Comparación de vía mediastinal posterior versus vía retroesternal para el reemplazo de esófago con ascenso gástrico parcial. Motivo de un cambio de estrategia / Comparison of posterior mediastinal versus retrosternal route for esophageal replacement with partial gastric pull-up. Rationale for a change in strategy

Introducción: existen dos rutas para realizar el reemplazo de esófago (RE), la retroesternal (RRE) y la mediastinal posterior (RMP). El objetivo del estudio es comparar los pacientes que recibieron un ascenso gástrico parcial empleando estas dos rutas. Material y métodos: Se revisaron las historias clínicas de 51 pacientes con ascenso gástrico parcial, en 27 años en el Hospital Garrahan. Se utilizó la vía RRE en 25 casos y la RMP en 26. Fueron comparados los datos epidemiológicos de los grupos y las variables para valorar la dificultad del acto quirúrgico, evolución inmediata y alejada. El estudio es comparativo, retro-prospectivo y longitudinal. Resultados: las características generales de los pacientes fueron similares. Los que recibieron el ascenso gástrico por vía RMP presentaron una menor incidencia de dehiscencia (p=0,017), de enfermedad por reflujo gastroesofágico (ERGE) (p=0,001) y de dumping (p=0,0001). No hubo diferencias estadísticamente significativas entre los dos grupos al comparar la duración del procedimiento, días de internación total y en Unidad de Cuidados Intensivos (UCI), días de permanencia en asistencia respiratoria mecánica (ARM), inicio de alimentación oral y estenosis de la anastomosis. Se observó una tendencia clínicamente relevante, que no alcanzó significancia estadística en las complicaciones intraquirúrgicas y número de dilataciones postoperatorias. No hubo necrosis del ascenso. Fallecieron 2 pacientes. Conclusiones: considerando la menor incidencia de dehiscencia, ERGE y dumping reemplazados por RMP, elegimos a ésta como nuestra primera opción para el reemplazo esofágico en la infancia (AU)

Introduction: The two routes for esophageal replacement (ER) are retrosternal (RRE) and posterior mediastinal (PMR). The aim of the study was to compare patients who received a partial gastric pull-up using either of these two routes. Material and methods: The clinical records of 51 patients who underwent partial gastric pull-up over 27 years at the Garrahan Hospital were reviewed. The RRE route was used in 25 and the RMP in 26 cases. The epidemiological data of the groups and the variables to evaluate the complexity of the surgical procedure, and shortand long-term outcome were compared. A comparative, retroprospective, and longitudinal study was conducted. Results: the general characteristics of the patients were similar. Those who underwent gastric pull-up via PMR had a lower incidence of dehiscence (p=0.017), gastroesophageal reflux disease (GERD) (p=0.001), and dumping (p=0.0001). No statistically significant differences were found between the two groups when comparing the duration of the procedure, days of total hospital and intensive care unit (ICU) stay, days on mechanical ventilation (MV), initiation of oral feeding and stenosis of the anastomosis. A clinically relevant trend, which did not reach statistical significance, was observed in intraoperative complications and number of postoperative dilatations. There was no necrosis of the pull-up. Two patients died. Conclusions: considering the lower incidence of dehiscence, GERD, and dumping associated with PMR, this was our first choice for esophageal replacement in infancy (AU)

Twenty-Four Hour pH Study and Manometry in Gastric Esophageal Substitutes in Children / 대한소아소화기영양학회지

PURPOSE: Studies on the physiology of the transposed stomach as an esophageal substitute in the form of a gastric pull-up or a gastric tube in children are limited. We conducted a study of motility and the pH of gastric esophageal substitutes using manometry and 24-hour pH measurements in 10 such patients. METHODS: Manometry and 24 hour pH studies were performed on 10 children aged 24 to 55 months who had undergone gastric esophageal replacement. RESULTS: Six gastric tubes (4, isoperistaltic; 2, reverse gastric tubes) and 4 gastric pull-ups were studied. Two gastric tubes and 4 gastric pull-ups were transhiatal. Four gastric tubes were retrosternal. The mean of the lowest pH at the midpoint of the substitute was 4.0 (range, 2.8–5.0) and in the stomach remaining below the diaphragm was 3.3 (range, 1.9–4.2). In both types of substitute, the difference between the peak and the nadir pH recorded in the intra-thoracic and the sub-diaphragmatic portion of the stomach was statistically significant (p < 0.05), with the pH in the portion below the diaphragm being lower. The lowest pH values in the substitute and in the remnant stomach were noted mainly in the evening hours whereas the highest pH was noted mainly in the morning hours. All the cases showed a simultaneous rise in the intra-cavitatory pressure along the substitute while swallowing. CONCLUSION: The study suggested a normal gastric circadian rhythm in the gastric esophageal substitute. Mass contractions occurred in response to swallowing. The substitute may be able to effectively clear contents.

The Usefullness of Gastric Pull-Up Reconstruction in Advanced Hypopharyngeal Cancer Surgery / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Various methods of reconstruction have been used after resection of hypopharynx. This study is aimed to evaluate the results and usefullness of gastric pull-up reconstruction. SUBJECTS AND METHOD: The clinical data of 12 hypopharyngeal cancer patients, who were treated with gastric pull-up primary surgery (9 patients, 75.0%) or with salvage surgery (3 patients, 25.0%) after radiotherapy with or without chemotherapy, were studiedfrom 1987 to 2002. This study was a retrospective review of 12 patients (8 males and 4 females, mean age 57.3 years). RESULTS: Nine (75.0%) patients were stage IV and 3 (25.0%) patients were stage III. Total pharyngolaryngoesophagectomies were performed and reconstructed by gastric pullup. Five year survival rate was 57.7%. Five patients died of locoregional recurrence or distant metastasis and 3 patients were lost. The mean time forthe initiation of oral feeding was 32.2 days (range 23 to 58 days). Postoperative complications were hemothorax (1), fistula (2), stenosis (1), hypocalcemia (1), and regurgitation (2). There was no flap failure. CONCLUSION: Although gastric pull-up after resection of advanced hypopharyngeal and cervical esophageal lesions has morbidity and mortality of a combined abdominal, thoracic and cervical operation, flap failure rate is relatively low compared with free flap reconstructions such as jejunal free flap, myocutaneous free flap (radial forearm free flap or anterolateral thigh free flap). Gastric transposition constitutes relatively safe and effective method of restoring the continuity of the upper digestive tract following surgery of extensive carcinoma of the hypopharynx, larynx, and cervical esophagus.

Use of the Stomach as an Esophageal Substitute after Total Pharyngolaryngoesophagectomy for Treating Cervical Esophageal Cancer or Hypopharyngeal Cancer

PURPOSE: The aim of this study was to analyze the post operative outcome of reconstruction with using the stomach after performing total pharyngolaryngoesophagectomy in patients with hypopharyngeal cancer or cervical esophageal cancer. MATERIALS AND METHODS: We conducted a retrospective chart review of 23 patients who underwent gastric pull up for esophageal substitution at the Department of Surgery, Yonsei University College of Medicine, between January 1991 and December 2006. All the patients had transhiatal esophagectomy performed without thoracotomy. RESULTS: There were seventeen males and six females with a median age of 58.1 years (range: 40-70 years). 19 cases were hypopharyngeal cancer, 13 cases had cancer in the pyriform sinus, 15 cases had cancer in the postcricoid area and one case had cancer in the glottic area. The rest were cervical esophageal cancers. The pathologic result was squamous cell carcinoma in all cases. The median total follow-up period was 33 months (range: 1-62 months) and there were two (8.6%) postoperative deaths: one was due to carotid rupture and the other was due to hepatic failure with liver metastasis. The complications were leakage in 1 patient (4.4%), pneumothorax in 1 patient (4.4%) and pneumonia in 1 patient (4.4%). CONCLUSION: The use of stomach for esophageal reconstruction has many benefits for treating hypopharyngeal cancer or cervical esophageal cancer, So, we made sure there was a sufficient length for the anastomosis after pharyngolaryngoesophagectomy and a rich blood supply from the stomach. There was a low incidence of the leakage at the anastomotic site, along with a low incidence of stenosis and bleeding.

Reconstruction of Hypopharynx and Cervical Esophagus Using Reversed Gastric Tube Procedure / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Among various reconstructive methods of hypopharynx and esophagus, stomachs are widely used in total esophagectomized cases. Reversed gastric tube procedure is different from gastric transposition (gastric pull-up) and the procedure was rarely reported. Present study was undertaken to evaluate the complications and results of reversed gastric tube procedure. MAERIALS AND METHODS: A retrospective analysis was carried out on the results of reversed gastric tube procedure for the reconstruction of pharynx and esophagus at Inha University Hospital from June 1996 to January 1998. Reversed gastric tube procedure was performed in six patients ; three patients with hypopharyngeal cancer, two patients with thyroid cancer and one patient with esophageal cancer. RESULTS: The success rate of the transferred gastric tube was 100%. Most common complication was pulmonary complication which was treated conservatively. There was no other serious complications. Oral feeding was well tolerated within two weeks by all except for one patient in whom intestinal obstruction occurred. One thyroid cancer patient who received manubriosternotomy and upper mediastinal dissection died 6 days following the surgey because of great vessel hemorrhage in the mediastinum. CONCLUSION: We concluded that the reversed gastric tube procedure was a safe method of reconstruction for patients with extensive tumors involving the cervical esophagus and requiring total esophagectomy.