Caustic Stricture Research Articles

Traitement par dilatation instrumentale des sténoses caustiques de l’œsophage de l’adulte : étude prospective de 132 cas

IntroductionIngestion of caustic is common, and it causes serious injury. Occurrence of esophageal stricture is a terrible sequel.AimTo evaluate efficiency and security of dilatation with Savary-Gilliard dilator in esophageal caustic stenosis in adults.Patients and methodsThis prospective study included 132 patients during a period of four years. The mean age was 26.7 ± 11 years (16/78). The sex ratio was 0.32. The substance drunken was a strong alkali in 78% and a strong acid in 20%. All the patients underwent an upper gastrointestinal endoscopy and a barium swallow. A severe esophageal stricture was noticed in 74% of the cases, and a gastric stricture was associated in 23%. Dilatation was realized with Savary-Gilliard dilator. The therapeutic results were judged after 12 months.ResultsThe average number of dilatation was 11 ± 8.5 (2/46). Success was observed in 80% and failure in 20% of the cases. Four perforations were recorded.ConclusionThe dilatation with Savary-Gilliard dilator is an efficient, sure, and simple method of treatment in esophageal caustic stenosis. It must be used at first; surgery should be planned in case of failure of dilatation.

Caustic stenosis of the oesophagus at Centre Hôpital D’Université(CHU) of Lome :Epidemiological and therapeutic aspects

Objective: The purpose of this study, was studying of the epidemiological factors and the results of management of these caustic stenosis of the oesophagus.Material And Method: A retrospective study. 38 cases of caustic stenosis of the oesophagus were, admitted and treated at the surgical departments of CHU of Lome, Togo, during the period January 1st1983 to 31st December 2004.Result: The caustic stenosis of the oesophagus represented the second most common oesophageal disease treated at the surgical department [ 38/15153(24.84%)]. 21 were male and 17 female. Caustic soda was the commonest substance ingested (14 cases / 38). Suicide was the most frequent reason for ingestion of caustic substances. The majority of our patients 28(71.05%) had early surgical intervention. The others were managed by endoscopy. The overall outcome was satisfactory in 37 cases. One patient died in this study. After a follow-up of a median of 7 years, four patients re- presented a moderate residual dysphagia.Conclusion: This caustic stenosis of the oesophagus represents a disease with an increasing frequency inside our societies. Adequate measures must be carried out to prevent the caustic burns of theoesophagus among our peoples.

Pediatric Laparoscopic-Assisted Gastric Transposition: Early Experience and Outcomes

astric transposition in children is a well-established treatment for long-gap esophageal atresia and long caustic strictures when preservation of the native esophagus is impossible, but does involve laparotomy and, often, thoracotomy incisions. The minimally invasive approach to this operation has been attempted in 7 patients to date in the UK, all at Great Ormond Street Hospital (London, UK). Four patients were male, 3 were female, with a mean age of 3 years and 7 months (range, 5 months to 13 years). Indications were long-gap esophageal atresia where primary anastomosis was impossible (5 patients) and caustic ingestion with long esophageal strictures (2 patients). The stomach was mobilized laparoscopically by using 5-mm instruments and a pneumoperitoneum of 10 mm Hg. Following pyloromyotomy or pyloroplasty, a tunnel in the posterior mediastinum was developed. The fundus of the stomach was drawn to the neck and sutured to the cervical esophagus. The patients were ventilated on our intensive care unit and then returned to the surgical ward before discharge. Gastric transposition was completed laparoscopically in 6 of 7 patients. The mean duration of surgery was 327 minutes (range, 240-455). All patients survived. Minor complications were pneumonia (2), pleural effusion (1), and hiatus hernia (2). The mean hospital stay was 16 days (range, 8-36). Our preliminary experience would suggest that laparoscopic gastric transposition is a safe alternative to open surgery with satisfactory results.

Oesophageal corrosive injuries in children: a forgotten social and health challenge in developing countries

An unsafe environment is a risk factor for child injury and violence. Among those injuries that are caused by an unsafe environment, the accidental ingestion of corrosive substances is significant, especially in developing countries where it is generally underreported. To address this challenging, unmet medical need, we started a humanitarian programme in Sierra Leone. By reviewing the current literature from developing countries and our own experience in the field, we developed a flowchart for management of this clinical condition. This injury is underreported in developing countries. Data available are heavily skewed towards well-resourced centres and do not reflect the entire reality of the condition. Late oesophageal strictures are usually severe. Parent's lack of knowledge, crowded living conditions and availability of chemicals in and around houses account for most ingestions. The widespread lack of any preventive measures represents the strongest risk factor. Timely admission was observed in 19.5% of 148 patients studied. A gastrostomy was performed on 62.1% of patients, 42.8% had recurrent strictures and 19% are still on a continuous dilatation programme. Perforation and death rate were respectively 5.6% and 4%. The majority of oesophageal caustic strictures in children are observed late, when dilatation procedures are likely to be more difficult and carry a significantly higher recurrence rate. Gastrostomy is necessary to maintain adequate nutritional status but mothers need training in feeding techniques. Both improvement in nutritional status and sustained oesophageal patency should be the reference points to a successful dilatation.

Management of Button Battery Stricture in 22-Day-Old Neonate

The ingestion of foreign bodies is a common problem in the pediatric age group and has long been recognized as such. Button batteries are no exception, especially nowadays with the increas- ing availability of electronic toys and devices. The ingestion of such batteries most commonly oc- curs in children less than 5 years of age with a peak incidence in children between the ages of 1 and 2 years. If the battery impacts in the esopha- gus, emergency endoscopic management is nec- essary. We report the clinical case of a neonate, where family neglect allowed her to swallow an alkaline button battery, and in whom the delay in removal led to serious complications. She was treated by endoscopic removal of the battery and followed by frequent dilatations. A review of the diagnosis and management of ingested button batteries is presented. Ingestion of a disc battery in this age group has not been reported in the lit- erature. Our case suggests that esophageal dilata- tion should still be considered as the first-line management for esophageal caustic stenosis, even in neonates, and requires a multidisciplin- ary approach for a successful outcome. button battery ingestion l esophageal dilatation l child neglect l foreign Body

Estenoses benignas de esôfago: abordagem endoscópica com velas de Savary-Gilliard

Benign esophageal strictures are complications that result from different causes. They are usually similarly approached, most of the cases needing endoscopic dilation. However the response to therapy, optimal timing for treatment and interval between sessions can vary. The authors evaluate 14 years of experience with benign stricture of the esophagus from the endoscopic point of view in the 'Clementino Fraga Filho' University Hospital, Federal University of Rio de Janeiro, RJ, Brazil. They evaluated etiology, length of stricture, number of dilations needed to reach satisfactory therapeutic response, and the relation between length of stricture and therapeutic response. We analyzed 2,568 endoscopic dilations using Savary-Gilliard dilators in 236 patients. The follow up period was 14 years and 10 months, until June of 2007. Peptic strictures were the more frequent, followed by caustic strictures. Long strictures and caustic strictures needed more sessions to abolish dysphagia. Peptic strictures and short ones had better response to a smaller number of sessions. In this study, peptic strictures were the commonest etiology and responded best to endoscopic therapy, in accordance with published literature. Caustic strictures were the most refractory, mainly the long segments. The longer the extension of stenosis, the greater was the number dilation sessions needed for relief. Short strictures had a good prognosis in the great majority of cases. The number of dilations depended directly on the etiology and the extension of the stricture.

Corrosive oesophageal strictures in children: Outcomes after timely or delayed dilatation

Among benign oesophageal lesions, caustic strictures are the most difficult to dilate. In low-income countries, children suffering caustic oesophageal injury are frequently referred to the hospitals late, sometimes weeks after ingestion. Therefore, dilatation may be performed late and in highly fibrotic strictures. Reports about endoscopic and clinical outcome of such delayed dilatations are scanty. The aim of this study was to evaluate the safety and efficacy of late caustic stricture dilatations in children, comparing it with the results of timely dilatations, both performed at the Hospital of the Italian Non-Governmental Organization "Emergency" at Goderich, Sierra Leone. From December 2005 to May 2007, 78 children (<15 years) complaining alkaline caustic ingestion were submitted to oesophageal dilatation, mainly (97%) using Savary dilators. Two groups were identified: children (group 1) with a late treatment (>6 weeks, 37+/-12 weeks), having arrived to the hospital late after ingestion, and children (group 2) dilated timely, i.e. at <6 weeks (4+/-1.4 weeks) after injury. Strictures were severe in all patients. Twenty-five children were dilated late after injury (6.4 dilatations/patient) with a follow-up of 11+/-2.5 months. A successful clinical outcome was observed in 91.6%. Four perforations (2.6% procedure-related) and one death (4.0%) were observed. Strictures recurred once in 72% of patients, twice in 31.8%. Thirty-one children were dilated timely (4.5 dilatations/patient) with a follow-up of 10+/-2.1 months and a clinical success rate of 96.7%. Procedure-related perforation rate was 0.7% with one death (3.2%). Stricture recurred once in 30% and twice in 3.3%. Delayed dilatation of caustic oesophageal strictures in children carries a higher risk of perforation and a higher recurrence rate.

Colon Patch Esophagoplasty: An Alternative to Total Esophagus Replacement?

Resistant benign esophageal strictures (ES) are likely to require esophageal replacement. The use of colon patch esophagoplasty (CPE) was originally described for the correction of long segment esophageal stenosis, however it was thought that the length of the stricture would limit the use of the patch technique. We performed CPE on 3- to 4-inch strictures with a good outcome. We report here on our results of the use of CPE for long and short ES. A retrospective study was carried out on patients operated for resistant ES using a vascularized colonic patch. The technique used was the same as described by Hecker and Hollmann with a few modifications. We used the right colon. Instead of passing the patch through the hiatus we placed it in the right pleural cavity through a small incision in the diaphragm. An appropriately sized patch was sewn to a generous longitudinal esophagotomy extending well beyond the stricture using running 4/0 polydiaxone sutures. Four patients underwent CPE, three because of an extensive caustic stricture and one with a stricture after failed atresia repair. All four patients were males. They were almost the same age except for the one with post-tracheoesophageal fistula (TEF) repair stricture. The site of the stricture was the mid esophagus in three and the lower esophagus in one. Three patients had an anastomatic leak which was treated conservatively and one patient required a postoperative fundoplication 10 days post-CPE to stop the leak. The first patient developed a patch diverticulum, which was resected 12 years after CPE. All had fundoplication pre-, intra- or post-CPE. The follow-up period ranged from 4 - 20 years. All patients are eating and growing normally after surgery. No malignant changes were seen in the older patient. The length of the stricture is not a problem in CPE. Our results are encouraging on the use of CPE as an alternative to esophageal replacement. We suggest using CPE even for an entire scarred esophagus. A postoperative leak due to a long suture line can be overcome by fundoplication and supportive therapy.

THERAPEUTIC OPTION FOR CHILDREN WITH ESOPHAGEAL CAUSTIC STENOSIS

Caustic ingestion is a leading cause of esophageal stenosis in children. Herein we report four cases using mitomycin C (MMC), a drug that inhibits cell division, protein synthesis and fibroblast proliferation and has been used as an adjuvant therapy for caustic esophageal stenosis that is recalcitrant to conventional dilation techniques. A retrospective chart review was performed on four pediatric patients with severe, recurrent esophageal stricture after caustic ingestion. The patients had required six to 20 esophageal dilations over a 4–16‐month period before MMC application. MMC was applied after an endoscopic dilation on saturated pledgets at a dose of 0.1 mg/mL for 2 min in the area where the strictures had been lyzed. From the four children treated with MMC, two have been asymptomatic for 16 and 20 months and two still require esophageal dilation, however, at longer intervals. All patients have shown satisfactory weight gain with food intake exclusively per oral. Although further studies are required, there is strong evidence that MMC is a safe and effective adjuvant therapy in the treatment of esophageal caustic stenosis.

Oesophageal Replacement in Children

The usual indications for oesophageal replacement in childhood are intractable corrosive strictures and long-gap oesophageal atresia. Generally, paediatric surgeons attempt to preserve the native oesophagus with repeat dilatations. However, when this is not successful, an appropriate conduit must be fashioned to replace the oesophagus. The neo-oesophagus should allow normal oral feeding, not have gastro-oesophageal reflux, and be able to function well for the life-time of the patient. A Medline search for oesophageal replacement, oesophageal atresia, gastric transposition, colon transposition, gastric tube, caustic stricture was conducted. The commonest conduits including whole stomach, gastric tube, colon and jejunum are all discussed. No randomised controlled studies exist comparing the different types of conduits available for children. The techniques used tend to be based on personal preference and local experience rather than on any discernible objective data. The biggest series with long-term outcome are reported for gastric transposition and colon replacement. Comparison of a number of studies shows no significant difference in early or late complications. Early operative complications include graft necrosis, anastomotic leaks and sepsis. Late problems include strictures, poor feeding, gastro-oesophageal reflux, tortuosity of the graft and the development of Barrett's oesophagus. The biggest series, however, seem to have lower complications than small series probably reflecting the experience, built up over years, in their respective centres. Long-term follow-up is recommended because of the risks of late strictures, excessive tortuosity of the neo-oesophagus and the development of Barrett's oesophagus.

Corrosive esophageal injuries in children: A shortlived experience in Sierra Leone

Children with caustic ingestions in developing countries are often treated at home, sometimes by traditional healers, or are referred, frequently late, to tertiary hospitals, which only seldom offer adequate endoscopic and dilatation facilities. Therefore, when dilatations are performed, the stricture is often already well established, making dilatation more difficult. The aim of this paper is to report our experience in the management of corrosive injuries in a group of children of Sierra Leone, all complaining accidental ingestion of caustic soda, many of them treated months after the ingestion. We considered all children admitted after corrosive ingestion, from November 2001 to November 2005, to the "Emergency" Surgical Center in Goderich-Freetown, Sierra Leone. In December 2005 the hospital was supplied with endoscopes and dilatation devices. The children still followed up clinically were recalled to submit them to an endoscopic follow-up and to a dilatation, if needed. Forty children were admitted (mean age: 4.5 years): 16 (group A) after an esophageal perforation during dilatation performed elsewhere (death rate: 56%). Twenty-four children (group B) were observed after ingestion, 58% being submitted to a surgical gastrostomy. Death rate after ingestion was nil. The mean interval between ingestion and endoscopy was 8.8 months. Fifty-three dilatations were carried out in 17 children over a 3 months period. We report three perforations (17.6%) and a death rate of 5.8% (1/17). Two patients were lost to follow-up. Three patients (17.6%) did not show any improvement. Four children complained recurrent dysphagia after the first dilatation cycle. Overall, 10 children (58.8%) showed a clear-cut improvement at 6 months. The majority of treated strictures were late, therefore difficult to dilate and at higher risk of perforation. Dilatation with Savary bougies seems safer than with balloon catheters. Recurrent strictures and a long-term dilatation treatment should be expected. Retrograde dilatations through gastrostomies should be the preferred method of treatment and surgical gastrostomies should be performed without hesitation. Esophageal replacement is unlikely in these countries, except in very few referral centres. Therefore, any effort should be made to treat caustic strictures by timely dilatation programs.

Colon interposition in the treatment of esophageal caustic strictures: 40 years of experience

The objective of this article was to analyze 40 years of experience of colon interposition in the surgical treatment of caustic esophageal strictures from the standpoints of our long-term personal experience. Colon interposition has proved to be the most suitable type of reconstruction for esophageal corrosive strictures. The choice of colon graft is based on the pattern of blood supply, while the type of anastomosis is determined by the stricture level and the part of colon used for reconstruction. In the period between 1964 and 2004, colon interposition was performed in 336 patients with a corrosively scared esophagus, using the left colon in 76.78% of the patients. In 87.5% a colon interposition was performed, while in the remaining patients an additional esophagectomy with colon interposition had to be done. Hypopharyngeal strictures were present in 24.10% of the patients. Long-term follow-up results were obtained in the period between 1 to up to 30 years. Early postoperative complications occurred in 26.48% of patients, among which anastomosic leakage was the most common. The operative mortality rate was 4.16% and late postoperative complications were present in 13.99% of the patients. A long-term follow up obtained in 84.82% of the patients found excellent functional results in 75.89% of them. We conclude that a colon graft is an excellent esophageal substitute for patients with esophageal corrosive strictures, and when used by experienced surgical teams it provides a low rate of postoperative morbidity and mortality, and long-term good and functional quality of life.

Akzidentielle und suizidale Verätzungen des oberen Gastrointestinaltraktes

Caustic ingestion can cause sever damages. Immediate management should be directed to airway securing, intravenous fluid replacement and pain relief. Early endoscopy is regarded as the most appropriate method based on which further clinical decisions are made. The effectiveness of dilution by milk or water has not been proven and might aggravate the damage. The use of systemic corticosteroids should also be abandoned as they do not prevent the development of strictures and may cause serious adverse effects. The most important prognostic factor concerning early mortality is the delayed diagnosis and therapy of full thickness esophageal or gastric necrosis. Patients with evidence of perforation require immediate surgery. Since it can be very difficult to classify the exact extent of damage intraoperatively according to the endoscopic findings, a resection of all high grad damaged segments should be performed in doubt. Reconstructive surgery should not be performed earlier then 4 months after the initial event. The used technique depends on the extent of the initial damage and surgery. Development of strictures is the most important physical consequence in burned areas in survivors. Short strictures are mainly treated by endoscopic dilatation. In cases of higher graded strictures, when repeated dilatations are often ineffective, early resection should planned. Because of the high incidence of esophageal cancer among victims of caustic strictures, routine endoscopic follow up is recommended.

Pediatric surgeons and gastroesophageal reflux

Background/Aims Better antacid medications and the introduction of laparoscopy destabilize the indications for fundoplication. This study aims at raising a discussion among pediatric surgeons on these indications, modalities, and the results of this operation. Materials and Methods A total of 252 refluxing children operated between 1992 and 2006 were divided into groups according to predominant symptoms (93 digestive, 47 respiratory, and 68 neurologic) or to comorbidities (27 esophageal atresia, 10 diaphragmatic hernia, 5 abdominal wall defects, and 2 caustic stricture), and the indications, complications, mortality, and long-term results were reviewed. Features of open (n = 135) and laparoscopic (n = 117) approaches were compared, and long-term integrity of the wrap was analyzed using the Kaplan-Meier method. Results Digestive, respiratory, and neurologic patients had more often laparoscopic plications, whereas all others rather had an open approach. The rate of complications was 22%, and they were more frequent in children operated by laparotomy ( P < .05). Median follow up was 51.3 months (range, 6-160). Overall wrap integrity was maintained in 89% of the children, and the proportions for digestive, respiratory, and neurologic groups were 95%, 95%, and 87%, respectively. For esophageal atresia, congenital diaphragmatic hernia, abdominal wall defects, and caustic stricture, they were 72%, 77%, 100%, and 0%, respectively. The functional results were fully satisfactory in 83% of patients. There were 17 deaths (6.7%), but only 3 in the first postoperative month and only 1 related to the operation (0.4%). Conclusions Fundoplication is a powerful method of reflux control. It is indicated after failure of medical treatment in gastroesophageal reflux disease and in symptomatic refluxers with some particular comorbidities. Surgery should be offered only after diagnosis has been firmly established, and the indications must remain identical for open and laparoscopic procedures. High technical standards and rigorous report of the results are required for keeping a relevant place of pediatric surgery in the treatment of this disease.

Jejunal pedicle grafts for reconstruction of the esophagus in children

Objective Reconstruction of the esophagus in children remains a challenge. Although jejunal grafts retain peristaltic activity, large series with long-term follow up are rare. We like to present our experience in a series of 24 children. Methods In the period 1988 through 2005, 24 children received an orthotopic jejunal pedicle graft reconstruction of the esophagus. Nineteen had esophageal atresia (18 had no distal fistula; all but 1 had a jejunal graft as a primary procedure), 3 had an extensive caustic stricture, and 2 had a peptic stricture. All strictures had been dilated many times, and peptic strictures had been treated with antireflux surgery as well. Median age at reconstruction was 76 days in the esophageal atresia group. The technique involves a right-sided thoracotomy with preparation of the esophageal ends or resection of the diseased esophagus. At laparotomy, a small pediculated jejunal graft is prepared and placed transhiatally in an orthotopic position in the right chest. Results All patients survived, and none of the grafts were lost. There were 5 intrathoracic leaks, 4 in the esophageal atresia group and 1 in peptic stricture group, requiring reoperation in 1. In the esophageal atresia group, there was 1 early distal stenosis requiring reoperation. In patients in which the distal esophagus was preserved (esophageal atresia and caustic stricture group), there were always signs of distal functional subobstruction, responding to dilatation in all but 1 patient. Gastroesophageal reflux was not a problem except for 1 patient with esophageal atresia, in whom the distal esophagus was resected because of ongoing distal obstruction with dilatation of the graft. Most patients eat and grow well, and respiratory problems were rare. Conclusion Orthotopic jejunal pedicle graft reconstruction of the esophagus in children is a demanding operation with considerably morbidity but good long-term results.

Removal of Metallic Stent by Using Polyflex Stent in Esophago-Colic Anastomotic Stricture

Benign strictures or anastomoses of the esophagus can be treated by stents. However, short-term and long-term complications, including migration and hyperplastic tissue reaction can occur. Bowel reconstruction by interposition has been performed after esophagectomy. Stricture of cervical anastomosis is an important late complication. Self-expandable metallic stents have been used to improve this problem. To remove the obstructed metallic stent, self-expandable covered plastic stents can be used. Herein we present the removal technique of tissue-embedded self-expandable metallic stents by using self-expandable covered plastic stents after colon interposition in a case of benign cervical anastomosis of the esophagus due to caustic stricture.

Use of a Self-Expanding, Removable, Plastic Stent (Polyflex®) for Esophageal Fistulae, Perforations and Benign and Malignant Strictures: Early Experience At a Single Institution

Use of a Self-Expanding, Removable, Plastic Stent (Polyflex ) for Esophageal Fistulae, Perforations and Benign and Malignant Strictures: Early Experience At a Single Institution Drew Schembre, Richard Kozarek Background: Traditionally, esophageal perforations, fistulae and recalcitrant strictures required surgical correction or placement of a permanent stent. A selfexpanding, plastic stent designed to be removed, (Polyflex Boston Scientific Inc., Boston), recently became available. We review our initial experience with the stent in a variety of esophageal situations. Methods: We reviewed all patients who received a Polyflex stent for an esophageal indication at our institution between 1/2004 and 11/2005. Indication for treatment, location, duration of placement, rate of migration and time to migration, complications and efficacy were recorded. Results: A total of 20 stents were successfully placed in 16 patients. 4 were placed for fistulae, 2 for perforations, 5 for malignant strictures, and 9 for benign strictures (6 anastamotic, 2 radiation and 1 caustic). Median follow-up was 12 months. 10 were placed in the proximal esophagus, 4 in the middle and 6 at the EG junction. 14 stents were eventually removed and 6 remained in place (3 for malignancy 3 anticipating removal). 4 stents migrated spontaneously (1 distally and 3 proximally). The median time in place was 4 weeks with a mean time to migration of 10 days. All stents that were removed, including migrated stents, came out easily with ‘‘rat’s tooth’’ forceps and slow, constant traction. None of the fistulae or perforations healed with stent placement. One fistula enlarged and one malignant stricture fistulized after stent removal. 8 stent placements resulted in at least temporary pain requiring narcotic analgesia. No deaths or other major complications occurred as a result of stent placement or removal. Of the 8 benign strictures in which the stent has been removed, 4 (50%) have experienced improvement of their dysphagia for at least 1 month. One patient who had 2 Polyflex stents placed for a caustic stricture has refused to return for stent removal, even after 12 months. Conclusion: Polyflex stents are easily placed and removed from the esophagus. Stent migration occurs occasionally, and may not occur for several days. Resolution of perforations and fistulae has been disappointing, but temporary stent placement can provide at least temporary relief of dysphagia from benign strictures.

Pharyngo-Colostomy With Supraglottic Partial Laryngectomy in Caustic Oropharyngeal Stricture

We present two cases of chronic caustic stricture from the oropharynx to the entire esophagus combined with laryngeal stricture in which the piriform sinuses were stenosed. The restoration of digestive continuity was accomplished by end-to-end pharyngo-colostomy at the level of the cricoid cartilage through the posterior mediastinal route. Supraglottic partial laryngectomy and pharyngoplasty were done simultaneously for the laryngeal and oropharyngeal stricture. The patients were able to swallow a soft blend diet to regular diet with negligible penetration.

Minimally invasive oesophageal resection for distal oesophageal cancer: A review of the literature

Oesophagus resection is adequate treatment for some benign oesophageal diseases, especially caustic and peptic stenosis and end-stage motility dysfunction. However, the most frequent indications for oesophageal resection are the high-grade dysplasia of Barrett oesophagus and non-metastasized oesophageal cancer. Different procedures have been developed for performing oesophageal resection given the 5-year survival rate of only 18% among patients operated on. A disadvantage of the conventional approach is the high morbidity rate, especially with pulmonary complications. Minimally invasive oesophageal resections, which were first performed in 1991, may reduce this important morbidity and preserve the oncologic outcome. The first reports of morbidity and respiratory complications with this approach were disappointing and it seemed likely that the procedure would have to be abandoned. However, in the past 5 years, Japanese groups and the group of Luketich in Pittsburgh have given these techniques an important impetus. The outcomes of the new series are different from those in the beginning period, and are leading to an enormous expansion worldwide. Important factors behind the change are standardization of the operative technique, the experience of many surgeons with more advanced laparoscopic procedures, important improvements in instruments for dissection and division of tissues, a better technique in use of anaesthesia, and a better selection of patients for operation. Two minimally invasive techniques are being perfected: the three-stage operation by right thoracoscopy and laparoscopy, and the transhiatal laparoscopic approach. The former may be applied successfully for any tumour in the oesophagus, whereas the latter seems ideal for distal oesophageal and oesophagogastric junction tumours. This review article discusses all these aspects, giving special attention to indications and operative technique.

Œsophagectomie pour lésion non tumorale

Oesophagectomy in benign conditions is an uncommon situation. Most of the time, emergent oesophagectomy is required for caustic necrosis or following oesophageal perforation. The aim of the intervention is then to remove the whole oesophagus, avoiding additional morbidity. Oesophagectomy without thoracotomy, and specially oesophageal stripping, achieve those two goals, quickly and safely. Other indications for oesophagectomy in benign conditions are more uncommon, mainly represented by peptic or caustic stenosis. In these indications, there is a small place for standard oesophagectomies, with or without thoracotomy. However, recent advances in minimally invasive surgery, either by laparoscopy or thoracoscopy, may change surgical approach for oesophagectomy in these indications. Various approaches for oesophagectomy are described in the present article, focused on particular techniques indicated in benign conditions. Oesophageal stripping, and minimally invasive oesophagectomy are particularly detailed.