Functional and mechanical sequelae of colon interposition for benign oesophageal disease.

OBJECTIVE: In an attempt to estimate the incidence and severity of the functional and mechanical problems associated with colon interposition for benign oesophageal disease, a retrospective analysis of a single centre experience was undertaken. METHODS: Between 1961 and 1990, a total of 365 patients who survived the postoperative stay in hospital were followed up over 7-38 years and form the basis for this study. Upper gastro intestinal symptoms in these patients were investigated clinically, radiologically, endoscopically and in the oesophageal laboratory. Mechanical and functional abnormalities requiring surgical intervention for relief of symptoms were documented. RESULTS: There were two late presentations of colo bronchial fistulae, two instances of persistent colo cutaneous fistulae, three cases of diaphragmatic herniation and two adenocarcinomata of the colo gastric junction in the patients with short segment colon interposition. Amongst the long segment colon interposition patients there was one hiatal obstruction, two thoracic inlet delays associated with pseudo diverticulosis and one hiatal obstruction. One other patient presented with an adenocarcinoma of the intrathoracic colon. There were four patients requiring revision of the cervical oesophago colic anastomosis, two of them on recurrent occasions. The remaining sequelae were functional and were associated with increasing redundancy of the colonic segments at different levels. There were 17 such patients, two of whom developed significant redundancy at two different levels. CONCLUSIONS: Although the patients with short segment colon interposition developed predominantly avoidable iatrogenic complications, those undergoing long segment colon interposition developed functional sequelae requiring re-operations in later life.

Revisional surgery after colon interposition for benign oesophageal disease.

Although the short-term results of colon interposition for replacement of the oesophagus in part or as a whole are known to be satisfactory, there have been several reports of functional problems associated with total replacement in the long-term follow-up of patients. We have retrospectively studied patients who have required revisional surgery for anatomical and functional sequelae over a 7- to 38-year period. Although the short-segment colon interpositions have been relatively trouble free, several mechanical and functional problems requiring revisional surgery have been encountered in the long-term follow-up of patients who underwent long-segment colon interposition.

Palliative management of esophageal carcinoma.

The surgical treatment of esophageal carcinoma is palliative surgery in 90 percent of cases. Much can be done by the motivated surgeon to ease the suffering of the patients and to help them die with dignity. In this context, compassion is more important than surgical statistics. Age, depletion resulting from complications and distant metastases are no longer contraindications to palliative surgery as defined herein.

Gastroesophageal reflux.

The incidence of recurrent reflux is higher than suggested by current reports and will increase when intensive postoperative follow-up becomes routine practice. The designs of all antireflux procedures need critical study and revision. The investigation and management of recurrent reflux demands far more attention than it has received in the past.

Preliminary results of a long myotomy with antireflux procedure for achalasia of the oesophagus.

In most centers the myotomy described by Heller and Zaayer is presently the treatment of choice for achalasia. Scrutinised reports show that the results of this operation are marred by complications. The reason is obvious: an insufficient myotomy may fail to relieve the symptoms of dysphagia and an incision sufficient to relieve obstruction may result in reflex oesophagitis. The technique described by Belsey consisting of a long myotomy combined with an antireflux procedure seems to be superior. The rational of this operation and preliminary results are discussed.

Late results of aortic valve replacement with the Starr-Edwards prosthesis.

Details are presented concerning 59 patients who left hospital between January 1964 and January 1969 after aortic valve replacement with the Starr-Edwards prosthesis. Of the 14 late deaths, 7 are known to have been due to causes related to the prosthesis and 4 to other causes. The 45 surviving patients have nearly all shown clinical improvement and only 3 are unable to work as a result of some complication of the operation. Aortic regurgitation and its consequences appear to be the most significant factor leading to symptoms. In 11 of 16 patients with anaemia there was evidence of intravascular haemolysis. The long-term consequence of this complication is not known.