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Esophagoplasty in post-burn esophageal strictures
ZH. Arzykulov, Y. Shaikhiyev, A. Shokebaev, A. Aliev
National Scientific Center of Surgery, Almaty, Republic of Kazakhstan
The results of the surgical treatment of 313 patients with post-burn scar strictures of the esophagus. Immediate and long-term results of esophagocoloplasty, esophagogastroplasty were examined.
When these methods were used, the frequency of complications in the early period was 12.8% after esophagocoloplasty and 13.9% after esophagogastroplasty. Postoperative mortality rate for the period from 1980 to 2000 was 2.8% (313 operations, 9 deaths). Over the past 14 years, there hasn't been any deaths after reconstructive - restorative interventions.
Introduction
Identify ways to improve the surgical treatment of benign esophageal strictures so far remains an important medical and social problem in the Republic of Kazakhstan. Despite all the improved methods of conservative and minimally invasive treatment of benign lesions of the esophagus, there are conditions that require you to perform radical procedures on the esophagus. This applies to diseases such as stricture due to the effects of chemical agents on the wall of the esophagus (burns by various cauterizing liquids, gastro-esophageal reflux). Accidental or suicidal esophageal damage by chemicals occur in more than 700 cases annually in Kazakhstan and there hasn't been any decline observed in the number of cases.
Currently, replacement of the esophagus and restoring oral diet is the most popular way of plastic stomach (gastric or whole stems) (3). In case stomach is impossible to be used as a plastic material, colonic plastic is widely used. (4). As a rule, preference that is given to esophagoplasty depends on the experience of the clinic and the method that are used by them.
The majority of the patients in whom these interventions are performed, tends to be people of working age and have greater life expectancy, so the main criterion for the effectiveness of early intervention are the long-term results of functioning artificial esophagus (5).
The above calls for a more careful selection of the method of operation and the type of esophagoplasty based on the study of the features and morphological characteristics of the graft in the immediate and late postoperative period (6,7).
Some patients who underwent plastic esophagus developed pathological conditions that are combined into a group of artificial esophageal disease. The incidence of the disease arising due to artificial esophagus is often dependent on how esophagoplasty has been done and has no tendency to decrease. Diseases of artificial esophageal disease arises from 10% to 50% after esophagoplasty (8, 9).
Patients and Methods
In the department of surgery of the gastrointestinal tract and endocrine organs of the National Scientific Center of Surgery reconstructive- restorative surgery for benign esophageal stenosis from 1980 to 2014 executed in 313 cases, accounting for 67.3% of the total number of treated
patients with esophageal diseases. Of them, combined post-burn cicatricial esophageal and gastric contraction was detected in 76 cases and combined lesions of the pharynx and esophagus in 41 cases. Isolated scar lesions were detected in the remaining 196 cases.
On distribution by sex, there were 135 men (43.13%), 178 women (56.8%) aged 16 to 71, the median age was 45. The causes of chemical burns among patients are presented in Table №1.
Table 1 - Causes of chemical injuries of upper gastrointestinal tract
Causes of burns Number of patients
Incidental 147 (46.96%)
Suicidal 85 (27.15%)
Under the influence of alcohol 81 (25.87%)
Total 313 (100%)
189 (60.38%) patients were poisoned by acids. Alkali poisoning was observed in 93 (29.71%) patients, burn due to unknown chemical agent was found in 31 (9.9%) cases.
The vast majority of patients admitted to us were underweight. This problem of body mass deficit was particularly pronounced in patients with total scar esophageal stricture, and ranged from 3 to 25 kg. Most patients had complaints of general weakness, weight loss, dysphagia, decreased ability to work, a feeling of heaviness in the epigastrium, as well as the presence of heartburn, nausea. In the group of patients observed, in many cases, patients abused alcohol not only on the pre-hospital phase, but, unfortunately, in the hospital. This category is full of people who are in depression, mostly young girls after failing suicide attempts.
For all the patients admitted in the surgical clinic with post-burn scar strictures, special techniques and general clinical examination was applied. In all 313 cases, performing firststage reconstructive- restorative surgery was not possible. Since expressed nutritional, metabolic disorders with impaired homeostasis, often with the presence of concomitant diseases causing the severity of the patients' condition, treatment had been split into two phases. The first step was performing gastrostomy, in order to establish enteral nutrition. It should be noted that in patients with coexisting gastric lesions the first stage gastrostomy, retrocolic posterior gastroenterostomy was performed. Reconstructive- restorative surgery in all patients was used in the second stage, after 4 - 8 months of the first treatment stage. We consider that during this time correction of nutritional status takes place. After admission in the hospital for reconstructive-restorative treatment, preoperative preparation was necessarily carried out, which was given considerable importance, since a wide range of pathophysiological changes can be manifested during surgical interventions for post-burn scar contractions of the esophagus which puts patients at high risk of postoperative complications.
Of the 313 patients 118 (37.69%) patients underwent shunt (bypass) coloesophagoplasty. The indications for shunt esophagocoloplasty were: 1. Associated scar stricture
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Вестник хирургии Казахстана №4, 2014
a b
Figure 1 - The deformation of the bottom and the body of the stomach due to roughly imposed gastrostomy a - gastrostomy superficially b - radio opaque research through gastrostomy
of the esophagus, pharynx and stomach. 2. The long scar stricture of the esophagus, with severe esophagitis and paraesophagitis, sometimes with different esophageal fistulas. 3. Necrosis of the graft after unsuccessful attempts esophagoplasty or improper imposition of gastrostomy tube (Figure 1). 4. Cicatricial stricture of the esophagus in patients who previously underwent perforation of the esophagus.
Formation of Colon graft (artificial esophagus) was carried out from the left side of the colon supplying the middle or left colic artery. Left half of the colon is preferred for this procedure, because the left side of the colon is longer than right and smaller in diameter, its blood supply is usually better than in the right half. The position of the graft (iso-or antiperistaltic) does not really matter, since the passage of food through the large intestine transplant is mainly due to the force of gravity, and not peristalsis. The left half of the colon was used in 88 (74.5%) cases, the left half with an additional segment connecting the sigmoid colon in the remaining 30 (25.4%) cases. Formed transplantation of colon is done in the anterior mediastinum, retrosternal. Blood supply of artificial esophagus in 81 (68.6%) cases was carried out at the expense of middle colic artery in 27 (22.8%) cases, the blood supply was carried out at the expense of the middle and left colic artery, 10 (8.5%) - due to the left sigmoid colon and the first artery. The proximal anastomosis in colon transplantation is formed from the pharynx on the neck. The distal anastomosis in colon transplantation is formed in the front wall of the stomach. However, in 16 patients with distal anastomosis graft formed from the abductor loop of gastroentero-anastomosis and 14 from the duodenum. Because there was no sufficient healthy platform on the front wall of the stomach.
Resection of the esophagus with one-stage esophagogastroplasty with holding the graft in the posterior mediastinum performed in 168 patients (53.67%). In this form of plasticity continuity of gastrointestinal tract iso-peristaltic stem was formed from the greater curvature of the stomach, with the creation of the cervical esophagogastroanastomosis. Shunt esophagogastroplasty with gastric tube holding retrosternal space without resection of the esophagus is formed in 26 (8.3%) cases.
Results
The analysis of postoperative complications after esophagocoloplasty shows that there was no leakage of colo-colon and colo-gastric anastomosis observed. Anastomotic
leakage in the neck after esophagocoloplasty (formed with the esophagus or throat) was observed in 12 (10.2%) cases, recurrent laryngeal nerve palsy in 3 (0.9%) patients.
Anastomotic leakage in the neck after esophagogastroplasty occurred in 27 (13.9%) patients.
Long-term results were studied in 290 (92.6%) patients in a period of 5 months to 15 years. The positive long-term outcome was achieved in 88% of patients. Diseases with artificial esophagus developed in the late period in 24 (7.7%) patients after esophagocoloplasty, and 8 (2.5%) patients after esophagogastroplasty. Confirmation of the diagnosis in all cases was carried out by using X-ray and endoscopy of artificial esophagus. Anastomotic stenosis in the neck was observed in 28 (17.1%) patients, anastomotic patency was restored by bougienage. One patient had complete obliteration of pharyngo-colo-anastomosis so reconstruction of anastomosis was performed on this patient.
Esophageal-cutaneous fistula developed in the neck in one case, 21 years after coloesophagoplasty. For this patient the elimination of the fistula was made and intraoperative forced probing scar-necked anastomosis was made. After the intervention fistula was eliminated, violation of swallowing disappeared. The patient was fully able to intake food in a
Figure 2 - Photo of the patient with esophageal-cutaneous fistula in the neck
natural way (Figure 2).
At 5 (4.2%) patients after the esophagocoloplasty developed complications as sagging of colon graft (sagging syndrome of colon graft). Given the anatomical features of the colon, its mesenteric circulatory system and in some cases can not exclude the sagging of the intestinal graft formed. When combined lesions of the pharynx and the esophagus is necessary to the formation of a longer intestinal transplant that failed to impose adequate high pharynx-intestinal anastomosis. In these cases it is difficult to avoid sagging of the graft. In connection with what we have developed a method of treatment (prophylaxis) syndrome sagging colonic graft. In order to eliminate sagging syndrome intestinal transplant was performed imposing additional gastrointestinal anastomosis in the anterior wall of the upper third of the stomach two-row interrupted sutures, the anastomosis is formed above the existing colo-gastric anastomosis. All patients had recovered enteral nutrition. Thus, the ability to work has been restored in these patients (Figure 3).
Thus, this method is simple to implement and conducive to the resumption of normal passage of food through the ar-
Figure 3 -X-ray of patients with the sagging syndrome of colonic graft before and after treatment a - sagging loop of colonic graft b - after treatment, there is no slack loop
tificial esophagus.
Lethality after esophagoplasty was 9 (2.8) patients. Four patients died after esophagocoloplasty, the mortality rate in this case was 3.4%. The cause of death was necrosis of colon graft, leading to death has evolved in 2 (1.8%) patients in the stage of development of methods of reconstructive-restorative surgery. At the present, it is threatening complication because of the proven method, formation of colon graft does not occur. In 2 cases the cause of death was pulmonary embolism. 5 (2.7%) patients died after esophagogastroplasty for the same reasons. Deaths were recorded up to the year 2000.
Discussion. In conclusion, we want to emphasize that the surgical treatment of post-burn scar obstruction of the esophagus, requiring total replacement of the affected organ, remains a challenge. There is now a need to further explore the immediate and long-term results of the two methods esophagocoloplasty and esophagogastroplasty. Regarding esophagogastroplasty, it is an effective and reliable method for the treatment of patients with post-burn scar strictures of the esophagus, coupled with the relatively no high number of postoperative complications and low mortality. If it is
impossible to use the stomach for esophagoplasty, artificial esophagus should be formed from colon intestine, preferably the left half which is more favourable for angio-architectonics, also the advantage of intestinal graft is the formation of plastics of any desired length. Now, we make extensive use of shunt esophagogastroplasty without removing the esophagus, in situations when a large part of the esophagus is obliterated in the scarring process and when size of the stomach allows to perform a given volume of intervention. As a consequence, aggressive of surgery has significantly reduced, and functional results are encouraged. Although, it requires further observation.
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