J Thorac Cardiovasc Surg 2001;122:384-386
© 2001 The American Association for Thoracic Surgery
Surgical approach by cervicosternolaparotomy for the treatment of extended cervical stenoses after reconstruction for caustic injury
Pierre Cattan, MDa,
Philippe Chiche, MDa,
Thierry Berney, MDb,
Bruno Halimi, MDa,
Karen Aïdan, MDa,
Michel Célérier, MDa,
Emile Sarfati, MDa,
Paris, France, Geneva, Switzerland
From the Department of Digestive Surgery, Hôpital Saint-Louis, Paris, France,a and the Clinique of Digestive Surgery, Geneva University Hospital, Geneva, Switzerland.b
Received for publication Sept 28, 2000. Accepted for publication Dec 18, 2000.
Address for reprints: Pierre Cattan, MD, Service de Chirurgie Digestive Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75475 Paris Cedex 10, France.
Surgical treatment of extended cervical stenoses after esophagoplasty for caustic injury usually requires interposition grafts or flaps. These procedures have been used with limited success because of transplant necrosis and anastomosis fistula and stricture. Here, we describe an alternative technique consisting in the complete release of the transplant by a cervicosternolaparotomy approach to allow its advancement followed by primary anastomosis.
Operative procedure
A comprehensive cervical exploration through the previous cervical incision is performed to ascertain that stenosis is not suitable for repair by a limited cervical approach. Then, before proceeding to sternotomy, a midline laparotomy is required. The laparotomy can be justified as follows: (1) Importantly, it allows complete dissection of the abdominal part of the transplant and of its vascular pedicle up to its origin, which provides a significant gain in length; (2) it allows the cephalad mobilization of the duodenocolonostomy or jejunocolonostomy; and (3) it gives safe access to the intramediastinal part of the transplant at the lower end of the substernal space. Sternotomy is best conducted in a cephalad direction. The anterior side of the transplant is released step by step from the internal part of the sternum before progressive sternal section. Then, complete transplant release is performed in the anterior mediastinal space with special attention to its vascular pedicle. The stenosis and all scar tissue are excised and a new anastomosis is performed in healthy tissue. The sternal manubrium and the head of the left clavicular bone are removed to open the upper thoracic inlet wide to avoid transplant compression.
Patients
Between 1995 and 1999, 8 patients (6 male and 2 female; median age 32 years) were operated on according to the technique described herein. Types of initial transplants, all routed substernally, and primary anastomoses are summarized inTable 1. Five patients had undergone several previous attempts at stenosis removal(Table 1
). All these procedures were followed by short-term stenosis recurrence, and two esophageal endoprostheses were complicated by migration and hemorrhage, respectively. Preoperative investigations consisted of standard laboratory tests, a chest radiogram, endoscopic examination of the upper digestive tract, and a barium swallow.
Results
In 5 patients, median length gain obtained by transplant release was 6 cm (range 4-9 cm), allowing a primary anastomosis. Attempt at transplant preservation failed in 3 patients, because of the length of the stenosis (2 patients) or injury to the transplant vascular pedicle (1 patient). In these cases, initial colonoplasty was replaced by another transplant during the same operation. Operative mortality was nil. Two transient cervical fistulas occurred. Two patients had major biliary reflux and underwent subsequent duodenal diversion. Median follow-up after revision was 12 months (range 10-60 months). Seven patients resumed normal feeding without further treatment. Stenosis recurred after cervical fistula in the last patient. She underwent 3 sessions of endoscopic dilations and was eating a blenderized diet at the end of follow-up.
Discussion
In the particular setting of caustic injury, stenosis of the upper digestive tract after esophagoplasty may result from delayed progressive caustic scarring of tissue or from the incomplete excision of scar tissue at the time of reconstruction. Such stenoses are difficult to treat because of their extent and the need to complete fibrotic tissue removal. Transplant stenoses related to partial ischemia or other causes represent the same therapeutic challenge. Limited anastomosis repair without total fibrosis excision is usually followed by short-term recurrence of stenosis. 1,2 To succeed, reoperation should include complete excision of scar tissue before a new anastomosis is performed. Wu and associates 3 have developed the idea of transplant release by sternotomy in 3 patients. However, this approach did not allow treatment of strictures longer than 2.5 cm. In contrast, additional abdominal transplant release brings a significant advantage. The length of the vascular pedicle is the limiting factor for transplant mobilization. Despite the impression that tension of the pedicle is tight, complete dissection up to its origin always provides a length gain. In most cases, it is likely that extended pedicle dissection had not been performed at the time of esophagoplasty. Another explanation may reside in the loosening of the vascular pedicle over time. In 5 of 8 patients, this procedure allowed preservation of the initial transplant. In the other 3 patients, transplant preservation failed, but this surgical approach allowed its safe excision and a successful secondary esophagoplasty during the same operation. Even in the case of major surgery, mortality was nil, morbidity was exceptionally low, and a high success rate was obtained with this technique.
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Fig. 1. Operative procedure. Cervical exploration (1). Midline laparotomy (2). Complete dissection of the vascular pedicle (a). Cephaled mobilization of the coloduodenostomy (b). Access to the lower end of the substernal space (c). Sternotomy conducted in a cephaled direction and release of the transplant in the anterior mediastinal space (3). Excision of the stenosis and new anastomosis (4).
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References
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