A new philosophy in esophageal reconstruction with colon. Thirty-years experience.

The author reports a personal series of 347 patients with colon interposition grafting as an esophageal substitute, the majority of them carried out for corrosive pharyngoesophageal strictures (284) followed by malignancy (54). A personal philosophy is exposed, based on increased flexibility in the choice of the type of colic interposition depending on the pattern of blood supply. This mobile policy called 'balanced operation' is opposed to the classic rigid approach based on the use of a single procedure of esophagocoloplasty. The author's choice is the ileocecum with long ileal loop (65 cm), favoring preservation of the ileocecal valve, and conferring an antireflux mechanism. In particular cases the cecum may be removed and an ileal graft carried out. If this arrangement is not feasible one should slide toward the left in a clockwise direction performing a left colon interposition (iso- or antiperistaltic). Overall mortality was of 16 cases (4.6%). Morbidity is analyzed and different particular arrangements like continuous colic loop, superlong graft, Roux-en-Y procedure are described. A general outline of pharyngeal reconstruction in corrosive strictures is presented.

[A new concept in esophageal reconstruction with colon (considerations on 329 operated cases)]. / O noua conceptie în coloesofagoplastie (consideratii pe 329 de cazuri operate).

The author reports a personal series of 329 cases of coloesophagoplasty from various etiology, the majority of them carried out for corrosive pharyngoesophageal strictures (276), followed by malignancy (44). A personal philosophy is exposed, based on more flexibility in the choice of the type of colic interposition depending on the pattern of blood supply. This mobile policy called "balanced operation" is opposed to the classic rigid approach based on the use of a single procedure in coloesophagoplasty. His choice is the ileocecum with long ileal loop (65 cm), favoring preservation of the ileocecal valve, and confering an antireflux mechanism. In particular cases the cecum may be removed and an ileal graft carried out. If this arrangement is not feasible one should slide toward the left in a clockwise direction performing a left colon interposition (iso- or antiperistaltic). Overall mortality was of 16 cases (4.9%). Morbidity is analysed and different particular arrangements like continuous colic loop, superlong graft, Roux en Y procedure are described. A general outline of pharyngeal reconstruction in corrosive strictures is presented.

[Results of the surgical treatment of severe caustic pharyngo-esophageal stenosis. The value of complete reconstruction of the pharynx by transposition of the ileum and colon]. / Résultats du traitement chirurgical des sténoses caustiques graves pharyngo-oesophagiennes. Intérêt de la reconstruction totale du pharynx par transposition de l'iléon et du côlon.

STUDY AIM: The aim of this study was to report the results of pharyngoesophageal reconstruction in extensive corrosive strictures and to describe an original conception concerning extensive chemical burns of the pharynx with involvement of the epiglottis, oro-hypopharyngeal junction and cricopharyngeal pinchcock. PATIENTS AND METHODS: A personal series of 253 esophageal reconstructions using the colon and ileum is reported. In 124 patients, the cervical anastomosis of the graft was performed at the level of the pharynx, and these cases with extensive pharyngeal lesions were the basis of this study. The anastomosis was performed with the hypopharynx in 27 patients, with the oropharynx in nine and a total reconstruction of the pharynx or "pharyngoplasty" was carried out in 69 patients. The pharyngoplasty was classified according to the approach, in anterior, posterior, lateral, superior (transmandibular) and inferior. In high strictures with epiglottic injury, epiglottectomy was necessary in order to prevent recurrence. A visceral pharyngoplasty was performed in 61 patients, using the colon in 42 and the ileum in 19, a skin reconstruction in six patients and a myocutaneous flap in two. RESULTS: The global postoperative mortality rate was 4.7%. Stenosis of the cervical anastomosis occurred in 4.9% of the whole series. With a follow-up from 6 months to 10 years, 70% of the patients resumed a normal oral diet, 21% had mild symptoms and 7% had poor results (patients with tracheostomy and gastrostomy). CONCLUSION: Extensive chemical burns of the pharynx are very severe and their treatment very difficult. For the author, total visceral pharyngeal reconstruction is considered to be the procedure of choice, using ileopharyngoplasty with realization of an ileal pouch. Good results were obtained in 70% of the patients with extensive corrosive strictures.

Stenosis of the esophagus in cicatricial pemphigoid resolved by colon interposition: report of a case.

We present herein the exceedingly uncommon case of a patient with cicatricial pemphigoid (CP) who gradually developed conjunctival, oral, and esophageal involvement. Despite long-term medical management with dapsone and disulone, the ocular lesions progressed to produce further scarring, which led to ankyloblepharon, symblepharon, and ultimately, blindness of the right eye. After a period of 5 years the patient developed a total esophageal stricture, intractable by dilation, necessitating esophageal reconstruction. The details of an original procedure using a continuous colic loop are described, highlighting the better tolerance of this technique by a high-risk patient. A discussion on the recent advances in diagnosing bullous dermatoses is presented following this case report.

The stimulation of fibronectin synthesis by high peak power electromagnetic energy (Diapulse).

The effect of Diapulse therapy (pulsed electromagnetic energy of 27.12 MHz frequency) on post-operative wound healing and plasma fibronectin concentration is investigated. Patients treated with Diapulse, locally and over hepatic area present higher fibronectin levels starting 3d day after surgery. These higher values correlate well with a clear improvement of wound healing processes.

[Hemorrhages occurring in reconstructive surgery on the pharynx and cervical esophagus]. / Hemoragiile survenite în chirurgia reconstructiva a faringelui si esofagului cervical.

The author presents 28 cases of cervical hemorrhages occurring in 235 cervical esophagoplasties (11.9%), generated by the lesion of the transplant vessels or of the vessels of the cervical area. The late postoperative hemorrhages are the most severe ones, often cataclysmic (eight cases with five deaths, 62.5%) being mainly the result of the primitive carotid erosion by a salivary fistula. In two cases the cataclysmic hemorrhage appeared after a simple cervical junction for a benign stenosis, a situation not yet mentioned in the literature. The double ligature of the primitive carotid is the only efficient method. Used in four cases, it was successful in three of them, with a single case of tardy hemiplegia following a rachianesthesia.

About reconstruction of the pharynx with colon in extensive corrosive strictures.

The author presents a series of 235 esophagocoloplasties, in 90 cases a pharyngeal reconstruction being performed. The colic graft was anastomosed to the hypopharynx in 43 cases, to the oropharynx in 14 cases, and in 33 cases a pharyngoplasty was done. A personal classification of the approach of the pharynx according to local innervation is attempted, and various original procedures of pharyngeal reconstruction are described (double pharyngoplasty "en Y", pharyngoplastia "vera"). A great effort was made in preservation of the larynx, which remains the main aim of the author.

[Total duodenal diversion in reflux esophagitis after colic esophagoplasty]. / La diversion duodénale totale dans l'oesophagite de reflux après l'oesophagoplastie colique.

Five patients with severe reflux esophagitis were treated by retrosternal colic esophagoplasty for esophageal stenosis of caustic origin. In 4 cases there was anisoperistaltism and in one case isopersitaltism. Treatment was by antral cologastric anastomosis in all cases, with a undojejunostomy in 3 patients and a colojejunostomy on loop in Y in the 2 others. Mortality was absent and long-term results were very good. Colojejunostomy on loop in Y is a simpler procedure not requiring gastric resection and long-term results were similar. An even less complicated variant of the latter operation that does not require colic section is also described. Prophylaxis of reflux esophagitis after colic esophagoplasty is discussed, the Roux type deviation being proposed for the treatment of cologastric ulcer after esophagoplasty.

[Double Y pharyngocolostomy. An original procedure]. / La pharyngo-colostomie double en Y. Procédé original.

An original procedure is presented which involves cervical anastomosis after colic esophagoplasty, allowing double drainage of pharynx. As a function of permeability of esophagus, two variants are described: "esophagopharyngocolostomy in Y" and "double pharyngocolostomy in Y". The operation is performed as either a one-stage (immediate) or, more frequently a two-stage procedure: to correct tracheal reflux after high pharyngocolic anastomosis (with oropharynx); in low end-to-side esophagocolic stenosis with colic tube in excess and in narrow caliber sclerous esophagus. This method was used in 6 cases of post-caustic esophageal stenosis with very good long-term results. The method is an anti-reflux procedure which also ensures prophylaxis of recurrent stenosis of the cervical anastomis.

[Total "pharyngoplastia vera" with the colon in caustic pharyngo-laryngeal stenoses]. / "Pharyngoplastia vera" totale avec côlon dans les sténoses pharyngo-laryngiennes caustiques.

An original procedure for pharyngeal reconstruction with colon in pharyngolaryngeal stenosis due to chemical burns has been named "pharyngoplasty vera" by the authors, since the 3 walls of the pharynx are reconstituted by lining it with visceral material. This is in contradiction with previously used techniques in which the graft caps the pharyngostomy produced by resection of scar tissue (pharyngovisceral anastomosis). The procedure generally respects the principles of conventional cutaneous pharyngoplasty--similar approach, extirpation of scar tissue, epiglotto plasty, conservation of constrictor muscles and above all, solid attachment of visceral material to the latter, and finally suture of the colon at the base of tongue and closure of pharynx. The method was used in a patient who regained deglutition rapidly, but the insufficient glottic space did not allow reopening of the canal.

[Peptic ulcer of the cologastric anastomosis in esophagoplasties]. / L'ulcère peptique de l'anastomose côlo-gastrique dans les oesophagoplasties.

Two cases of cologastric anastomotic peptic ulcer after esophagoplasty for stenosis from caustic burns are reported, one developing 2 1/2 years and the other 12 years after operation. One case was treated by complex gastrocolic resection and the other by distal gastrectomy with ulcer excision and retrimming of the cologastric anastomosis. Long-term postoperative results were good. The different surgical procedures reported in the literature are discussed, and the value of combined gastrotomy and exploratory colotomy for detection of lesion extension emphasized. The preferred method is complex cologastric resection with conservation of the stomach in the digestive circuit.