Esophagojejunal Anastomosis Research Articles

Bile Reflux Esophagitis

This study was designed to determine the relative contribution of acid and/or duodenal contents on development of reflux esophagitis in the rat. Gross and microscopic changes in the esophageal mucosa at 10, 15, 30, and 60 days were recorded in sham-operated animals and in two experimental groups. One study group had a transsection of the esophagogastric junction (model I), and the other a total gastrectomy (model II). Bowel continuity was reestablished by esophagojejunal anastomosis. Subgroups of both animal models received either no treatment of cholestyramine or aluminum phosphate for 30 days in drinking water. At 30 dyas a similar degree of esophagitis was found in the untreated animals of both study models. Cholestyramine improved the degree of esophagitis in model II, whereas aluminum phosphate increased mucosal alterations in model I. At 60 days, 50% of the animals no longer had esophagitis and had regained satisfactory nutritional status. It is concluded that: (1) bile reflux is a major factor in esophagitis; (2) cholestyramine protects against bile reflux, and (3) proper nutritional status is of major importance in mucosal healing.

Simplified EEA stapled anastomosis by the end-insertion technique

A simplified technique for stapled esophagojejunal anastomosis after total gastrectomy using the GIA and EEA stapling instruments is described. The technique is also suitable for esophagogastric and ileorectal anastomosis.

A Stapling Instrument for End-to-end Inverting Anastomoses in the Gastrointestinal Tract

A stapling instrument is described for end-to-end inverting anastomoses applicable principally to low rectal anastomosis or esophagogastric or esophagojejunal anastomosis. The instrument creates an inverting anastomosis held by a double staggered row of stainless steel wire staples creating an anastomosis 21.2 mm internal diameter with no significant inverted flange. The early experience is encouraging.

Barrett-esophagus Following Total Gastrectomy: A Contribution to it's Pathogenesis

We have undertaken esophagoscopy 1/2 to 17 1/2 years after surgery in 20 patients with a total gastrectomy and an esophago-jejunal anastomosis. In 5 cases we found a complete columnar lining of the distal esophagus (Barrett-esophagus). 2 other cases showed a multilocular columnar epithelium. One case with a Barrett-esophagus had endoscopy before surgery, and it could be proved that the columnar lining developed after surgery. We suspect that it was the same in the remaining cases. All examined patients, except one, showed an erosive esophagitis of varying severity. These observations support the current view that the columnar lined esophagus is usually an acquired one. The pathogenesis is not completely clear, but reflux of digestive juices destroying the squamous epithelium and impairing healing is the condition for columnar lining. The observations on patients with total gastrectomy prove that it must not necessarily be gastric juice. The very urgent question of the origin of columnar lining cannot be answered at present.

Large leiomyosarcoma of the stomach cardia treated by gastric-remnant interposition.

AbstractA case is presented of a large invasive leiomyosarcoma of the stomach cardia, with metastases to the spleen. Operation consisted of removal of the tumor, most of the stomach, and the adherent spleen. Continuity of the gastrointestinal tract was established by gastric‐remnant interposition, thus avoiding total gastrectomy. Instead of the usual Roux‐Y procedure, a loop of jejunum was used in order to insure a good blood supply at the esophagojejunal anastomosis.

Cancer of the esophagus: Surgical experience in 101 resections from 1948 to 1955

We have divided our surgical experience into two periods. During the first period, when surgery of the esophagus was still in the development stage, results were little encouraging, but it helped to work out the present technics. From 1948 until August, 1955, 164 patients were observed. Fifty-four (32.9 per cent) were not operated upon; 110 (67 per cent) were explored; of these, 101 (91.8 per cent) underwent resection. This high percentage of resections shows that there was not any selection of favorable cases, so that many were rather advanced, but there was hope of doing them good by palliative operations. The resections of infra-aortic cancers brought about a death rate of 17.6 per cent (on fifty-one resected); the death rate of supra-aortics was 62.7 per cent (forty-three cases); of the cervicothoracics, three of five cases died (60 per cent). We think that these figures should be referred to the hospital medium in which we have been working. The final results will be the object of a further study, and we merely state that there are three patients surviving five years, eight surviving between five and three years, and a not exactly stated number surviving less than two years which, however, being so recent are not yet interesting. In our general hospitals it is very difficult to follow up the patients, because so many arrive indiscriminately from faraway places of this large country with whom contact is lost afterward. Of 226 cancers of the esophagus, three cervical cases were observed. In one the operation of Wookey was practiced with good functional result, but the patient died from metastasis just when the plastic procedure was finished. That type of operation is confined to aged patients or those on whom, because of their general condition, a cervical subpharyngogastric anastomosis cannot be done. With carcinoma of the upper thoracic esophagus, two locations are considered: the thoracocervical supra-aortic and the retroinfra-aortic (mid-thoracic) carcinoma. In the first case resection will be followed by cervical esophagogastric anastomosis; in the second case esophagogastric anastomosis is done intrathoracically and supra-aortically. After having tried different ways of entrance, at present we proceed as follows. If the radiograph reveals that the tumor is little extended, if there are few metastasic adenopathies and the patient is in a good general condition, left-sided bicostal thoracotomy is practiced, with mobilization of the aortic arch by previous ligation of the upper intercostals. If the tumor is extended and prevailingly retroaortic (mid-thoracic), it is attacked by right-sided thoracotomy together with left-sided laparotomy (after Lewis). In these cases the resection is considered as palliative only. In 65 per cent of these operated patients ganglionic metastases have been found at the abdominal coronary group (left gastric artery). In cases of non-extended carcinomas of the lower esophagus and cardiac orifice of the stomach, end-to-side esophagogastrostomy following the technic of Sweet is done at the fore or hind gastric surface correspondingly, by low left-sided thoracotomy. End-to-end tubular esophagogastric anastomosis is effected only by exception. When the tumor enters the lower esophagus, reaching a point above the level of the lower pulmonary veins, supra-aortic esophagogastric anastomosis is practiced. If the tumor of the cardias extends into the stomach, total gastrectomy with esophagectomy is made, followed by infra-aortic intrathoracic esophagojejunal anastomosis. Only exceptionally ypsiliform anastomosis (Roux or Rienhof) is applied. We are not given to palliative ultraresections in advanced cases because of the high death rate and bad further results. Since 1948 these patients have been treated by esophagofundic side-to-side derivative anastomosis. If the top of the stomach is invaded, the circuit is established with a jejunal loop. Only once could we practice this type of anastomosis on a mid-thoracic carcinoma with a good result (patient surviving fifteen months). A new type of intervention for the non-resectable cases is being developed. Through a simple gastrostomy without thoracotomy a tube could be placed through the tumor, thus re-establishing the passage of the esophagus and allowing radiotherapy to be practiced. As general anesthesia the authors recommend flebonovocaine complemented with small doses of pentothal-curare. The operated hemithorax is drained, keeping a slight aspiration during three to four days. In common resections no nasopharyngeal sound is used, this being applied only with subpharyngo or esophagogastric cervical anastomosis in order to avoid the laryngeal reflux. Once the esophagectomy is finished, a temporary tracheotomy is recommended for any patient with a past history of bronchial disturbance and bronchorrhea.

TOTAL GASTRECTOMY

CREDIT for the first successful total gastrectomy goes to Schlatter, 1 who in 1897 reported his case in which gastrointestinal continuity was reestablished by means of an esophagojejunal anastomosis. It was just one year later that Brigham 2 accomplished the operation successfully by employing an end to end esophagoduodenostomy. In the following years total gastrectomy was performed in isolated instances, with a rather forbidding mortality rate. As the years passed the operation was extended to more and more cases, until at present it has become a rather standard procedure. Pack and McNeer 3 have presented surveys of the trends and have commented on the decline in popularity of esophagoduodenostomy during the intervening years. In their reports of an early series covering the years 1884 through 1920, the end to end method was employed in 41.3 per cent of the cases. In the interval, 1921 through 1930, the incidence of the