New Trends in Esophageal Replacement for Benign Disease

Transcription

1 New Trends in Esophageal Replacement for Benign Disease Mark B. Orringer, M.D., Marvin M. Kirsh, M.D., and Herbert Sloan, M.D. ABSTRACT In the past three years 21 patients have required esophageal replacement for benign disease: 6 patients with caustic stricture, 5 with reflux esophagitis, 5 with neuromotor abnormalities, 2 with strictures following radiation therapy, 1 with iatrogenic perforation, 1 with monilial esophagitis, and 1 with esophageal atresia. Esophageal substitution was achieved using isoperistaltic left colon in 17 patients and stomach in 4. The preoperative evaluation, postoperative complications, and results of esophageal replacement in these patients are discussed. Changing trends in the benign conditions requiring esophageal substitution are reviewed. Esophageal substitution for nonneoplastic disease is indicated in a variety of situations that are only relatively benign, since the inability to propel food from the mouth into the stomach in a normal fashion, regardless of the cause, may have disastrous effects upon nutrition and general health. The nature and frequency of the disorders requiring esophageal replacement have recently changed, at least partially because of advances in the surgical treatment of reflux esophagitis and partially as a result of the commercial availability of newer, extremely corrosive oven and drain cleaners. This discussion reviews the current spectrum of indications for esophageal replacement for benign disease and some of the major technical considerations in the available reconstructive procedures. Clinical Material In the past three years 21 patients (12 male and 9 female), ranging in age from 2 to 60 years, have From the Department of Surgery, Section of Thoracic Surgery, The University of Michigan Medical Center, Ann Arbor, MI. Presented in part at the Twenty-third Annual Meeting of the Southern Thoracic Surgical Association, Acapulco, Mexico, Nov 4-6, Address reprint requests to Dr. Orringer, C-7175 University Hospital, Ann Arbor, MI required esophageal replacement for dysphagia resulting from benign disease: 6 patients with caustic strictures; 5 with reflux esophagitis; 5 with esophageal neuromotor abnormalities; 4 patients had strictures, 2 following radiation therapy, 1 from iatrogenic perforation, 1 from monilial esophagitis, and 1 from esophageal atresia (Table). Esophageal dilations failed to relieve dysphagia in 5 of the 6 patients with caustic strictures and resulted in perforation in Patient 9 when attempted prematurely only 11 days after his injury. Four of the 5 patients with reflux esophagitis had peptic strictures. In Patient 4 peptic stricture followed a distal esophagectomy with esophagogastrostomy for benign stricture without a gastric drainage procedure. Patient 2 had recurrent reflux esophagi tis following a Belsey transthoracic hiatal hernia repair that was complicated by delayed gastric emptying from vagus nerve injury. In all 5 patients with esophageal neuromotor abnormalities, previous esophagomyotomy had failed to provide lasting relief from dysphagia and regurgitation. In Patients 13,15, and 16, the combination of an esophagomyotomy with a gastric fundic wrap (Nissen fundoplication or Collis-Belsey procedure) had resulted in functional distal esophageal obstruction. There were 2 postirradiation esophageal strictures in this series; the first case involved the upper and midthoracic esophagus and occurred 18 months after the patient (No. 17) received 5,000 rads to the mediastinum as treatment for an unresectable thymoma. In the second case, Patient 18 developed a cervical esophageal stricture approximately 20 months after receiving 5,000 rads to the neck for an epiglottic squamous cell carcinoma. Patient 19 had a nondilatable distal esophageal stenosis following several attempts elsewhere to repair an iatrogenic perforation 409

2 410 The Annals of Thoracic Surgery Vol 23 No 5 May 1977 Esophageal Replacement for Benign Disease Patient No., Age, and Sex Esophageal Disorder Prior Esophageal Operations (interval befom esophageal replacement) Operation 1 67, M 2. 50, M 3. 59, M F 5. 69, M F 7 26, F 8. 45, F 9. 53, M , M , M , M , M 14 61, F , F , F 17 47, F , M 19 57, F , M 21. 2, M Recurrent HH, peptic stricture Recurrent HH, ulcerative reflux esophagitis HH, peptic stricture; previous spontaneous perforation Pcptic stricture after esophagogastrostomy HI<, peptic stricture Caustic stricture Causticstricture. HH, refluxesophagitis Caustic stricture Perforation of acute caustic stricture Caustic stricture Caustic stricture Achalasia; reflux esophagitis Achdasia Achdasm, megaesophagus Diffuse spasm, reflux esophagitis Diffuse spasm Radiation stricture, upper thoracic eso3hagus Radiation stricture. cervical esophagus Strichire after perforation Monilial stricture, cervical perforation Atresi.i, TEF TransahdominalHHrepair twice(4yr. 3 Yr) Transthoracic HH repair (1 yr) Drainage of mediastinum and bilateral empyemas after spontaneous perforation (14 yr) Distal esophagectomy, esophagogastrostomy (1 yr) Dilations (6 mo) Dilations (25 yr) Dilations (4 rno) Thoracic esophagectomy, cervical esophagostomy, gastrostomy (1 mo) Dilations (2 mo) Dilations (1 mo) Esophagomyotomy twice (24 yr, 7 yr); transthoracic HH repair (7 yr) Esophagomyotomy twice (6 yr, 2 mo); Collis-Belsey repair (2 mo) Esophagomyotomy, esophagoplasty (1 Y r) Transabdominal Nissen HH repair (5 yr); esophagomyotomy (2 yr); takedown of HH repair (1 yr) Esophagomyotorny (10 yr); transthoracic HH repair (1 yr), esophagomyotomy, Collis-Belsey repair (6 wk) Partial resection, dilations (2 yr) Transabdominal HH repair, repair of perforation, esophagomyotomy (1 yr) Dilations, drainage of cervical perforation (3 mo) Division of TEF; cervical esophagostomy, gastrostomy (2 yr) Distal esophagectomy, SS colon Distal esophagectomy, SS colon Thoracic esophagectomy; cervical esophagogastrostomy Thoracic esophagectomy; cervical esophagoga strostomy Thoracic esophagectomy; LS colon Thoracic esophagectomy; LS colon ; subtotal gastrectomy Subtotal gastrectomy, thoracic esophagectomy; LS colon Substernal reversed gastric tube bypass Thoracic esophagectomy; LS colon Thoracic esophagectomy, LS colon Thoracic esophagectomy; LS colon Thoracic esophagectomy, LS colon Distal esophagectomy; esophagogastrostomy HH = hiatal hernia; SS = short-segment colon ; LS = long-segment colon ; suhst. = substernal colon, TEF = tracheoesophageal fistula. that had occurred during a transabdominal Nissen fundoplication. Severe monilial esophagitis, resulting in an extensive nondilatable stricture, occurred in Patient 20, a diabetic who received broad-spectrum antibiotic therapy following ii partial small bowel resection. After 3 months of unsuccessful dilations, during which the cervical esophagus was perforated, he underwent substernal colonic. Patient 21., a 2-year-old boy who had undergone division of a tracheoesophageal fistula with feeding gastrostomy and cervical esophagostomy lor esophageal atresia at 3 days of age, underwent substernal colonic esophageal substitution. Procedure Preoperative Evaluation Preoperative evaluation of adult patients consisted of a barium swallow examination and esophagoscopy. Rigid esophagoscopy, with evaluation of the pliability of the esophageal stenosis using Jackson dilators, biopsy, and dilation (when possible using Hurst-Maloney dilators), were performed under general anesthesia in all 16 patients with organic esophageal obstructions. The fiberoptic esophagoscope was used in the other 4 adults with esophageal motor abnormalities. A preoperative barium enema was obtained in each candidate for colonic esophageal replacement.

3 411 Orringer, Kirsh, and Sloan: Esophageal Replacement for Benign Disease Operation Esophageal substitution was achieved using isoperistaltic left colon based upon the ascending branch of the left colic artery (17 patients) and stomach (4 patients) (see the Table). Among the 17 patients in whom colon was used, 7 underwent one-stage total thoracic esophagectomy and long-segment colonic with a cervical esophagocolonic anastomosis, 2 had distal esophagectomies and short-segment colonic s, and 8 underwent substernal colonic s. A left thoracoabdominal incision, mobilizing the colon through the peripherally opened diaphragm, was used whenever one-stage esophagectomy and reconstruction with colon was performed. Two of the patients with caustic esophageal strictures had associated gastric stenosis from their caustic injuries. In Patient 10 a one-stage sleeve resection of the stomach and substernal colonic was performed. In Patient 11, subtotal gastric resection was followed by a one-stage thoracic esophagectomy and left colonic after one month. Of the 4 patients in whom stomach was used to replace the esophagus, 2 underwent one-stage total thoracic esophagectomy with a cervical esophagogastric anastomosis, 1 had resection of the distal esophagogastric anastomosis and a new intrathoracic esophagogastrostomy, and 1 underwent a substernal reversed gastric tube bypass. Re s u 1 t s The nature and frequency of postoperative complications were influenced by the age, nutritional status, previous operative history, and extent of the esophageal injury in these patients. A cerebrovascular accident ultimately resulted in the death of Patients 14 and 5 at 4 months and 16 days after operation, respectively. After resection of a megaesophagus from the left chest in Patient 14, intrathoracic hemorrhage occurred, requiring a right thoracotomy for control of bleeding from pleural adhesions. Patient 12 underwent a substernal reversed gastric tube bypass. A cervical anastomotic leak developed that had still not closed after 6 weeks, when an unexplained respiratory arrest occurred, with secondary anoxic brain damage. The patient died from sepsis 13 weeks after the bypass procedure; postmortem examination showed purulent pericarditis associated with a gastric tube-pericardial fistula. This represents the only death in this series directly attributable to the bypass procedure. In Patient 9, severe upper esophageal injury following ingestion of lye crystals necessitated anastomosing the colon graft to the scarred cervical esophagus, and a cervical anastomotic leak and stricture developed. This patient also subsequently required release of extensive intraoral and pharyngeal scars. Patient 15 experienced a transient cervical anastomotic leak and wound infection after a colonic operation that was prolonged because of dense intraabdominal and mediastinal adhesions associated with her prior operations. Similarly, Patient 20, a diabetic, developed a pelvic abscess following a substernal colonic bypass that was complicated by extensive adhesions from his prior peritonitis and abdominal operations. Patients 7, 10, and 17 experienced postoperative high small bowel obstruction after colonic, either because of excessive approximation of the mesocolon after the ligament of Treitz was reconstructed or because of an internal hernia through the reconstructed mesocolon. Each required operative correction of this problem. In addition, the gastric outlet obstruction that occurred in Patient 10 after sleeve resection of the stomach for a caustic injury required revision of the anastomosis. After substernal colon bypass, Patient 3, a chronic paranoid schizophrenic, required a tube cecostomy to correct postoperative cecal dilatation. This condition was thought to be the result of an adynamic ileus secondary to the phenothiazine drugs that he was taking for his mental disorder. Patients 4 and 17 required prolonged ventilatory assistance for postoperative respiratory insufficiency. Patient 4, a debilitated 64-year-old woman, died 6 months postoperatively of arteriosclerotic heart disease, pneumonia, and renal failure, but was able to eat normally up to the time of her death. Patient 17 developed an unexplained generalized myopathy after substernal colonic bypass of her strictured upper esophagus, which had been injured by radiation therapy for an unresectable thymoma. She remained dependent on a respirator for 5 months and even-

4 412 The Annals ol Thoracic Surgery Vol 23 No 5 May 1977 thymoma were found. Sixteen of the 17 remaining patients in this series are eating regular diets after 3 to 36 months (average, 17 months) of follow-up. Mild dumping symptoms have occurred in 1 patient who underwent a cervical esophagogastrostomy and in 4 patients who had colonic s. These symptoms have been controlled by limiting the size of meals and the carbohydrate intake. Two of the patients who had colonic s intermittently regurgitate food shortly after eating. None of the patients with colonic esophageal substitutes, however, has experienced reflux of gastric contents to the pharynx or pulmonary symptoms of aspiration. The only patient in this series with an intrathoracic esophagogastric anastomosis eats a regular diet but has occasional nocturnal substernal discomfort; gastroesophageal reflux has been shown with acid reflux testing in this patient. 6 Fig 1. Barium szuall~m, showing causticirijur!y of esophagus and stomach (Patient 11). (A) Note irivolvenlent of eritiw thoracic esophagus arid distortion of distalstomach. (B) Detail of stomach, shouiirig typical stenosis of gastric antrum. tually died of pulmonary sepsis. On postmortem examination the colonic bypass was intact, and multiple small pleural metastases from the Comment The need for esophageal replacement after ingestion of corrosive agents has increased. Our changing approach to caustic esophageal injuries has been reviewed recently [lo]; this approach reflects the more extensive injuries we are encountering following ingestion of the highly corrosive drain and oven cleaners now available commercially. In the past, esophageal strictures that followed ingestion of the common household cleaning solutions were most often localized and could be treated by chronic dilation. Salvage of the esophagus after injury by the newer agents, however, is now seldom possible, and the extent of the esophageal damage contraindicates bougienage earlier than 4 to 6 weeks after the injury [5, 321. Thus a perforation occurred in Patient 9 when his acutely strictured esophagus was dilated only 11 days after caustic ingestion. In addition, the type of severe associated gastric injury seen in Patients 10 and 11 (Fig 1) is increasingly common. The almost instantaneous tissue destruction caused by ingestion of the newer corrosives may require an urgent esophagogastrectomy in the acute phase of injury, or esophageal replacement with gastric resection later. Patient 9, whose extensively strictured esophagus was perforated, was treated by im-

5 413 Orringer, Kirsh, and Sloan: Esophageal Replacement for Benign Disease mediate total thoracic esophagectomy, cervical esophagostomy, and gastrostomy followed by substernal colonic 1 month later. While immediate repair and drainage of the perforated but otherwise undiseased esophagus is acceptable treatment in many cases, we are reluctant to place an esophageal suture line proximal to a severe stricture. We also oppose the fundic patch operation of Thal[20], which relies on the healing of the opened, strictured esophagus to which the gastric fundus is sutured; the procedure requires the addition of an intrathoracic fundoplication to control reflux [211. In effect this creates an incarcerated paraesophageal hiatal hernia, and we are aware of 3 patients who developed necrosis and ulceration of their strangulated intrathoracic fundic wraps. We believe therefore that it is generally safer and more efficient to resect and reconstruct the perforated, severely strictured esophagus than to rely on the healing of diseased tissue and risk the morbidity of a chronic esophageal fistula. We now perform esophageal resection for peptic stricture much less commonly than in the past. The unacceptable incidence of recurrent reflux for the standard Mark IV Belsey hiatal hernia repair performed in the presence of significant esophagitis and shortening [151 was the reason for distal esophagectomy and shortsegment colonic in Patients 1 and 2. More recently, the efficacy of the combined Collis-Belsey operation in reversing severe peptic esophagitis has been responsible for the salvage of esophagi that were previously routinely resected [16, 171. Of our last 21 patients with peptic strictures, only 2 have had nondilatable strictures. In the remainder, intraoperative dilation has been possible; after the Collis-Belsey operation, regression of the strictures has generally been dramatic. Even when not complete, reversal of esophageal fibrosis by prevention of reflux allows better swallowing than can be achieved with esophageal replacement. We therefore believe that esophageal resection for peptic esophagitis is rarely indicated as a primary operation and should be reserved for patients in whom newer methods of reflux control have failed. The spectrum of neuromuscular disorders from diffuse esophageal spasm to achalasia may also require esophageal bypass or replacement when, as in Patient 14, symptoms persist or recur following one or two esophagomyotomies. Patients with a combination of esophageal spasm and gastroesophageal reflux may cause extraordinarily difficult problems in management. Frequently these patients, like Patient 15, show neurotic behavior and give a history of multiple esophageal operations. The few patients who fail to respond to a second esophagomyotomy or those who have already had various combinations of myotomies and antireflux procedures may require esophagectomy and reconstruction as the only means of ultimately relieving their esophageal symptoms. Esophageal replacement for neuromotor abnormalities may also be necessitated by the development of severe reflux esophagitis after esophagomyotomy, which occurs in as many as 30% of patients [6,13] and is a compelling argument for combining an antireflux procedure with a myotomy [2,7]. However, it may be quite difficult to achieve the correct balance between a competent distal esophageal sphincter mechanism and the intraesophageal pressure required to propel food through it and into the stomach. The resulting functional esophageal obstruction demonstrated by Patients 13, 15, and 16, which may occur when an antireflux operation is performed with an esophagomyotomy, is among the most difficult complications faced by esophageal surgeons. As in Patients 13 and 16, its successful resolution may necessitate esophageal replacement. While acute postirradiation esophagitis is fairly common, few cases of chronic benign strictures following radiation therapy have been reported [9, 181. Because of the increased incidence of malignant degeneration of the esophagus in patients exposed to irradiation years before [22], whenever one encounters an esophageal stricture in a patient who has received prior radiation therapy to the thorax, larynx, or thyroid, malignancy must be excluded. The preoperative esophageal biopsies and subsequent follow-up indicate that the postirradiation strictures in Patients 17 and 18 were benign. Monilial esophagitis is an uncommon dis-

6 414 The Annals of Thoracic Surgery Vol 23 No 5 May 1977 ease, characteristically occurring in patients with conditions that impair normal function of the body s immune system [19]. Once diagnosed, the condition responds well to oral nystatin and rarely progresses to esophageal stricture formation. We have found only a single case report of a localized mild upper thoracic esophageal stricture occurring in a patient with chronic moniliasis [8]. We believe that Patient 20, a diabetic receiving broad-spectrum antibiotics for peritonitis, represents the first reported case of monilia causing a chronic nondilatable stricture of the upper esophagus requiring an intes- Fig2. Barium s.tc~alllxi~s in Patient I, zidio ingestidlye at the ageof 1 year. (A, B) Preoperativeviews showinghiatalherliia thatformedasshortened, strictured esophagus failed togroiu with the patient. Symptoms of severe reflux esophagitis superimposed upon long-standing dysphagia from the steriosed esophagus 7vould riot have been reliezwd by esophageal bypass. (C) Postoperative viiw after one-stage esophage,rtomy arid long-srgnien t colonic. Note,:ritraabdoniirial segnierit of distal colongraft, zilhich is considerc~diriiportarit ir7 preveiitiori ofreflux. tinal bypass. Wider use of chemotherapeutic agents in the treatment of malignant disease and of various immunosuppressive drugs in patients after organ transplantation will predictably result in an increased incidence of monilial esophagitis, the recognition and treatment of which will be essential if stricture formation is to be averted. The techniques we utilize for esophageal replacement are discussed in detail elsewhere [14]. The substernal route for esophageal bypass, avoiding the need for thoracotomy, is preferred in the child with esophageal atresia requiring esophageal replacement, and in the patient in whom esophagectomy or esophageal exclusion for trauma or control of a chronic fistula has been necessary. Unless there is pain or bleeding from the diseased esophagus, there is no absolute indication for resection (Fig 2). The risk of malignant degeneration within the scarred esophagus is not great enough to warrant esophagectomy on this basis alone [3,111. However, the unresected esophagus remains a potential source of bleeding from reflux A B C

7 415 Orringer, Kirsh, and Sloan: Esophageal Replacement for Benign Disease esophagitis, particularly when caustic injuries involve and distort the esophagogastric junction (Fig 3). We have not used jejunal for esophageal replacement because of its length limitations and tenuous blood supply. We now also avoid reversed gastric tube bypass because of our concern about the potential for disruption of its long gastric suture line such as occurred in Patient 12, resulting in a gastric tube- Fig3. Lateralview from barium su~allozostudy after substertial colonic bypass of severely stenotic esophagus(patient8). Patient hadnosymptoms of gastroesophageal reflux preoperatively, but barium obviously flozos retrograde through a distorted esophagogastricjunctior?. The potential for bleeding from reflux esophagitis exists in this patient eveii though dysphagia froni the caustic stricture has been relieved. pericardial fistula and eventual death. The incidence of anastomotic disruption and subsequent stricture formation is also quite high with this procedure [41. The mobility and excellent blood supply of the stomach and the simplicity of esophagogastrostomy make this operation our reconstructive procedure of choice in elderly patients. A gastric drainage procedure is an essential part of this operation to prevent delayed gastric emptying, which may increase gastroesophageal reflux and result in esophagitis as occurred in Patient 4. Because of the frequency of complications of reflux associated with esophagogastrostomy, we avoid this procedure in younger patients who have a reasonable life expectancy. Isoperistaltic left colon based on the ascending branch of the left colic artery, as described by Belsey [l], is in our opinion the best current method of esophageal reconstruction for benign disease in the first four decades of life. Our recent experience indicates the following changing trends in esophageal replacement for benign disease: (1) fewer esophagectomies for peptic strictures, (2) an increased need for esophageal as well as gastric resection following caustic ingestion, and (3) more esophageal replacements for long-term failures of esophagomyotomy for neuromotor abnormalities. In addition, as the number of immunosuppressed patients increases, severe monilial esophagitis may become a more common indication for esophageal replacement or bypass. References 1. Belsey R: Reconstruction of esophagus with left colon. J Thorac Cardiovasc Surg 49:33, Belsey R: Functional disease of the esophagus. J Thorac Cardiovasc Surg 52:164, Carver CM, Sealy WC, Dillon MJ: Management of alkali burns of the esophagus. JAMA 160:447, Cohen DH, Middleton AW, Fletcher J: Gastric tube esophagoplasty. J Pediatr Surg 9:451, Daly JF: Corrosive esophagitis. Otolaryngol Clin North Am, June 1968, p Hatafuku T, Tetsuo M, Thal AP: Fundic patch operation in the treatment of advanced achalasia of the esophagus. Surg Gynecol Obstet 134:617, 1972

8 416 The Annals of Thoracic Surgery Vol 23 No 5 May Henderson Rt), Ho CS, Davidson JW: Primary disordered mcltor activity of the esophagus (diffuse spasm). Ann Thorac Surg 18:327, Kantrowitz PA, Fleischli DJ, Butler WT: Successful treatment of chronic esophageal moniliasis with a viscou:; suspension of Mycostatin. Gastroenterology.57:434, Kapur TF: Late post-radiation changes in the larynx, pharynx, oesophagus and the trachea. J Laryngol Otol82:447, Kirsh MM, Ritter F: Caustic ingestion and subsequent damage to the oropharyngeal and digestive passages. Ann Thorac Surg 21:74, Marchand P: Caustic strictures of the esophagus. Thorax 10:171, Middlekamp JN, Ferguson TB, Roper CL, et al: The management and problems of caustic burns in children. J Thorac Cardiovasc Surg 57:341, Nemir P Jr, Fallahnejad M, Brose B, et al: A study of the causes of failure of esophagocardiomyotomy for achalasia. Am J Surg 121:143, Orringer MB, Kirsh MM, Sloan H: Esophageal reconstruction for benign disease-technical considerations. J 'Thorac Cardiovasc Surg (in press) 15. Orringer MB, Skinner DB, Belsey RHR: Longterm results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 6325, Orringer MB, Sloan H: Collis-Belsey reconstruction of the esophagogastric junctionindications, physiology and technical considerations. J Thorac Cardiovasc Surg 71:295, Pearson FG, Tanger B, Henderson RD: Gastroplasty and Belsey hiatal hernia repair. J Thorac Cardiovasc Surg 61:50, Seaman WB, Ackerman LV: The effect of radiation on the esophagus. Radiology 68:534, Sheft DJ, Shrago G: Esophageal moniliasis: the spectrum of the disease. JAMA 213:1859, Thal AP: A unified approach to surgical problems of the esophagogastric junction. Ann Surg 168:542, Thomas HF, Clarke JM, Ray1 JE, et al: Results of the combined fundic patch-fundoptication operation in the treatment of reflux esophagitis with stricture. Surg Gynecol Obstet 135:241, Whitfield AGW, Bond WH, Kunkler PB: Radiation damage to thoracic tissues. Thorax 18:371, 1963