The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery.
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OBJECTIVE: To discuss the pathophysiology and incidence of the short esophagus, to review the history of treatment, and to describe diagnosis and possible treatments in the era of laparoscopic surgery. SUMMARY BACKGROUND DATA: The entity of the short esophagus in antireflux surgery is seldom discussed in the laparoscopic literature, despite its emphasis in the open literature for more than 40 years. This may imply that many laparoscopic patients with short esophagi are unrecognized and perhaps treated inappropriately. Intrinsic shortening of the esophagus most commonly occurs in patients with chronic gastroesophageal reflux disease that involves recurring cycles of inflammation and healing, with subsequent fibrosis. The actual incidence of the short esophagus is estimated to be approximately 10% of patients undergoing antireflux surgery. Of this group, 7% can be appropriately managed with extensive mediastinal mobilization of the esophagus to achieve the required esophageal length. The remaining 3% require an aggressive surgical approach, including the use of gastroplasty procedures, to create an adequate length of intraabdominal esophagus to perform a wrap. Several effective minimally invasive techniques have been developed to deal with the short esophagus. CONCLUSIONS: Because a short esophagus is uncommon, there is a natural concern that many surgeons will not perform enough antireflux procedures to become familiar with its diagnosis and management. A complete understanding of the short esophagus and methods for surgical correction are critical to avoid "slipped" wraps and mediastinal herniation and to achieve the best patient outcome. (+info)
A 54-year-old man with a complaint of dysphagia was found to have a prominent stricture in the proximal esophagus. A biopsy of the stenotic area indicated sarcoma, leading to subtotal esophagectomy. The surgically removed esophagus demonstrated a well-defined intramural mass, consisting of a mixture of fibroblastic cells with bland cytological appearances and inflammatory cells. Reflux esophagitis which was present distal to the stricture seemed to play a role in the development of this inflammatory pseudotumor. (+info)
Denervated stomach as an esophageal substitute recovers intraluminal acidity with time.
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OBJECTIVE: To determine whether the denervated stomach as an esophageal substitute recovers normal intraluminal acidity with time. SUMMARY BACKGROUND DATA: Bilateral truncal vagotomy to the stomach as an esophageal substitute reduces both gastric acid production and antral motility, but a spontaneous motor recovery process takes place over years. METHODS: Intraluminal gastric pH and bile were monitored during a 24-hour period 1 to 195 months after transthoracic elevation of the stomach as esophageal replacement in 91 and 76 patients, respectively. Nine patients underwent a second gastric pH monitoring after a 3-year period. The percentages of time that the gastric pH was less than 2 and bile absorbance exceeded 0.25 were calculated in reference to values from 25 healthy volunteers. Eighty-nine upper gastrointestinal endoscopies were performed in 83 patients. Patients were divided into three groups depending on length of follow-up: group 1, less than 1 year; group 2, 1 to 3 years; group 3, more than 3 years. RESULTS: The prevalence of a normal gastric pH profile was 32.3% in group 1, 81.5% in group 2, and 97.6% in group 3. The percentage of time that the gastric pH was less than 2 increased from group 1 (27.3%) to group 2 (56.1%) and group 3 (70.5%), parallel to an increase in the prevalence of cervical heartburn and esophagitis. The percentage of time that the gastric pH was less than 2 increased from 28.7% to 81.2% in the nine patients investigated twice. Exposure of the gastric mucosa to bile was 12.8% in patients with a high gastric pH profile versus 19.3% in those with normal acidity. In the esophageal remnant in six patients, Barrett's metaplasia developed, intestinal (n = 2) or gastric (n = 4) in type. CONCLUSIONS: Early after vagotomy, intraluminal gastric acidity is reduced in two thirds of patients, but the stomach recovers a normal intraluminal pH profile with time, so that in more than one third of patients, disabling cervical heartburn and esophagitis develop. The potential for the development of Barrett's metaplasia in the esophageal remnant brings into question the use of the stomach as an esophageal substitute in benign and early neoplastic disease. (+info)
Esophageal perforation in a sword swallower.
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We present the case of a 59-year-old man who sustained an esophageal perforation as a result of sword swallowing. An esophagogram established the diagnosis, and surgical repair was attempted. However, 19 days later, a persistent leak and deterioration of the patient's condition necessitated a transhiatal esophagectomy with a left cervical esophagogastrostomy. The patient recovered and has resumed his daily activities at the circus, with the exception of sword swallowing. This case report presents an unusual mechanism for a potentially lethal injury. Our search of the English-language medical literature revealed no other report of esophageal perforation resulting from sword swallowing. Management of such an injury is often difficult, and a favorable outcome is dependent on prompt diagnosis and treatment. (+info)
Reversed gastric tube (RGT) esophagoplasty for failure of colon, jejunum and prosthetic interpositions.
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Reversed gastric tube (RGT) esophagoplasty is preferred by the author as the primary procedure for esophageal replacement. Many patients undergoing RGT esophagoplasty, however, have previously had multiple operative procedures. A particularly challenging problem in esophageal reconstruction is the patient who has already had unsuccessful intestinal or prosthetic interposition operations in attempts to reconstruct the esophagus. In such patients, it has been possible to replace the esophagus by means of the RGT operation. Of 67 RGT esophagoplasties, 9 patients (13.4%) had previous interposition operations that had failed. Six had undergone colon interposition; 2 of these had strictured, 1 had partially sloughed leaving a cervical salivary fistula, and in 1 the proximal end was never patent. In each instance, bypass with RGT was performed without resecting the colon transplant. The colon had necrosed and was removed in 2 patients. Of the remaining 3 patients, in 1 a plastic esophageal prothesis had sloughed and two had free jejunal transplants, 1 of which had impaired vascularity and the other had fibrosed. The specific techniques used to reconstruct the esophagus by reversed gastric tube esophagoplasty, as they relate to this particular group of patients, are described. (+info)
Laparoscopic esophagomyotomy for achalasia: does anterior hemifundoplication affect clinical outcome?
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OBJECTIVE: To determine whether the addition of anterior hemifundoplication to laparoscopic esophagomyotomy for achalasia yields better clinical outcomes than laparoscopic esophagomyotomy alone. SUMMARY BACKGROUND DATA: Although hemifundoplication may prevent gastroesophageal reflux after esophagomyotomy for achalasia, it may also lead to persistent dysphagia in these patients with esophageal aperistalsis. METHODS: This is a retrospective study of 51 consecutive patients (mean age 47.5 +/- 12.6 years) who had laparoscopic esophagomyotomy for achalasia by our group between August 1995 and January 2001. In 29 patients (57%) an anterior hemifundoplication was added to the esophagomyotomy. In 22 patients (43%), no wrap was added. Patients scored (0 = none; 1 = mild; 2 = moderate; 3 = severe) symptom severity (dysphagia, regurgitation, heartburn, chest pain) preoperatively and postoperatively. Weight gain, use of gastrointestinal (GI) medication, tolerance to food, and patient satisfaction were also assessed. RESULTS: Mean patient follow-up was 33 months, and there were no operative deaths. Four patients were converted to open operation (8%). The wrap and no wrap groups were similar in terms of esophageal dilation, preoperative symptom severity and duration (5.7 +/- 7.1 versus 6.1 +/- 7.0 years), and preoperative weight loss (18 +/- 15 versus 20 +/- 20 pounds). Both groups had similar improvement in symptom grade postoperatively and equivalent satisfaction rates (86%). Postoperative weight gain, GI medication use, and food intolerance was also similar. Postoperatively, patients in the wrap group did not have higher dysphagia scores or lower heartburn scores than the no wrap group. CONCLUSION: The addition of anterior hemifundoplication to esophagomyotomy for achalasia does not improve or worsen clinical results. (+info)
Aortic valve replacement after esophagectomy with substernal gastric tube reconstruction.
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A 67-year-old woman with a history of esophagectomy with substernal gastric tube (GT) reconstruction and left lower lobectomy required aortic valve replacement (AVR) for aortic valve regurgitation and stenosis. Through a median sternotomy (MS) with cardiopulmonary bypass (CPB), we performed AVR without injury to the GT. Careful peeling of the GT and detailed information of the operative field by multidetector-row computed tomography (MDCT) scan enabled us to carry out the operation safely in the usual operative view. (+info)
Reconstruction of thoracic esophagus with pediculated diaphragmatic flap in dogs.
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PURPOSE: To verify whether pediculated diaphragmatic flaps were suitable to correct iatrogenic wounds in dog's esophagus injuries. METHODS: Seven dogs were submitted to resection of a segment of the esophageal wall, which was then corrected by suturing a pediculated diaphragm flap. Endoscopic evaluation of the esophageal wall was done forty days after the surgical procedure. RESULTS: Three animals died, one due to implant ischemia, caused by strangulation of the phrenic artery; other due to wound infection; and the last, due to mediastinitis. Scar retraction was observed, however, there was no stenosis, allowing the passage of a 9,8 mm probe with no difficulty. The limits between the implants and the native esophagus were indistinguishable, and the implant was covered by esophageal mucosa. CONCLUSION: The diaphragmatic flaps are suitable on the restoring of continuity in dog's thoracic esophagus. (+info)