Surgery for benign esophageal stricture

Evaluation and management of benign esophageal strictures

Patients with progressive or solid food dysphagia should be evaluated for the presence of an esophageal stricture. Barium esophagram and endoscopy can define strictures as benign or malignant. The majority of benign strictures are acid-related. Benign strictures are best managed by esophageal dilation with acid-suppressing medications if a peptic stricture is suspected. If dysphagia recurs, repeat dilation should be performed. There are a variety of interventions for refractory strictures which include injection of intralesional corticosteroids, temporary placement of self-expanding plastic stents and surgery.

Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon

OBJECTIVE

To describe the technique and results of an alternative colon interposition procedure in which the ascending and transverse colon is used as graft, but that still relies on the left colonic artery for blood supply.

SUMMARY BACKGROUND DATA

The standard procedure to obtain a left colon interposition graft requires ligation of the middle colic artery and mobilization of the left and right flexure. This approach carries a risk because preparation of the left flexure may damage arterial or venous collaterals located at this site that are crucial for graft perfusion.

METHODS

The authors modified the standard technique so that mobilization of the left flexure is no longer necessary. To obtain a colon interposition graft that is long enough, the ascending colon was included into the graft by ligating the middle and the right colic artery. The left colic artery remained the blood-supplying vessel. From January 1997 to June 1998, 15 patients underwent modified colon interposition with a cervical anastomosis (12 esophagectomies, 3 esophagogastrectomies).

RESULTS

In all cases, intraoperative blood supply from the left colic artery to the proximal ascending colon was sufficient. After surgery, four major complications occurred (27%). Endoscopy demonstrated a vital graft in all patients. In one patient a leakage of the cervical anastomosis was observed. One patient died of herpes pneumonia. Postoperative artificial ventilation was required for an average of 2.8 +/- 4.6 days, the average intensive care unit stay was 6.9+/-4.5 days, and the average total hospital stay was 24.1 +/- 15.1 days.

CONCLUSION

An intact left colic artery, including its collaterals at the splenic flexure, supplies sufficient blood to the proximal ascending colon after central ligation of the middle and right colic artery. Even without mobilization of the left flexure, a sufficient graft length can be obtained. Preliminary complication rates with the use of this technique for colon interposition are in the range of those found for the standard colon interposition technique. These modifications may represent an alternative to established procedures for creating a colon interposition graft.

Comparative evaluation of acid- and bile-induced damage to pedicled jejunal or colonic segments in the rat

The choice of the esophageal substitute after surgical resection for peptic stricture lies between the colon and jejunum. The current study was designed to compare long-term resistance of the colonic and jejunal mucosa to gastric or mixed duodenogastric secretions. The following preparations were performed in Wistar rats: transposition of a colonic or jejunal patch (a) to the gastric body, with or without truncal vagotomy, or (b) to the gastric antrum and proximal duodenum, with or without truncal vagotomy. Jejunal and colonic patches were removed 4, 8, and 12 months after surgery. The only damage to the transposed mucosae was the alteration of microvilli. The alteration was more severe in colonic than in jejunal patches and was prevented by truncal vagotomy. Long-term resistance of the transposed mucosae to the environmental challenge may depend on their adaptation potentiality, involving both specific and nonspecific mechanisms. Nonspecific mechanisms include the increased production of mucus and the gastric-like transformation of the superficial epithelial layer. Specific mechanisms include the reduction of the mucosal surface size for jejunal segments and the shifting in mucin secretion patterns for colonic segments.

Replacement of the esophagus by a segment of colon provided with an antireflux valve

A method has been developed to prevent reflux of gastric contents into an interposed segment of colon substituting for the esophagus. The operative procedure includes construction of an intussusception valve at the cologastric junction. The method was used in 5 patients, who have been followed clinically for 17 to 30 months. Clinical observations including endoscopy as well as radiography and dynamic scintigraphy indicate that the addition of an antireflux valve at the distal end of the interposed segment of colon prevents gastrocolic reflux without jeopardizing the emptying of the colon transplant.

Dukes A carcinoma after colonic interposition for oesophageal stricture

The management of caustic and peptic oesophageal strictures refractory to medical treatment and repeated dilatations continues to be a challenge. Colonic interposition with subtotal oesophagectomy is felt by many surgeons to be the best treatment. Complications in the short and long term are, however, frequent. We report a case of a colonic carcinoma originating in a colonic interposition and growing up into the oesophageal remnant.

Colonic interposition for benign esophageal disease. Long-term clinical and endoscopic results

Replacement of the esophagus for benign disease requires familiarity with the long-term results of various esophageal substitutes. In the present study, 60 esophageal reconstructions for benign disease using colonic interposition have been presented. The operations were performed mainly without thoracotomy, using both antiperistaltic and isoperistaltic colonic segments. There were no differences in swallowing ability between patients with antiperistaltic and patients with isoperistaltic interpositions. Regurgitation symptoms, however, seemed to be somewhat more common and more difficult in patients with antiperistaltic colonic transpositions. Endoscopic signs of colitis were common, but they did not correlate with regurgitation symptoms. Bacterial cultures from the transplanted colon mainly revealed the usual mouth organisms. Candida albicans was frequently found in the fungal samples. There were no differences in the results between patients with follow-up periods of more and less than 2 years. The clinical results were good or fair in a great majority of the patients.

The combined Collis-Nissen operation for esophageal reflux strictures

This report evaluates the efficacy of the combined Collis-Nissen operation in achieving long-term reflux control in patients with reflux strictures. A Collis-Nissen procedure with dilation of a reflux stricture was performed in 64 adults. The strictures were mild (easily dilated) in 37, moderate (requiring some force to dilate) in 17, and severe (requiring very forceful dilation) in 10. Two strictures were perforated intraoperatively. There was 1 postoperative death, and 4 patients have been lost to follow-up. The remaining 59 patients have been followed from 2 to 120 months (average, 43 months) after operation. Subjectively, reflux is absent in 48 (81%), mild in 4 (7%), moderate in 5 (9%), and severe in 2 (3%). Objectively, intraesophageal pH studies show good or excellent reflux control in 94% at 1 year and 66% at 2 to 5 years. Dysphagia has been eliminated in 71%, is mild in 10%, moderate (requiring occasional dilation) in 12%, and severe (requiring regular dilations) in 7%. The combined Collis-Nissen operation provides good long-term reflux control and relief of dysphagia in most patients with reflux strictures. However, patients with reflux strictures after previous repairs are likely to have unsatisfactory results and may best be managed with resectional therapy. Resection may also ultimately prove to be a better option for patients with more severe strictures.

[Reoperation following Nissen fundoplication]

The main causes of unsatisfactory results after Nissen fundoplication can usually be explained by tactical and technical mistakes. The fixation of the stomach to the diaphragm is one case of the development of pain syndrome, telescopic phenomenon and relative or complete dispersion of fundoplication with subsequent development of a recurrent reflux oesophagitis. The fundoplication should be done only in hospitals which have experience in oesophageal and gastric surgery. The collar of fundoplication should be formed with the two sides (the anterior and the posterior) of the stomach after extensive mobilisation of the cardia region. The operation includes the obligatory fixation of the collar to the oesophagus in order to avoid complications like pain syndrome, sliding of the collar and recurrent reflux oesophagitis.