolds and Young (1948) felt that the use of the jejunal Roux-Y increased the curability of lesions of the stomach and lower esophagus by widening the margins of resection [132]. Sweet (1949) felt that intrathoracic jejunal transplant was better than any external plastic repair; he used it in a case in which the stomach was also burned by lye and thus was not satisfactory for esophageal replacement [155]. Robertson and Sarjeant (1950) introduced the substernal avascular route for visceral esophageal bypass, thus avoiding a thoracic incision [136]. A jejunal Roux-Y anastomosis was performed. They felt that it was not necessary to do a jejunogastrostomy and they advocated staging of the operation. Holinger et al. (1954) presented 3 cases in which esophagojejunal Roux-Y bypass of the stomach had been done through the anterior mediastinum for benign stricture [57]. Normal development followed. There was considerable discussion of this presentation as to the advisability of bypassing the stomach in children. All their patients with esophagogastrostomy developed esophagitis and stricture, but those with jejunal bypass of the stomach did not. Merendino and Dillard (1955) introduced jejunal interposition as a substitute for competent esophagogastric junction [91]. Four to five cm. of jejunum were anastomosed isoperistaltically between the esophagus and stomach. Vagotomy and pyloroplasty were performed to prevent regurgitation and esophageal irritation. Twelve cases were presented, with 1 death. Thomas and Merendino (1958) reviewed 33 cases of jejunal interposition substitution for esophagogastric valve [158]. There were 4 deaths, but the rest of the patients were relieved of symptoms, although a few had the dumping syndrome. Most operations were for severe problems such as peptic esophagitis with stricture, cardiospasm, varices, lye strictures, and postoperative stricture. Androsov (1956) reported 688 cases of small bowel esophageal reconstruction, stating that it was long enough for a primary anastomosis in only 75% of cases [7]. In situ vascular anastomoses were used at times to improve blood supply. He cited contributions by other Russian surgeons.
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Jezioro and Kus (1958) reported retrosternal esophageal bypass in 23 cases in which the jejunum was used and 5 cases in which the ileocolon was used [64]. T h e small bowel was brought behind the colon. A slot was cut in the manubrium to enlarge the inlet and avoid vessel compression. T h e cervical anastomosis was always done later. If blood supply was doubtful, the bowel was placed subcutaneously or the upper end was brought through an intercostal space and a skin tube was later constructed to reach the cervical esophagus. Occasionally, the bowel loop was remobilized and lengthened, sometimes by divisions of more esophageal vessels. Their surgical technique was presented. Skvartsov (1961) reported 60 cases of posterior mediastinal jejunal bypass of the esophagus, 54 of which had successful results [151]. He felt the route was shorter and therefore better. Hanna, Harrison, and Derrick (1967) reviewed results in 134 patients who had visceral esophageal substitutes [52]. The use of the stomach as a substitute worked well for treatment of carcinoma, but when it was used for benign disease, 4 out of 5 patients developed regurgitation, esophagitis, and stricture. Pyloroplasty invariably caused a dumping syndrome. The small bowel proved to be the best substitute for use with benign lower esophageal lesions because it was isoperistaltic and functioned as a sphincter, thus preventing regurgitation and heartburn. All segments of the colon were satisfactory but sometimes foul breath was noted due to fermentation in the haustral pockets. Comparing the function of visceral substitutes by cinefluoroscopy, they found that the stomach emptied the fastest, the small bowel functioned the same as it did in the abdomen, and the transverse and left colon were a little more active than the right colon. They concluded that the small bowel offered the best results, but was technically more difficult. T h e jejunum functions well for esophageal replacement since it has normal peristaltic action in any location. It is technically difficult to develop a vascular pedicle for long esophageal reconstructions, and it is even impossible at times. Staging ligation of the vessels, freeing the peritoneum, elevating the mesentery and in situ anastomosis with new vessels help to improve the blood supply. Still, the loops of bowel are much longer than the vascular pedicle, and excess bowel is thereby left in the thorax. For short segment replacements of the lower esophagus, and particularly for substitution of an incompetent cardioesophageal sphincter, jejunal substitution seems a very satisfactory method.
STOMACH
Biondi (1895) developed a method in the laboratory for intrathoracic esophagogastrostomy [ 191. Voelcker (1908) successfully resected a carcinoma of the cardioesophageal junction through the abdomen,
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using a two-layer anastomosis for esophagogastrostomy [ 1621. Meyer (1909) performed esophagogastrostomy in dogs by sutures [93]; others had used Murphy buttons. He emphasized methods which would avoid contamination of the mediastinum by esophageal content. He knew of no survivals in the other 20 cases operated upon with esophagogastrostomy by European surgeons. Kirschner (1920), in a patient with lye stricture, brought the stomach subcutaneously to the neck by dividing the left gastric, left gastroepiploic, and short gastric vessels [71]. A Roux-Y jejunostomy to drain the lower eso+ageal stump was performed utilizing a Murphy button. The esophagogastrostomy was performed later. Kiimmell (1922) brought the stomach to the neck through the esophageal bed after resection for carcinoma, thus avoiding an intrathoracic esophagogastrostomy and esophagojejunostomy at the lower end [74]. Fischer (1923) reviewed surgery of the esophagus and felt that the resurgence of extrapleural resection was justified in view of the complications with the transpleural resection [40]. Ohsawa (1934) resected the esophagogastric junction for carcinoma in 18 cases with end-to-side esophagogastrostomy through an open free thoracotomy [ 1151. Adams and Phemister (1938) resected a carcinoma of the cardioesophageal junction with an intrapleural esophagogastric anastomosis [3]. They listed the 18 successful esophageal resections to that time. Adams (1966) maintained a preference for the stomach as a replacement for the resected esophagus up to the neck [2]. When circulation was carefully preserved, vagotomy and pyloroplasty performed, and the hiatus enlarged to prevent venous obstruction, the results were good. In 1944 Garlock reported a case of esophagogastrostomy above the aortic arch after resecting a carcinoma of the midesophagus [41]. He found that the stomach readily reached the apex of the pleura. In 1948 he performed a cervical esophagogastrostomy for high carcinoma [42]. Although the patient died, the stomach was viable. In 1954 he reported experience with the surgical treatment of 457 cases of carcinoma of the esophagus; he found that the results were good with resection and esophagogastrostomy for lower esophageal lesions, but that there were few five-year survivals in midesophageal lesions [431. Ochsner and De Bakey (1941) reviewed the surgery of carcinoma of the esophagus, discussed according to the level of the lesion [lll]. Twenty-six patients had been resected; there were only 6 instances of survival, 5 of which were after 1938. Sweet (1945), using the Kirschner technique of dividing the left gastric arteries, found that esophagogastrostomy could be performed at the level of the aortic arch [153]. In 1948 he reported two successful cases of esophagogastrostomy in the neck, in both of which he resected the first rib andt1avicle for more room [ 1541. He used delayed transthoracic cervical esophagogastros.
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tomy for reconstruction of congenital esophageal atresia in a 2 l-monthold patient. Sweet, in 1952 [156] and 1954 [157], recommended esophagogastrostomy for intrathoracic carcinoma of the esophagus because of its palliation of distressing dysphagia and for the small percentage of cures. Brewer (1949), after resection of carcinoma, anastomosed the stomach to the pharynx by a staged operation [21]. Rapant and Hromada (1950) reviewed the literature and reported cervical retrovascular esophagogastrostomy bypass of stricture in two cases [129]. They preserved the vagus nerves in the second case and thus avoided gastric atony. Ripley, Olsen, and Kirklin (1952) reported that esophagitis invariably followed esophagogastric anastomosis as it did with anything interfering with the lower esophageal sphincter [133]. Vagotomy alone did not prevent esophagitis since that only interrupted the cephalic phase of gastric secretion. Burford, Webb, and Ackerman (1953)recommended resection and esophagogastrostomy for established esophageal stricture due to caustic burns [23]. Unexplainably, none of these patients developed esophagitis, although it was often a severe problem following esophagogastrostomy for patients with carcinoma or reflux esophagitis with stricture. Nakayama (1954) gave an account of 399 cases of carcinoma of the midesophagus; he recommended a right thoracoabdominal incision for esophagogastrostomy, emphasizing that vessels on the greater and lesser curvature must be preserved and that when blood supply is questionable, the stomach should be put subcutaneously [102]. He later (1964) recommended a three-stage operation using antesternal stomach for replacement of the esophagus [103]. In the first operation the abdomen was explored, lymph nodes resected, and a gastrostomy performed. In the next stage, an esophagectomy with esophagostomy was performed, bringing the upper esophageal end out of the skin below the clavicle. In the third stage, one year later, the stomach was freed up and brought subcutaneously to the esophagostomy. When additional blood supply was needed, a vessel anastomosis could be made from the internal mammary. When the stomach would not reach, the jejunum, colon, or a reverse gastric tube could be used with possible anastomosis of vesseIs. 13 Jewett, Carberry, and Adler (1959) studied 2 children-ages and 16-eight years after high intrathoracic esophagogastrostomy had been performed; they reported that the stomach had diminished to a tube in both and that there was no abnormality in eating, growth, or stomach emptying (although only one had a pyloroplasty) [63]. Grimes (1960), in reviewing five years experience with esophageal replacement, recommended esophagogastrostomy, especially for carcinoma [48]. When vagotomy and pyloroplasty were included, the results were good. Ong and Lee (1960) adtocated pharyngeal gastric anastomosis after resection of carcinoma of the hypopharynx and cervical esophagus [116]. In 3
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cases success was attributed to the fact that the stomach had the best blood supply, elasticity, and ability to heal. Paulino (1964) recommended a high esophagogastric anastomosis for benign stenosis, stating that the higher the anastomosis the less the esophagitis [122]. Demuth and Ames (1964) reported an 8-year-old child who had developed uneventfully after primary right transthoracic esophagogastrostomy was performed for congenital esophageal atresia [3 13. Balasegaram (1968) brought the stomach through the posterior mediastinum for replacement of the resected carcinoma of the hypopharynx and esophagus [91. With hypopharyngeal tumors, a neck dissection was included. He believes that the stomach has the best blood supply of all the viscera and is superior to staged skin flaps. In his experience, it is better than jejunum, colon, and reversed gastric tubes. Mullen, Young, and Sealy (1968) concluded after 20 years of experience with esophageal replacement that the stomach was the best organ to use within the thoracic cavity when combined with vagotomy and pyloroplasty [99]. When the anastomosis had to be done in the neck, they recommended right colon and terminal ileum. The stomach is a good esophageal substitute-it has an excellent blood supply, mobility, and length. A one-stage esophagectomy and esophagogastrostomy is probably the easiest reconstruction procedure technically and has the fewest anastomoses to perform. When vagotomy and pyloroplasty are included, the stomach empties well. There is less of a problem with regurgitation and esophagitis, and a large atonic dilated intrathoracic stomach is avoided. The intrathoracic segment often narrows down into a tube. The higher the anastomosis, the more the stomach is intrathoracic. In such a negative pressure area there is less regurgitation and less esophagitis. There is now renewed enthusiasm for gastric substitution of the esophagus at nearly all levels.
GASTRIC TUBES
Depage (1903) made a tube from a vertical flap of the anterior stomach close to the lesser curvature and brought it to the xiphoid [33]; he reported satisfactory use in 6 cases. Using dogs and cadavers, Beck and Carrel1 in 1905 [14] and Jianu in 1912 [65] made a tube from the greater curvature of the stomach and brought it antethoracically. In 1914, Jianu used this tube intrathoracically successfully for stricture in two patients [66]. Meyer (1915) used reversed intrathoracic tubes successfully during 6 resections for cardioesophageal carcinoma [94]. He stressed the need to drain the thoracic cavity by tubes postoperatively. Lotheissen (1913) reported 4 successful operations using a greater curvature tube for esophagogastrostomy [811. In 2, the tube reached the cervical esophagus, but in the other 2 additional skin tubes were needed.
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Mes (1948) made a tube of the greater curvature of the stomach that would reach the neck, leaving the lesser curvature in place [921. He stated that this could be done because the greater curvature of the stomach normally stretched with meals and because the gastroepiploic vessels were looped in arcades. Gavriliu (1951) revived use in Hungary of the reversed gastric tube [44]. Heimlich (1962) gave the results in 15 patients treated for peptic esophagitis and stricture by reversed gastric tube as an esophageal replacement [53]. None had shown evidence of esophagitis in follow-ups of from three months to four years. In 8 of 10 patients who had died of recurrent carcinoma there was no esophagitis found at autopsy. Heimlich (1966) also recommended subcutaneous reversed gastric tube for bypass of the entire stenosed esophagus [541. Those who advocate the use of the reverse gastric tube state that the upper end of the tube is from the antrum of the stomach, which does not secrete acid, and therefore does not result in regurgitation esophagitis. In addition, the stomach tube itself is resistant to gastric juice. T h e length is adequate for replacement of the entire esophagus. One would assume, however, that the extensive closure of the stomach remnant and the tube is fraught with technical problems. This is probably responsible for the fact that this procedure has not been widely used.
COLON
Kelling (1911) used a segment of isoperistaltic transverse colon, preserving the left colic artery for a blood supply [69]. The segment was anastomosed to the stomach and brought subcutaneously to the nipple line to bypass a carcinoma of the esophagus. Before the cervical esophagostomy and colon could be connected, however, the patient died. Lunblad (1921) used antethoracic transverse colon for total bypass in a 3-year-old boy with stricture [83]. The patient lived normally until the age of 37, when he died accidently. Roith (1924) used the ascending and the right transverse colon subcutaneously to the neck with anastomosis of the colon to the stomach for stricture [137]. The patient lived nornially until his death from an intercurrent illness three years later. Ochsner and Owens (1934) in their review of the literature found only 20 cases of colon esophagoplasty [112]. There were more complications than with combinations of jejunum and skin, but the recovery rate was higher. Orsini and Lemaire (1951) used the left colon intrapleurally and suggested anastomosing the colon to the jejunum in order to avoid gastric regurgitation [117]. Rudler (1951) used ileum and right colon retrosternally with distal anastomosis to the jejunum [139]. Rudler and Monod-Broca (1951) used retrosternal ileocolon [140]. In compiling a
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collective review, they found reports of 28 patients who underwent colon esophageal bypass; of these 28, there were 8 operative deaths. Although cervical fistulas were usual, the lower end invariably healed. Battersby (1953) used a one-stage right colon thoracoabdominal esophageal replacement as palliation in 4 patients who had carcinoma and in 2 who had benign lesions [12]. Battersby and Moore (1959) reported 5 cases of right colon replacement for congenital atresia of the esophagus [13]. In 3 the colon had been placed substernally and all had survived. Death occurred in the 2 patients in whom the colon had been placed intrathoracically. Battersby and Moore recommended delaying reconstruction until the patient was at least 9 months of age and in good general condition. Montenegro and Cutait (1958) reported 26 cases in which the transverse and left colon were used isoperistaltically for treatment of stricture [96]. T h e colon was passed through the pleura to the neck and distally anastomosed to the stomach. In carcinoma an esophagectomy was performed first, followed by colon replacement three months later. In the treatment of esophageal varices, total esophagectomy was performed followed by colon replacement. They felt that isoperistaltic colon and anastomosis to the fundus of the stomach stopped regurgitation. Camara-Lopes (1953) reported use of intrathoracic left colon for replacement of resected esophageal carcinoma and reviewed the development of colon esophagoplasty [24]. Dogliotti and Guglielmini (1953) used isoperistaltic colon and terminal ileum retrosternally for esophagoplasty [35]. Mahoney and Sherman (1954) gave an account of a case of substernal right colon total esophageal bypass for carcinoma [85]. They felt that the stomach was too large, skin tubes were too complicated, jejunal loops were too long, and the blood supply was poor. T h e colon was satisfactory because it was longer, it allowed a more adequate resection of carcinoma, the anatomy was better, the blood supply was always good, and it was resistant to gastric juice. This procedure also left the stomach in its normal place, thus avoiding the anorexia, nausea, and distressing symptoms often seen in patients with a thoracic stomach. Dale and Sherman (1955) reported 2 cases of congenital esophageal atresia reconstructed at 2 years of age by right colon retrogastric anterior mediastinal transplant [SO]. Sherman, Mahoney, Dale, and Stabins (1955) advocated the use of colon in preference to other esophageal substitutes; they also presented 5 cases in which the right colon had been used for intrathoracic esophageal reconstruction [149]. Three were for carcinoma and 2 were for congenital esophageal atresia. Sirak, Clatworthy, and Elliot (1954) found no difference in jejunal and colonic interposition in experimental esophagitis [ 1501; histamine ulcerated both. They concluded that the diminution of acid formation by a partial gastric resection combined with vagotomy
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and pyloroplasty, or gastroenterostomy would probably make either acceptable. Scott (1955) reported a case of peptic ulcer in a colonic transplant which they had resected [146]. Goligher and Robin (1954) gave an account of 2 cases of staged left colon reconstruction after pharyngectomy [45]. First, staged vessel ligation was begun. Later, the pharynx was resected and the left colon brought subcutaneously to the neck for replacement; distal cologastrostomy was then performed. T h e patient thereafter talked with a pharyngeal voice. Mustard and Ibberson (1956) found that carcinoma of the upper esophagus was seldom curable [ 1001. They recommended use of palliative bypass with jejunum or colon in the anterior mediastinum followed by x-ray therapy. Najarian and associates (1956) utilized the ileocecal valve as a substitute for the cardioesophageal sphincter in dogs; they found that histamine did not produce irritation proximal to the valve and that the colon was more resistant to peptic irritation than the stomach or duodenum [ l o l l . Neville and Clowes (1958) gave a report of 18 patients with colon esophageal reconstruction [ 1091. Twelve patients had carcinoma above the arch of the aorta, and 11 had it below; 1 had a stricture of the entire esophagus, and 4 had low strictures. Most of the esophagocolic anastomoses were done in the thorax. Pyloromyotomy or pyloroplasty and gastrostomy were performed. Neville and Clowes (1963) recommended interposition of an isoperistaltic segment of transverse colon for resection of stricture due to reflux esophagitis [110]. Clowes and associates (1964) preferred the right colon for intrathoracic bypass and the left for total bypass through the esophageal bed [28]. By that time peristalsis was felt to be unimportant. Nardi (1957) reported two cases of substernal right colon esophageal bypass without resection of the scarred esophagus; he felt that this avoided the hazards of resection of the esophagus [106]. The colon was adequate in length and was resistant to peptic digestion, and he doubted that carcinoma occurred in the scarred esophagus in a significant number of patients. Scanlon and Staley (1958) presented their technique of right colon retrosternal replacement of the esophagus as used in 10 patients; there were 2 deaths [1441. They believed that the right colon offered adequate length, a good blood supply, limited bulk, and resistance to peptic digestion. In 1963 they reported replacement of the cervical esophagus by colon in 3 patients [145]. Patterson and Robbins (1958) reported 11 cases of right colon replacement of the esophagus; there were 3 deaths among those with carcinoma, all of whose operations had been performed in one stage [121]. They concluded that the operation should be staged in the critically ill patient. By 1964 Haight had used substernal right colon in delayed reconstruction for congenital esophageal atresia in 14 cases; he had also saved the right colic artery for an additional blood supply [51].
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Koop and Kavianian (1965) reevaluated colonic replacement of the esophagus and stomach for varices and were satisfied [72]. Six additional patients had been operated upon since their initial publication; in 5 of these, the first operation performed was a colon substitution. Longino, Wolley, and Gross (1959) reported 18 children in whom right colon replacements were made for esophageal atresia, caustic stricture, peptic esophagitis with stricture or bleeding, and varices not responding to decompression shunts [79]. These replacements were brought behind the stomach and retrosternally. T h e operation was delayed until the child was 1% years old or 20 pounds in weight. If the stricture was short and low, the colon could be placed posteriorly in the chest. Gross and Firestone (1967) gave an account of 47 cases of colon reconstruction of the esophagus in infants and children; these reconstructions were done using the transverse colon antiperistaltically plus a pyloroplasty [501. Petrov (1964) reported the use of retrosternal colon in 100 cases; he preferred the right [ 1241. McBurney et al. (1 959) reported retrosternal right colon bypass for carcinoma of the esophagus in 13 patients [89]. Esophagectomy was performed two weeks later when possible. Unresectable lesions were treated by x-ray therapy. Baranofsky and associates (I 960) demonstrated the colons marginal artery anatomy by barium gelatin suspension; they found the left colon preferable [lo]. Ogura, Roper, and Burford (1961) reported 5 cases in which there were extensive stenosing caustic burns of the larynx and esophagus [114]. Scarring of the larynx was excised and skin grafts on stents were used for reconstruction. The right colon was used to bypass the scarred esophagus. Popov (1961) used colon bypass for benign stricture [125]. The left colon was used in 18 patients and the right colon was used in 2. Seven were placed retrosternally, 3 intrapleurally, and 10 subcutaneously. Occasionally, he noted vascular obstruction at the menubrium when the substernal route was used. f Reynolds and associates (1961) gave a report o their use of the right colon to replace the esophagus in 22 patients; they had good results for benign disease, but there were early recurrences and discouraging results for carcinoma [ 1311. In carcinoma, esophagectomy was followed in six weeks by subcutaneous or intrapleural right colon replacement. Gregorie and Othersen (1962) recommended preoperative x-ray therapy for carcinoma of the esophagus [47]. They followed therapy with one-stage left colon bypass and esophagectomy in 7 patients. Jiminez-Martinez and associates (1962) reported colon esophageal replacement in 46 cases; they came to prefer the left colon because it was less bulky, a better size for esophageal anastomosis, the length was more adequate, and the retroperistaltic direction was of no consequence [67]. Bergan and Bie (1963) gave an account of 45 cases in which the right colon was used, but they felt the peristaltic direction was of no
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importance [16]. Luna and Ernst (1963) used the left colon in 11 cases [82]. In the 6 patients with carcinoma, colon bypass was followed by x-ray therapy and, subsequently, esophagectomy. May and associates (1964) reported 36 cases of left colon total esophageal bypass [881. Results were good in the 9 with benign disease who had been treated by bypass without esophagectomy. In malignant disease, one-stage esophagectomy and colon bypass proved unsatisfactory because of the mortality, and staging was begun. May and his associates concluded that preoperative high-voltage x-ray therapy, left colon bypass, and subsequent esophagectomy produced the best results. Belsey (1965) reported 105 cases of left colon isoperistaltic esophageal reconstruction [15]. In 76, short colon segments were used for interposition. T h e anastomosis was made on the posterior surface of the stomach and, being intraabdominal, did not allow reflux. Later in the series all long colon transplants were anastomosed in the neck rather than in the chest. Othersen and Clatworthy (1967) found the colon to be the best esophageal replacement in children, and they delayed the operation until the child was 18 to 24 months old, when erect posture helped food passage [118]. Hong and associates (1967) reported the use of right colon and terminal ileum in 115 patients for bypass of benign stricture of the esophagus [591. Chrysospathis (1967) reported the use of colon for esophageal bypass in 102 cases; he preferred the right or isoperistaltic left colon [26]. Holland (1967) reported perforation of a left colon esophageal bypass for carcinoma and concluded that vagotomy and pyloroplasty were necessary to protect the colon [58]. Malcom (1968) found 11 cases, in the literature, of peptic ulcer in colon transplants used for esophageal replacement [86]. Wilkins and Skinner (1968) recommended colon interposition for replacement of resected strictures due to regurgitation esophagitis; vagotomy and pyloroplasty were included [ 1661. T h e colon has been the most commonly used visceral esophageal substitute since 1950. Its use increased rapidly with the advent of antibiotics and improved bowel preparation. The blood supply of the entire colon is good through the marginal artery of Drummond and the vascular arcades. Some have used the right colon preferentially to maintain isoperistaltic direction of the implant, but it is doubtful that the direction of the peristalsis is of any importance. Some use the right colon and include a segment of ileum which is smaller and a better size for anastomosis with the cervical esophagus. The ileum takes up less room in the thoracic inlet and is less likely to obstruct the blood supply, particularly the veins. T h e ileocecal valve is of no value in the upper esophagus. It may, however, be useful when a short segment of ileum and a cap of cecum are used for lower esophageal interposition in
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replacement of the incompetent cardioesophageal sphincter. T h e transverse colon transplanted in either peristaltic direction functions satisfactorily and is most useful for short-segment lower esophageal replacement. T h e left colon is ordinarily used antiperistaltically because it is easier to use the midcolic artery for blood supply. It can be directed isoperistaltically, however, by preserving the left colic artery for the vascular pedicle. We prefer the left colon because the blood supply is longer, more consistent, and almost invariably adequate; the lumen size is more nearly that of the esophagus; the bulk is less in the thoracic inlet; and the direction of peristalsis is of no consequence.* The colon is only relatively resistant to peptic ulceration, however, and must always be protected by vagotomy and a gastric drainage procedure.
SHORT VISCERAL SEGMENTS W I T H LONG VASCULAR PEDICLES
Kergin (1953) used a segment of transverse colon on a long vascular pedicle to bypass a high esophageal obstruction due to paraffinoma [70]. Androsov (1964) used a segment of sigmoid on a long vascular pedicle for localized esophagoplasty [8]. Kasai et al. (1965) used a long pedicle jejunal segment to replace a cervical esophagus [68]. In performing this type of operation, one isolates a short segment of bowel with mesentery and a blood supply of adequate length to reach the level where esophageal replacement is required. T h e length of the vascular pedicle required determines the segment of bowel isolated. For high lesions, sigmoid colon offers the longest vascular pedicle. T h e unneeded portion of bowel is then resected at the mesenteric border maintaining the entire vascular pedicle, marginal artery, and vascular arcades. The method works satisfactorily; however, indications for localized resection of the upper esophagus are infrequently encountered.
VASCULAR SUPPORT FOR T H E UPPER END OF PEDICLED VISCERAL TRANSPLANTS
Longmire (1947) anastomosed the internal mammary artery to the marginal artery at the upper end of a jejunal transplant to improve the blood supply [80]. Androsov (1956) reported the same procedure, and he also sometimes anastomosed the gastroepiploic artery to the lower end of the vascular arcade [7]. Martin and Flege (1964) anastomosed the internal mammary artery to the upper end of a colon transplant [87]; Ishigami et al. (1968) used it for the stomach [61]. With the available small vessel anastomosis instruments and experience in small blood vessel anastomosis, this addition will probably be of help when blood supply is of questionable adequacy.
*A motion picture by the authors (contained in the library of the American College of Surgeons) presents this technique.
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FREE VISCERAL GRAFTS W I T H B L O O D SUPPLY B R O U G H T IN BY L O C A L C O L L A T E R A L O R VESSEL ANASTOMOSES
Puestow and Reagan (1933) isolated segments of bowel in an incision and later divided the mesentery; the segments remained viable from collateral circulation [127]. Seidenberg et al. (1959) reported a technique of revascularizing isolated jejunal segments to replace the cervical esophagus in dogs [147].The superior thyroid artery was sutured to the vascular arcade, and the anterior facial vein was anastomosed by a ring cuff. This was used clinically and remained viable until the patient died of a stroke a week postoperatively. Roberts and Douglass (1961) replaced the cervical esophagus and hypopharynx successfully with a revascularized free jejunal graft [135]. Hiebert and Cummings (1961) replaced the cervical esophagus by transplanting a revascularized free graft of gastric antrum, using the same vessels [55]. Nakayama et al. (1964) reported 21 cases of autograft of the bowel using a new vessel anastomosis instrument [ 1051. One graft was ileum and the rest sigmoid. Of the 21 cases, 16 had successful results. T h e 5 deaths occurred in patients who had had a radical resection for carcinoma. Part of the clavicle was resected, and branches of the subclavian vessels were used. If the stricture extended too far into the chest for anastomosis, the graft was placed beneath the skin, and a reverse gastric tube subsequently was brought to meet it. T h e last 9 cases were uneventfully successful. As stated in the last section, techniques are now available for small vessel anastomosis; free visceral grafts are therefore possible. For benign disease, its use is appealing, but an extensive operation like this for local resection of carcinoma of the esophagus would seem to have limited value.
END-TO-END ANASTOMOSIS
Dobromyssloff (190 1) successfully resected 3 to 4 cm. of intrathoracic esophagus through a posterior flap incision with end-to-end anastomosis [341. Saint (1929) reviewed surgery of the esophagus [141]. He demonstrated the segmental blood supply of the esophagus and a method of two-layer anastomosis that would not interfere with the blood supply. Samson in 1938 [142] and Shaw in 1939 [1481 performed end-to-end esophageal anastomosis for esophageal atresia with tracheoesophageal fistula; however, both patients died several days after surgery. Haight and Towsley (1943) successfully accomplished end-to-end anastomosis for this lesion, using an extrapleural approach [51a]. Gross (1948) reported resection of short strictures of the esophagus with primary endto-end anastomosis [49]. Parker and Brockington (1949) gave an account of 2 cases of palliative resection and end-to-end anastomosis for incuraVOL.
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ble carcinoma; 1 was successful [119]. Tuttle and Day in 1950 [ 1601 and Burford, Webb, and Ackerman in 1953 [23] reported cases of resection of short strictures followed by end-to-end anastomosis. Kunkel and Kunkel (1958) reported resection of midesophageal carcinoma with primary anastomosis in 4 cases with a nine-and-one-half-year cure in 1 [75]. Localized esophageal lesions that can be adequately resected without sacrificing too much esophagus may be repaired by end-to-end anastomosis. A two-layer anastomosis made without tension is the most likely to heal without a leak. One must mobilize the esophagus to some extent in order to avoid tension on the anastomosis; but extensive mobilization is not always safe because of the relatively segmental blood supply of the esophagus. Short benign lesions are completely amenable to primary anastomosis; congenital esophageal atresia with tracheoesophageal fistula is usually amenable; in rare instances, palliation of malignant lesions may perhaps be managed this way.
N O N Y I S C E R A L M E T H O D S OF ESOPHAGEAL REPLACEMENT
Neuhoff (1917) tried fascia lata transfer into visceral defects [ 1071; however, Neuhoff and Ziegler (1 922) found that fascia lata esophageal replacements in dogs invariably stenosed [ 1081. Granulation tubes, made by placing gauze packs around the esophagus, were then tried. A week later the esophagus was resected and replaced by a rubber tube. When the tube was removed, the granulation tract remained open for a short time. Hoover (1938) resected a cervical carcinoma, leaving a strip of mucosa in back [601. With subsequent dilations the esophagus healed. Four years and seven months postoperatively the patient was eating well. Robe and Bateman (1949) reconstructed the pharynx with tantalum wire mesh covered by fascia lata [134]. T h e fascia sealed off infection while granulation tissue grew into the wire mesh. Edgerton (1952) reported 4 patients in whom a tantalum mesh stent covered by split thickness skin (with the epidermis inside) was used for esophageal replacement [36]. T h e tantulum could be subsequently removed. Javid (1952) bridged esophageal defects with fresh and preserved aortic grafts; he had good results in dogs [621. Clinical results in 7 cases were initially good, but the grafts soon became obstructed. Berman (1952) developed a plastic tube to replace a segment of resected esophagus; he found that in dogs it was covered with scar [171. He used this in 6 patients who had carcinoma and 1 who had stricture; satisfactory function was restored. In 1954 he reported on 60 collected cases in which the results were favorable [l 81; but Wawro (1954) reported fatal complications, attributed to the tube, in 2 patients [165]. None of these substitutes have been satisfactory since they did not
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heal to the tissues nor did they remain patent. Further attempts at developing such methods have not been undertaken since visceral substitutes have become so satisfactory.
PALLIATIVE E X T R A C O R P O R E A L ALIMENTATION TUBES
Torek (19 13) successfully resected transpleurally the thoracic esophagus for carcinoma (a first) [159]. T h e patient would not permit antethoracic skin tube reconstruction; he lived 13 more years using an external tube between the cervical esophagostomy and gastrostomy for alimentation. After 24 unsuccessful intervening cases at Lenox Hill Hospital, Eggers (1924) accomplished the second successful transthoracic esophagectomy, again using the external tube for alimentation [37]. Turner (1934) stated that Evans had resected the cervical esophagus for carcinoma in 1909; the patient was still well 24 years later and eating by use of a rubber tube from the pharynx to the gastrostomy [38]. Nakayama (1964) used an external alimentation tube for the interval between esophagectomy and delayed reconstruction [ 1041. Although this method has never been used much, it is of possible aid when reconstruction must be delayed after esophagectomy. Theoretically, it might be of use in delayed reconstruction for congenital esophageal atresia.
P A LLIA TI VE IN T R AL UMINAL TUBES
Souttar (1927) stated that carcinoma of the esophagus was highly malignant and almost never curable [152]. He described the use of an intraluminal flexible spiral German silver-wire tube to allow alimentation. H e had seen 100 cases of carcinoma of the esophagus and had used intralumiiial palliative tubes in 50 with good results. Mackler and Mayer (1954) presented a permanent intraluminal tube for palliation in unresectable carcinoma [841. Puestow and Gillesby (1955) felt that the results of using palliative intraluminal tubes of any type were discouraging [ 1281. Mousseau and associates (1956) presented indications for the use of a permanent intraluminal tube [98]. Celestin (1959) presented a permanent intraluminal esophageal tube [25]. OConnor et al. (1 963) recommended a palliative tube that was introduced endoscopically [113]. They reported experience with 378 patients in whom there were 4 esophageal perforations but only 2 deaths. Barnard et al. (1966) reported the satisfactory use of the Mousseau-Barbin tube in 10 patients with cancer [l 11. When the tumor was obviously not resectable, they did not explore the chest but instead placed the tube through an esophagoscope with the help of a gastrostomy. Fell (1966) reported the use of a soft polyvinyl tube, the lower end of which was sutured to the
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gastric and abdominal wall to fix it in place [39]. Adams (1966) reviewed the complications of endoesophageal tubes, citing his own experience in 10 cases [I]. He concluded that these tubes were helpful in some of the patients who were unresectable but not terminal. Alford and Sawyers (1967) used the Souttar tube during x-ray therapy in 10 patients; this resulted in improved nutrition [4]. Obviously, palliative intraluminal esophageal tubes have been of value in the hands of some surgeons; in the light of recent reports, they may well be worth considering for some patients. Certainly, those patients who cannot swallow saliva and maintain an adequate oral fluid intake need some type of help to avoid drooling and dehydration. Perhaps this is an acceptable adjunct in their care.
HISTORICAL REVIEW
Early esophageal resection and reconstruction procedures were extrathoracic. T h e cervical esophagus was resected and reconstructed with skin flaps. Later the lower esophagus and cardioesophageal junction were resected, with esophagogastrostomy, by an abdominal approach. T h e development first of differential pressure and then of endotracheal anesthesia, and the realization of the importance of postoperative chest tube drainage, opened up the field of intrathoracic surgery; infection, however, remained the significant problem. It was thought that one could not safely open the esophagus in the chest because of the contamination that would be produced by its contents. Transthoracic resection with cervical esophagostomy and gastrostomy prevented pleural contamination. Delayed reconstruction was accomplished antethoracically by skin tubes and by both jejunal segments and reversed gastric tubes, sometimes augmented by skin conduits for additional length. Posterior incisions for extrapleural resection, esophageal removal by invagination, or mobilization of the esophagus through abdominal and cervical incisions and pull through resection followed by delayed reconstruction, were used. Posterior extrapleural and cervical anastomoses using abdominal and cervical incisions with transposition of the stomach through the posterior mediastinum to the neck were employed. Subsequently, transthoracic resection with esophagogastrostomy by various suture methods or buttons became popular. Antibiotic control of infection helped improve results and stimulated the development of intrathoracic surgery; improved surgical techniques resulted, and esophageal resection with esophagogastrostomy proved successful at progressively higher levels. Jejunal loop visceral esophageal substitutes were placed intrapleurally and substernally. T h e intrathoracic course was shorter and functioned better, made the .vascular pedicle length more adequate, and was more satisfactory
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cosmetically. Better bowel preparation allowed use of the colon, and it has subsequently become the most commonly used visceral substitute for the esophagus in benign disease. Esophagogastrostomy eliminates the competent esophagogastric junction and may result in reflux esophagitis. This is usually adequately controlled by vagotomy and pyloroplasty. Intrathoracic esophagogastric resection is the method of choice in dealing with lower esophageal and cardiac carcinomas. Some prefer esophagogastrostomy for reconstruction after resection of esophageal carcinoma at any level. Reflux esophagitis due to an incompetent esophagogastric junction associated with benign disease is probably treated more satisfactorily by bowel interposition, protected by vagotomy and pyloroplasty. Total esophageal bypass or substitution is also probably most satisfactorily accomplished using colon, again protected by vagotomy and pyloroplasty. Because of the severity of the problems encountered with loss of viability of visceral substitutes or anastomotic leaks, there is still some advantage to having anastomoses outside the thorax. For this reason esophageal anastomosis is often preferentially made in the neck for higher esophageal lesions. There are sometimes indications (e.g., when the blood supply is questionable) for placing these substitutes subcutaneously, thereby making such complications far less hazardous. There may be instances in which long segments of visceral substitute need additional blood supply at the upper end by bloodvessel anastomosis. There may be instances in which a short segment of bowel on a long vascular pedicle or an isolated revascularized segment of bowel or stomach would be effective, but in the opinion of most, these would be more acceptable for benign lesions.
T H E M A N A G E M E N T OF SPECIFIC LESIONS
Esophageal reconstruction is still being accomplished in various ways [120]. T h e specific lesion, age and condition of the patient, and personal experience of the surgeon are significant factors in the choice of method.
CONGENITAL ESOPHAGEAL ATRESIA
Congenital esophageal atresia with or without tracheoesophageal fistula is treated by primary end-to-end anastomosis if there is adequate length [51a, 731. When there is no fistula, the distal segment of esophagus is usually not long enough for primary anastomosis; cervical esophagostomy and gastrostomy are then performed, with a delayed substitution when the child is a year or so of age [50]. This is usually accomplished using a segment of colon placed retrosternally. When the infant is premature or in poor condition, staging is advocated [56]. If
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tracheoesophageal fistula is present, it must first be closed. Gastrostomy for feeding is performed. Aspiration and methods of stretching of the upper esophageal pouch are used until the growth and improved condition of the patient allow end-to-end anastomosis of the esophageal segments.
LONG STRICTURE OF T H E ESOPHAGUS
Long strictures of the esophagus-usually due to caustic burnsmay require esophageal reconstruction when dilatation is impossible or unsatisfactory. Total esophageal bypass is usually obtained by substernal colon segments. Although some surgeons prefer the stomach, we prefer the left colon; but it makes no difference which part of the colon is used or whether it is isoperistaltic or antiperistaltic. The colon must be protected by vagotomy and pyloroplasty from the irritation of regurgitation of gastric content. It is probably not necessary to resect the scarred esophagus.
LOWER ESOPHAGEAL STRICTURE DUE TO ESOPHAGITIS
If the stricture is not severe, short strictures of the lower esophagus due to regurgitation esophagitis may be handled by dilatation. If the esophagus has not been too badly shortened, reduction of the herniated stomach into the abdomen and reconstruction of a competent hiatus will prevent progression of the stricture. When a competent esophagogastric junction cannot be reconstructed, a number of surgeons believe that the method to be used to relieve both the cause of the esophagitis and the resulting stricture is stricture resection and bowel interposition. Interposition of the jejunum [91], colon [15, 1 lo], or ileocecal valve [loll is probably equally effective and the use of each depends upon personal preference. Nevertheless, the easiest and most direct method is resection with esophagogastrostomy, and this no doubt has been the most widely used. Vagotomy and pyloroplasty should always be used with any of these procedures.
ESOPHAGEAL VARICES
The treatment of severe esophageal varices by esophagectomy and colon substitution seems well proved, particularly if portal decompression procedures are ill advised or ineffective [72, 87, 961.
CARCINOMA OF T H E ESOPHAGUS
Carcinoma of the esophagus must be considered according to the level of the lesion. Most surgeons treat lower esophageal and cardiac gastric carcinomas by resection of the tumor and adjacent celiac lymph nodes, along with primary esophagogastrostomy. The accompanying vagotomy and pyloroplasty usually prevent significant esophagitis.
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Carcinoma of the middle and upper third of the esophagus is almost impossible to cure. Since there is no satisfactory treatment, there are consequently differing methods of approach. Some try to obtain cures by using combinations of radical total esophageal resection, high voltage x-ray therapy, and substitution of the colon or stomach for the esophagus [27, 88, 105, 1201. Carcinoma spreads submucosally with skip areas, and extensive esophagectomy is necessary when attempting a cure [143]. In high lesions, resection of cervical lymph nodes is necessary in order to include drainage areas. T h e usual visceral replacement for subtotal esophagectomy is the colon, which is technically more satisfactory than the jejunum for long segments. Now that the importance of vagotomy and pyloroplasty is realized, there has also been a resurgence of interest in esophagogastrostomy at any level within the thorax. With high anastomosis, the esophagitis is reduced because the intrathoracic stomach is in an area of negative pressure and there is less regurgitation. When surgical resection of the mid and upper thoracic esophagus is attempted for cure, the approach is variable. Both resectability of the primary tumor and extent of metastases need to be determined before extensive surgery is undertaken. Left thoracotomy with transdiaphragmatic exploration or left thoracoabdominal incisions allow this. Since midesophagectomy is easier and therefore more competently performed from the right, combined right thoracotomy, then laparotomy or laparotomy, and then right thoracotomy are used. Thoracotomy and esophagectomy with subsequent reconstruction weeks or months later are still used at times. At other times, laparotomy with resection of nodes, and subsequent right thoracotomy for esophagectomy is preferred, with reconstruction then or later [ 1051. When one considers the many protocols being used-some of which include x-ray therapy-and the varying types of visceral reconstruction being used, one realizes the complexity of the problem and the reason that one cannot say as yet which is the best method. Cervical esophageal reconstruction by skin tubes has fallen into disfavor since visceral substitutes, particularly the colon, have proved effective. This can be accomplished in one stage, thus avoiding the morbidity of multiple operations, fistulas, and painful dermatitis. Adding lymph node resection to the procedure theoretically will increase cure rates. Whether surgical procedures, for other than quite small tumors, have more to offer than high voltage x-ray therapy alone is still debatable. Many surgeons have become disenchanted with attempting to cure carcinoma of the upper esophagus and are using only palliative procedures, except for unusual cases. Palliative esophagogastrostomy with or without resection can be used to reestablish alimentation. Bypass of
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obstructing lesions by jejunum or colon, either alone or in combination with x-ray therapy, is being employed. Esophagoscopy and coring out of tumor may be of some value, but gastrostomy as a definite procedure has little place. Palliative intraluminal tubes are not generally used but have proponents.
SUMMARY
T h e development of esophageal reconstruction and replacements has been presented and the management of various esophageal lesions requiring these modalities has been discussed.
REFERENCES
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Esophageal Reconstruction and Replacements Ivan A. May and Paul C. Samson Ann Thorac Surg 1969;7:249-277 DOI: 10.1016/S0003-4975(10)66183-8
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