Klinika za plasticku Hirurgiju VMA, Beograd

Transcription

1 RECONSTRUCTION OF SKIN (ESOPHAGUS--A NEW METHOD 1 By Professor V. ARNERI Klinika za plasticku Hirurgiju VMA, Beograd STRICTURES of the oesophagus caused by caustic soda, which do not respond to repeated dilatation, present a difficult surgical problem. The ideal method would be to excise the stricture and to join, by direct anastomosis, the proximal and distal ends of the oesophagus. That, however, is not possible because of extensive anatomical alterations on the wall of the oesophagus, common in burns by chemical agents. Intrathoracic operative procedures in high strictures of the oesophagus caused by caustic soda have a considerable percentage of mortality and are hardly recommendable. In contrast the antethoracic procedures of dermatojejuno-oesophagoplasty reduce the mortality to practically nil. In our 127 cases repaired by tube and flap techniques the mortality was zero. In the first stage of the antethoracic procedure the jejunum is brought up and the diseased part of the oesophagus extirpated. These steps, carried out by Professor Papo, precede the skin reconstruction (Papo, 1954 a, b ; Papo and Fajgelj, I959). Although we found that antethoracic techniques, with tube pedicles and local flaps, gave highly satisfactory results, their main drawbacks were multiple, prolonged, and exhaustive operative stages. An account of our work on this problem has been published earlier (Arneri and Papo, I955). In order to avoid multiple operations on patients whose physical condition was already impaired, we sought to find a simpler method whereby total reconstruction of the skin oesophagus could be performed in one stage only. We considered that the principle of the conversion of a buried strip of skin into an epithelium-lined tube could be applied to this problem. As is generally known, this principle was applied in the treatment of hypospadias, first by Marion-Duplay (Duplay, I874; Marion and P~rard, i942), and later by Denis Browne (I949). In I955, guided by this principle, we worked out a new technique of phalloplasty which proved highly satisfactory. This technique consisted in forming a urethra by burying an abdominal strip of skin. (A film on this was shown at the Second International Congress of Plastic Surgeons in London in I959.) Encouraged by this, we adopted a similar technique to the oesophagus and demonstrated that it could be applied with success comparable to hypospadias. Pre-operative Measures.--Before the operation is undertaken certain general conditions must be fulfilled. First, the skin must be free of deep and irregular scars. A longitudinal scar, however, is not a contra-indication for operation. Secondly, the oesophagostomy must be of a size that will allow the free passage not only of liquids but of solid food. In cases where a circular scar causes stricture of the oesophagostomy, a local plastic "Z " procedure must be undertaken to convert the circular scar into a zig-zag scar to prevent the recurrence of the stricture. i A film on this method was shown at the Winter Meeting of the British Association of Plastic Surgeons in London, x

2 414 BRITISH JOURNAL OF PLASTIC SURGERY Thirdly, the enterostomy must also be patent and any excessive mucosal prolapse should be excised. Fourthly, the general condition of the patient must be stabilised by blood transfusions, high protein diet, vitamins, etc. Particular attention must be paid to the psychological conditioning of the patient. The operation is usually performed under endotracheal ana:sthcsia. However, in co-operative patients in whom the distance between the 0esophagostomy and enterostomy does not exceed IO cm., local analgesia may be considered. The Operation.--By two parallel incisions, made along previously marked parallel lines which also encircle the oesophagostomy and enterostomy, a strip of skin 4 cm. in width is isolated. The edges of the strip are undermined by not more than 2 mm. (Fig. I). Around the oesophagostomy the edges need not be undermined because, after the incisions are made, they tend to curl up spontaneously towards each other. A triangular skin flap is then raised below the enterostomy and sutured to the edges of the strip of skin, covering the enterostomy in a roof-like manner (Fig. 2). By this technical modification a suspension of the enterostomy is obtained, and the incidence of abscess and eventual fistula is greatly reduced. The next step is to raise two massive sliding flaps on both sides of the original skin strip. The undermining must be extended up to the middle clavicular line in order to secure maximum mobility (Fig. 3). It is important to find the proper plane of cleavage so as to minimise bleeding which may otherwise be very profuse. All bleeding points must be carefully controlled because ha~matomata under the flaps are liable to become infected from the free communication between the oesophagostomy and enterostomy. Before the flaps are sutured together over the strip of skin, two stab incisions are made at some distance below the level of the enterostomy through which two fine perforated nylon tubes are inserted in order to secure continuous suction drainage (Fig. 4). The flaps are sutured together in two layers by subcutaneous catgut stitches, and silk or steel wire stitches. The stitches coapt the skin edges only and must not be too tight (Fig. 5)- The operation is completed by the application of a specially constructed apparatus some distance from the suture lines. The apparatus, which reduces tension on the sutures, is fixed to the skin by adhesive tape, adjusted into the proper position and fastened by screws (Fig. 6). Post-operative Treatment.--In the course of the first seven days after the operation, atropine 3 mg. per day, is given to the patient to reduce the secretion of saliva. The patient is also instructed not to swallow but to spit out saliva. Antibiotics and vitamins are administered during the first seven days. On the first day liquids only are given through the gastrostomy, increasing quantities of solid foods being gradually added on the following days. To prevent reflux from the enterostomy the patient is placed in a semi-sitting posture. Stitches are removed on the tenth day from the operation, while the drainage tubes are withdrawn on the fourteenth day. The apparatus is removed after three weeks. If the post-operative course is uneventful, small quantities of saline are

3 RECONSTRUCTION OF SKIN O~SOPHAGUS--A NEW METHOD 415 FIG. I FIG. 2 Fig. I.--The edges of the strip are undermined by not more than 2 ram. Fig. 2.--Note the strip of skin. The triangular flap is raised and ready to be sutured over the enterostomy. FIG. 3 FIG. 4 Fig. 3.--Note the extensive undermining. Fig. 4.--Approximation of lateral flaps burying the strip of skin.

4 416 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 5 Fro. 6 Stitches and two nylon tubes in place. cautiously given by mouth on the fourth week to test the patency of the new oesophagus. From the sixth week onwards the patients are allowed to drink freely, and after two months the taking of solid foods is encouraged. A period of six months must elapse before the gastrostomy is closed. This is done if the clinical and control X-ray examinations show a normal passage for food and barium. Comment.--We used this technique for the first time in The patient was a girl of 24. The distance between the oesophagostomy and enterostomy was 16 cm. The technique we applied originally has, however, undergone considerable modifications. At first, the reconstruction of the oesophagus was performed in two stages, whereas now the whole operation is completed in one stage (Fig. 7). The two-stage technique, however, provided us with the opportunity of observing the process of epithelialisation by direct oesophagoscopy through the skin opening. Epithelialisation was seen to be completed by the fifteenth day, with the exception of a small granulating surface around the enterostomy. In order to avoid this area of delayed healing we introduced a second modification which consisted in raising a triangular skin flap to cover the enterostomy in a roof-like manner. This proved to be most effective in completing the process of epithelialisation. Instead of the former lateral incisions made to relieve tension we introduced, as our third modification, a special apparatus. This technical device proved most effective in relieving tension on the suture lines, converting the strip of skin into an epithelium-lined tube, and preventing the formation of dead spaces. Finally the former transnasal tube and the usual rubber drain were replaced by continuous suction drainage.

5 R E C O N S T R U C T I O N OF S K I N ( E S O P H A G U S - - A NEW METHOD FIG. 7 A, One-stage operation performed in Distance between the oesophagostomy and enterostomy measures 20 cm. B, Apparatus in place. C, T h e same patient after four years. 417

6 418 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 8 A, One-stage operation performed in I958. Partial disruption of sutures occurred twelve days after the operation. B, T h e same case after five years. C, X-ray. Note the straight edges of the skin canal in contrast to typical intestinal patterns.

7 RECONSTRUCTION OF SKIN (XSOPHAGUS--A NEW METHOD 419 These and other minor modifications have enabled us to perform the whole reconstruction in one stage. Since I955 we have operated on eighteen patients using this technique, the first four in two stages, the remainder in one stage. The most common post-operative complications were fistulas which usually appear between the eighth and twelfth day. In the first four cases we had a fistula FIG. 9 A, X-ray of skin oesophagus one year after the operation. ]3, The same case three years later. Note widening of the skin canal. in two. In the remaining fourteen cases (operated in one stage), fistulas appeared in only four, while in one case a partial disruption of sutures occurred on the twelfth day (Fig. 8). The fistulas healed spontaneously and the disrupted wound was successfully closed by secondary suture. The other post-operative complications were subcutaneous localised abscesses which, in two cases, appeared between the third and fourth months after the operation and both responded to simple drainage. Regular follow-up clinical and X-ray examinations of all the nineteen patients, operated by this technique during the past nine years, have shown no stricture or

8 420 BRITISH JOURNAL OF PLASTIC SURGERY other complications and that the passage of food was free. It is, moreover, interesting to note that the radiographs show a widening of the oesophagus in comparison with the first X-rays. The most likely explanation could be the same as that advanced by Johanson (I953) for cases of strictures of the urethra, that hydrostatic pressure during use provides a dilatory mechanism. In our cases the passage of food and liquids could provide this mechanism (Fig. 9)- The major advantages of this method over tubes and flaps are the ostensible shortening of the period of treatment and the possibility of performing the whole reconstruction of the oesophagus in one stage regardless of its length. I wish to thank Professor Dr Papo, who performed the antethoracic and abdominal operations, and I am deeply indebted to Dr Gazikalovic for constructing the special tensionrelieving apparatus. REFERENCES A~NERI, V., and PAPO, I. (1955). Trans. int. Soc. plast. Surg., ISt Congress, p. 59. BROWNE, D. (1949). Proc. R. Soc. Med., 42, 466. DtrPLAY, S. (1874). Arch. gdn. Mdd., p JOHANSON, B. (1953). Acta chir. scand., Suppl MARION~ Go and P~RAR9, J. (1942). " Technique des operations plastiques sur la vessie et sur Fur&re." Paris : Masson et Cie. PAPO, I. (I954a). Vojno-sanit. Pregl., xx, (1954 b). Sinai Hosp. ft., 3, I. PAPO, I. and FAJGELJ, I. (1959). Minerva med., Torino, 5o, 1215.