[Reconstructive surgery of the oesophagus. Possibilities and organization]. / Rekonstruktivna hirurgija jednjaka.

For a number of anatomical and pathological reasons, reconstructive surgery of the oesophagus remains a difficult and complex surgical procedure. The vast experience of performing 1155 reconstructive surgical procedures at Prva hirurska klinika (First surgical clinic), part of Belgrade Medical Faculty, enables the author to reflect upon options and limitations of such operations. There is a considerable discrepancy between the results obtained from reconstructive surgery of the oesophagus and the cardia affected by malignant growths, and form treatment of benign strictures of the oesophagus--the latter producing significantly better results. Digestive tract tissue used in the reconstructive surgery, is applicable depending on the pathological condition, its location, the possibility of isolating a sufficiently long section, and its adequate vascularization. Best results were achieved when a segment of thejejunum was used, but only for distal lesions of the oesophagus. Good results were achieved also when segments of the colon were used, the left colon proving more useful than the right one. Stomach tissue produced the worst results in a series of reconstructions, because it was used primarily in cases where the oesophagus was affected by malignant growths. When comparing the data from this series with the findings from the world literature, we come to almost identical results as in cases of reconstructive surgery of the oesophagus affected with carcinoma. Our experience in reconstructive surgery treatment of benign lesions of the oesophagus produced consistently better results that those shown in reputable foreign statistics.

[Correction of failed primary surgical interventions in benign lesions of the esophagus]. / Korekcija neuspelih primarnih hirurskih intervencija kod benignih lezija jednjaka.

In an retrospective analysis of documentation and printed paper in period between 1964-1998 168 patients required reoperations in benign esophageal lesions. Failed initial interventions were found in 66 (39.28%) pts. operated in our clinic and 102 (60.71%) pts operated in other institutions in our country. The corrective procedure was possible in 140 (83.33%) pts and impossible in 11 (6.54%). Post-operative mortality was 7.73% so the definitive failed corrections were 14.27%. The main cause of failure were: Defective operative technique, wrong preoperative diagnosis and indications including inadequate initial procedure. Among the 168 pts undergoing corrective surgery, more than a half of pts had obstructive lesions requiring resections and reconstructions. Dilatation of the stricture was possible in 16% followed by total diversion, particularly in previous gastric surgery. Malignant degeneration of benign lesions were found in 10.71%. Only 4 pts (2.3%) refused suggested operations. Satisfactory long-term results especially in patients undergoing esophageal corrective reconstructions for benign diseases were good to excellent in regular yearly postoperative routine control examination.

[Esophagus preserving surgery--eversion and mucosal stripping]. / Postedna hirurgija jednjaka--everzioni i mukozni stripping.

The eversional stripping and esophageal mucosal stripping methods as standard procedures in the preserving esophageal surgery are presented in this paper. These procedures have indication limit and results are excellent in selected risk dependent group of patients. This review describes technique, indications and advantages of these techniques in comparision with conventional finger esophageal dissection.

[Surgical treatment of cardial carcinoma]. / Hirursko lecenje karcinoma kardije.

In the period from 1970 to 1996, in the Departmenf of Esophagogastric Surgery, Belgrade, Yugoslavia 562 have been operated with curative intent due to cardiac carcinoma. Since 1970 until 1985, in 182 patients a distal esophagectomy and proximal gastrectomy followed by eosphagogastro anastomosis had been performed. In the period between 1982 and 1996, a distal esophagectomy with total gastrectomy and radical or extended radical dissection and intrathoracic esophagojejuno anastomosis in 380 patients (192 hand sewn 3/0 interrupted sutures and 188 spapled anastomosis) had been performed. In our opinion for the majority of patients with advanced cardiac carcinoma distal esophagectomy and total gastrectomy, via the left thoracoabdominal approach, with D2 pancreas preserving splenectomy and dissection of lymph nodes in stations 16a1 and 16a2 is a surgical therapy of choice. Overall complications of such a procedure not differ in type and number from those after standard total gastrectomy and D2 dissection.

[Overview of reconstructive surgery and functional compensation in the digestive tract]. / Osvrt na rekonstrukciju i kompenzaciju funkcije digestivnog trakta.

This paper represents a short and overall overview of the reconstructive procedures of the esophagus, stomach, colon and rectum. Optimal reconstructive procedure has not been chosen only for the reconstruction of the digestive system. Precise selection of the patients and reconstructive methods must enable the correction of the possible functional disadvantages. Usage of adaptional and reserve possibilities of other organs and tissues will help the functional compensation of the lost segments of the digestive system. The understanding of the importance of the physiological approach to the reconstruction of the digestive system using the segments of stomach, jejunum or colon is of the most importance so that in this difficult segment of surgery adequate improvements can be achieved.

A paraesophageal bronchogenic cyst with esophageal communication.

Paraesophageal bronchogenic cysts are a rare developmental anomaly of the upper digestive tract. Although often asymptomatic, their growth can cause severe symptoms and complications because of the location. The diagnosis is difficult and is mostly by histopathologic findings after extirpation of the cyst. The authors present a case of a paraesophageal bronchogenic cyst, of typical histologic structure (ciliated epithelium and hyaline cartilage) connected with the esophageal lumen by a narrow canal composed of stratified squamous epithelium. According to the available literature, only three cases of bronchogenic paraesophageal cysts with esophageal communication have been reported.

[Leiomyoma of the esophagus. Case report]. / Leomiom jednjaka. Prikaz bolesnika.

Of all oesophageal tumours benign tumours account for less than 10%, of which 4% are leiomyomas. These tumours are most frequently asymptomatic, mostly localized in the lower oesophageal third. The most frequent symptoms, if any, are the following: dysphagia, unspecific retrostemal pain, heartburn, and occasionally, weight loss. Tumour enucleation is a therapy of choice in patients with oesophageal leiomyoma. In case of successful surgical removal, the prognosis is good and complains are practically eliminated. A male patient, aged 53, with paroxysmal tachycardia, in whom transhiatal enucleation was carried out in order to remove a large oesophageal leiomyoma after which cardiac complains were eliminated, is reported.

Modification of the Merendino procedure.

The jejunal interposition operation after resection of distal esophagus and cardia, designed by Merendino and Dilard, has not been widely employed until now. The complexity of the procedure, demanding high performance, and still unacceptable postoperative mortality, were limiting factors and a challenge for many surgeons. The aim of this paper is to present three modifications of the original technique, without changing the basic concept of the Merendino procedure. These modifications differ from the original technique in three main ways: the longer isoperistaltic jejunal segment, the terminolateral mechanical esophagojejuno anastomosis, and the placement of the lower jejunogastric anastomosis on the posterior wall of the stomach. This report comprises an experience in 29 patients operated on in period 1972 through 1995. There were two postoperative deaths and long-term results were excellent in all except one patient who had an ischemic stenosis of the transplanted jejunal segment. Despite this, the Merendino procedure, simplified by these modifications, deserves to be more frequently used in the treatment of undilatable or recurrent strictures and other benign lesions which require resection of the distal esophagus and cardia.

[Paraesophageal hiatal hernia of the diaphragm]. / Paraezofagealne hernije hijatusa dijafragme.

Paraesophageal hernia (type II hiatal hernia) accounts for less than 5-10% of all herniation through the esophageal hiatus. Anatomically, it is distinguished from the more common sliding variety (type I hiatal hernia) by the position of the gastroesophageal junction. The management of paraesophageal hiatal hernia is influenced by the tendency of the herniated stomach to develop volvulus, which potentiates life-threatening complications that include complete gastric obstruction, bleeding, infarction and perforation. In a cases with gastroesophageal reflux one of the antireflux procedures had to be done. In the Institute of Digestive Diseases, in the 16 years period from 1980-1996, 37 patients had treated of paraesophageal hernia. Authors discuss their management strategies, especially the using of antireflux procedures.

[Surgical treatment of achalasia]. / Operativno lecenje ahalazije.

A total of 356 patients were treated for achalasia during a thirty eight years period, ranging from 1955 to 1993 the author presents his results and therapeutic recommendations. Since 1970, patients were treated in a standardized manner, using the transabdominal approach in 85,71% patients and the transthoracic approach in 14,29% pts. The operative technique for cardiomiotomy is described in detail for both approaches. To achieve good postoperative result it is necessary, to perform complete miotomy in a length of 6-8 cm. The miotomy should extend no less than 2 cm onto the stomach. All circular muscle fibers of the esophageal muscular layer should be severed. Antireflux procedure was added in all 294 patients operated since 1970. The demonstrated Dor fundoplication was done for a transabdominal approach and the Belsey mark IV antireflux procedure for the transthoracic approach. Reflux esophagitis was found in 12,82% of patients postoperatively while esophageal stricture in only 1,5% patients. In another group of 49 patients operated prior to 1970 postoperative check-up demonstrated the reflux esophagitis in 35,13% and an esophageal stricture in 5,4%. Antireflux procedure is an additional but important procedure in the treatment of achalasia. Inappropriate indications and an inadequate technique result in severe complications. Different approaches in the surgical management of achalasia are discussed.

Paraoesophageal hernia repair with and without concomitant fundoplication.

There is currently no consensus as to whether an antireflux procedure should accompany surgical repair of paraoesophageal hernia. Forty consecutive patients with paraoesophageal hernia were studied. Surgery routinely included transabdominal hernia reduction, excision of the sac and crural repair. The addition of fundoplication was based on the presence of preoperative endoscopic evidence of oesophagitis. Twenty-three patients without endoscopic oesophagitis had no antireflux procedure whereas 17 with oesophagitis underwent concomitant antireflux surgery. Thirty-six patients were followed for 1-7 years. Patients without endoscopic oesophagitis had no postoperative reflux problems. All patients with oesophagitis who underwent fundoplication were improved or cured of reflux. The selection of patients for antireflux repair can satisfactorily be based on preoperative endoscopic findings.

Prevalence and clinicopathologic features of multiple squamous cell carcinoma of the esophagus.

BACKGROUND: The occurrence of independent synchronous esophageal carcinoma in patients with grossly invasive esophageal cancer (GEC) is well known. Although multiple primary carcinoma of the esophagus is not uncommon, the exact prevalence is controversial, and its clinicopathologic features remain relatively unknown. METHODS: Fifty-four patients with squamous cell GEC who underwent transthoracic esophagectomy with systematic lymphadenectomy between 1987 and 1991 at the Institute for Digestive Diseases, Belgrade University Clinical Center, were included in the study. RESULTS: Detailed histopathologic examination of the esophagus resected for squamous cell carcinoma was performed in 54 patients and revealed 17 patients (31%) with associated cancer independent of the main tumor. The second lesion was significantly less invasive than the main tumor. There was no significant difference (P = 0.06) in sex, age, main tumor site, tumor differentiation, tumor diameter, lymph node involvement, or tumor stage between patients with multiple cancer and patients with solitary cancer, but there was a significant difference in the depth of invasion (P < 0.01). The tumor stage in patients with multiple cancer was determined by the main tumor stage and was not influenced by the associated lesion. The prevalence of multiple primary cancer of the esophagus is lower in other reports than in this series. CONCLUSIONS: The patients in this study had significantly more invasive main tumors. It seems likely that a higher prevalence of multiple cancer may be expected in patients with advanced main tumor penetration. These results support the concept that the entire esophagus may be considered as one entity of field cancerogenesis.

[Limited or extensive surgery in gastric carcinoma?]. / Ogranicena ili ekstenzivna hirurgija karcinoma zeluca?

Although the incidence of gastric cancer has dropped it is still the most frequent carcinoma of dhe digestive tract. Surgical management of gastric carcinoma was always dependent on the stage of the disease. Contemporary knowledge of gastric lymph drainage and attempts to remove metastatic glands with the tumor gave rise to more optimism. In the beginning such and approach did not fulfill expectations, but during the past decades, especially in Japan, it became evident that more aggressive and extensive surgical procedures could benefit certain groups of patients. In order to asses this new approach it is necessary to have a unique TNM classification and to perform a rigorous and systematic identification of cancer metastasis in the lymph nodal system of the stomach. Comparison of partial gastric resection with limited standard lymphadenectomy to total gastrectomy with extensive lymphadenectomy is not possible. Nevertheless, patients with gastric cancer stages Ib, II and IIIa profit from more extensive surgery. The author present the modifications in the extent of surgical procedures for the management of gastric cancer. Special emphasis is drawn to the surgical technique and results of systemic extensive lymphadenectomy. The author has demonstrated the benefits of the new extensive surgical approach in he management of gastric cancer in his series. Operative mortality in the group of patients after systemic lymphadenectomy was 6.7% and the 5-year survival rate was 21.0%. In the group of patients where gastric resection with standard lymphadenectomy was performed postoperative mortality was 14.0% and the 5-year survival was only 5.3%.

[Complications in esophagojejunal anastomosis]. / Komplikacije pri izvodenju ezofagojejuno anastomoza.

In the period between January 1, 1982 until December 31 1993, in the Center for Esophageal Surgery, Institute for Digestive Disease - 1 st Surgical clinic in Belgrade, 345 esophago-jejuno anastomosis (EJA) were performed. In 326 pt's EJA, with the Roux-en-Y reconstruction with the segment of the small intestine, was performed after a total gastrectomy due to a malignant disease of stomach or cardia and in 7 due to an extensive corrosive changes of the stomach. In 12 pt's a resection of the distal esophagus due to an undilatable stricture and the reconstruction with the short segment of the small intestine (Merendino) was performed. In all 345 pt's a terminolaternal EJA was performed. In 149 pt's EJA was done mechanically by staplers (e.g., the EEA instrument) and in 196 an interrupted two layer suture was performed. In 326 pt's (operated due to a malignant disease) complications occurred in 29 of them (8.89%) while in the group of patients with benignant disease only in 2 pt's or 10.52%. A dehiscention of EJA occurred only in the group of pt's with malignant disease. Comparing the way of performing EJA a higher percentage of anastomotic leaks was found in the group of hand sewn anastomosis (18/8.16%) while in the group with a stapler performed anastomosis anastomotic leak was found only in 7 pt's (4.69%). In two pt's where a stapler anastomosis was performed there was a hemorrhage from the anastomosis during the operation, and in 8 pt's or 5.36% an unsuccessful anastomosis using a stapler was performed. Overall mortality was 6.66% or 23 pt's. Due to anastomotic leak 13 pt's died (3.76%). In 5 pt's 4 to 14 months after the operation a stenosis of anastomosis developed on EJA that severely compromised EJA and needed further medical treatment. None of the pt's was reoperated.

[Advantages and disadvantages of esophagogastroplasty in reconstruction of malignant and benign esophageal stenosis]. / Prednosti i nedostaci ezofagogastroplastike u rekonstrukciji malignih i benignih stenoza jednjaka.

Advantageous morphology, sufficient blood supply and good tissue quality predispose use of stomach for ideal substitute in subtotal and total esophagoplasty. Additional advantages are one act surgery and possibility of single anastomosis formation. In an eighteen years' time, since 1976., two hundred nine (209) patients were operated with use of esophagogastroplasty for malignancies and benign diseases of esophagus and hyphopharinx. The esophagogastric anastomosis is most common reconstructive procedure for esophageal and hyphopharingeal malignancies. Anastomosis on pharyngeal level was made in 13 pts., on cervical esophagus level in 168 pts. and on thoracic esophagus level in the rest of 28 pts. Overall postoperative morbidity was 25,36%. Most common complication was anastomotic dehiscence (18,66%), transplant necrosis occurred in 2% of pts., whereas stenosis of the anastomosis was observed in 4,78% of pts. Overall intrahospital mortality was 14,38%, while specific mortality (anastomotic dehiscence and/or transplant necrosis) was 10,04% (21 pts.), whereas nonspecific mortality (predominantly lung insufficiency) was 4,78% (10 pts.). Anastomotic dehiscence is major disadvantage of this method.

[Primary suture of the esophagus with reinforcement using autologous tissue in the therapy of perforation of the thoracic esophagus]. / Primarna sutura jednjaka sa pojacanjem autolognim tkivom u terapiji perforacije torakalnog jednjaka.

Perforations of the esophagus are the serious problem and only promptly diagnosis and treatment with effective operation can change the fatal destiny of this patients. The most effective operations of early diagnosed perforations are the primar suture with buttresses with circumferential wrap of parietal pleura. Authors discuss 15 patients with perforations of thoracic esophagus. In six patients the perforation was only sutured, and in nine patients the suture line was buttressed with Grillo pleural wrap. In this group one patient had a leak at the suture line and died after reoperation. This data indicate that the pleural wrap should be used routinely.

[Anastomosis suture technic and complications of esophagocoloplasty in corrosive lesions]. / Tehnika sivenja anastomoza i komplikacije kod ezofagokoloplastika zbog korozivnih lezija.

For the reconstruction of the esophagus due to a corrosive stenosis a colon transplant is usually used. In all esophagocoloplastics three anastomosis are necessary: anastomosis that continues the alimentary tract, anastomosis of the distal part of transplant with the stomach or duodenum, and the most important proximal anastomosis of the esophagus (or pharynx) with the transplant. In the period of 29 years (from January 1, 1964 until December 31, 1993) on the Institute for digestive diseases in Belgrade 250 esophagocoloplastics were performed with 750 anastomosis, in the patients with corrosive stenosis of the esophagus. All the anastomosis are sewn in two layers with the interrupted or continuous stitch, except for the anastomosis with the pharynx where due to a structure of the wall a one layer continuous stitch was only possible. From 750 anastomosis in 30 patients or 4% an anastomotic leakage occurred and in only 4 patients or 0.5% it ended lethaly. Stenosis of the anastomosis occurred in 18 patients or 2.4%.