Colon interposition for benign esophageal disease: experience with 23 patients.

Twenty-four colon interpositions were performed in a group of 23 patients comprising both adults and children between 1965 and early 1982. The indications for operation were caustic injury in 13 patients, peptic stricture in 6, congenital atresia or stenosis in 2, and gunshot or foreign body injury in 2. Long colon segments, consisting of isoperistaltic left colon in seven instances, antiperistaltic left colon in four, and right colon in five, were utilized for 16 procedures in 15 patients. Short segments of left colon were used in 8 patients, isoperistaltic in 6 and antiperistaltic in 2. There were no operative deaths. Ischemic complications necessitated removal of the transplant and replacement with another segment in 1 patient and revision or drainage procedures in 2 others. Strictures of the esophagocolic anastomosis occurred in 6 patients. Five of these strictures occurred among the 13 patients with caustic injury and appeared to be due to unrecognized caustic damage in the esophageal segment used for the anastomosis. Three patients died of unrelated causes eight months to 4 1/2 years after operation, and 3 others were lost to follow-up. Seventeen patients were available for current follow-up 1 to 16 years after operation, including 7 who were followed more than 7 years. When the swallowing ability of these 17 patients was assessed using rigorous criteria, 9 were found to have an excellent to good result; 5, a good to fair result; and 3, a poor result. No patient showed late deterioration of function. We conclude that interposed colon is the ideal esophageal substitute for the patient with benign disease.

Carcinoma of the esophagus: twelve years' experience with a philosophy for palliation.

Twelve years of experience have now been gained with a new therapeutic approach to carcinoma of the esophagus. In this approach, the primary goal of treatment is palliation, with cure an important but secondary objective. Carcinomas in the upper third of the esophagus are treated by radiation therapy unless there is severe obstruction or tracheal invasion, in which case colon interposition is performed. Limited resection with esophagogastrostomy is performed through a right thoracotomy and midline laparotomy for neoplasms in the middle third of the esophagus and through a left thoracotomy for carcinomas in the lower third. Since 1969, 161 patients have been evaluated, of whom 107 (66%) have been managed according to the new protocol. Twenty patients with carcinomas of the upper third of the esophagus were treated primarily by radiotherapy and 7 by colon interposition. Resection was performed in 78 of the 80 patients with carcinomas of the middle and lower thirds. There were 9 operative deaths (10%). Palliation, of superior quality to that obtained by previous methods, was provided to 95 of the 107 patients. Survival also is at least on a par with that obtained before.

Palliation of esophageal carcinoma with intraluminal tubes: experience with 30 patients.

Between 1968 and 1978, 26 patients with carcinomas of the thoracic esophagus and 4 with adenocarcinomas involving the esophagogastric junction were treated by the insertion of indwelling intraluminal (endoesophageal) tubes. Four different types of tube were inserted by the pull-through technique. Thirteen of the 30 patients died in the hospital within 30 days. However, among the 20 patients who did not have neoplasms of the upper third of the thoracic esophagus or who had not had a prior resection, only 5 died. The principal cause of death was aspiration pneumonia. Survival averaged 2.5 months. Four patients survived 5 to 7 months. Deglutition was adequate in most patients but was not as satisfactory as after esophagogastrectomy. Our best results were obtained in patients with carcinoma of the middle or lower third of the esophagus, with or without an esophagorespiratory fistula, who had not had a previous resection.

Carcinoma of the esophagus: experience with a philosophy for palliation.

The preliminary results of a new therapeutic approach to carcinoma of the esophagus were reported in 1972. The primary objective of treatment should be palliation, with cure an important but secondary goal. Lesions in the upper third of the esophagus are treated by irradiation unless there is severe obstruction or tracheal involvement, in which case colon bypass is carried out. Limited resection and esophagogastrostomy is performed through a right thoractomy and midline laparotomy for middle-third lesions and through a left thoracotomy for lower-third carcinomas. Since 1969, 85 patients have been evaluated, of whom 65 (76%) have been treated according to the new protocol. Thirteen patients with upper-third carcinomas were treated primarily by radiation therapy and 6 by colon bypass. Resection was performed in 45 of the 46 patients with middle- and lower-third lesions. There were 5 operative deaths (9.8%). The quality and duration of palliation have been far superior to that achieved by previous methods of treatment and, perhaps surprisingly, survival rates have improved.