The stomach as an esophageal substitute after total or subtotal esophagectomy : comparison between the gastric tube and the whole stomach
(1997)
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- The thesis addresses two main questions of major clinical importance regarding the surgical treatment of esophageal cancer: <BR> 1. What is the potential of esophagectomy including extensive thoraco-abdominal lymph node clearance to provide oesophageal cancer patients with long-term survival and cure? <BR> 2. What are the qualities of the stomach as an esophageal substitute after total or subtotal esophagectomy regarding surgical feasibility, technical complications, and alimentary comfort? <BR> In the introduction, we reviewed the current knowledge according to the world literature concerning, vasculature, innervation and mobility of the stomach which is required for a clear understanding of the to issued presently studied. <BR> The review of a personal series of 306 esophagectomies performed for malignancy showed that resection of the esophagus en-bloc with the loco-regional lymph nodes was technically feasible in 213 patients (70%). Five-year survival rate after radical esophagectomy was 70% for the 104 patients having no lymph node involvement (T1-T2-T3-N0) and 31% for the 109 patients having metastatic lymph nodes. (T1, T2, T3, N1). Five-year survival rates improved with increasing experience on the procedures over the years. Comparison of results obtained form 1984 to 1988 with those from 1989 to 1997 showed that the 5-year survival rate increased form 63.6% to 75.5% for patients classified N0 and from 17.5% to 39% for those classified N1. <BR> Replacement of the esophagus with the stomach is governed by anatomical constraints in relation to the shape, vascularisation and innervation of the organ, the distance to bridge between the abdomen and the neck, and the need for complete lymphatic clearance of the lesser curvature. We have compared the classic technique of gastric tubulisation with stapling resection of the lesser curvature to a personal technique in which the lesser curvature of the whole stomach is denuded for the purpose of gastric lengthening and lymph node clearance. <BR> Adequate lengthening of the whole stomach in order to easily reach the neck without undue tension on the gastric wall is a question of major surgical important. Measurements of the gastric dimensions at operation and on stomachs form fresh cadavers and brain-dead organ donors indicated that complete denudation of the lesser curvature lengthened the distance between the pylotus and cardia of the whole stomach by 19.4% (range 10-38%), and that tubulisation of the denuded whole stomach could provide the gastric transplant with .7% to 11.4% additional length. <BR> The vascular inflow and drainage of the gastric transplant depend exclusively on the right gastroepiploic pedicle. Injection of a stained saline solution in the right gastroepiploic artery of fresh cadavers or brain-dead organ donors, while all the other gastric vessels except the uppermost short gastric veins were ligated, showed that the main intramural vascular pathways from the right gastroepiploic artery up to the fundus (i.e., the site of the esophageak anastomosis) run within the wall of the lesser curvature. Our clinical experience with 121 patients whose esophagus was replaced by a gastric tube and 136 patients who had an esophageal replacement with the whole stomach prepared as described, showed that maintenance of the vascular pathways within the lesser curvature significantly lowered the risk of the technical complications (fistula and/or stenosis) at the level of the cervical esophagogastric anastomosis. <BR> The quality of swallowing depends, among other factors, on the size of the esophagogastric anastomosis. In 11 patients, we used a terminalized semi-mechanical side-to-side suture technique derived from a personal enoscopic technique of stapling division of Zenker devierticulum. Assessment of this original suture technique by barium swallow study showed that it resulted in a larger cervical anastomosis than that usually achieved with the classic manual end-to-side suture technique. The larger diameter of the cervical anastomosis made with the terminalized semi-mechanical side-to-side suture technique allowed patients to swallow larger pieces of solid food soon after operation. Our radiological study also showed that the existence of a moderate narrowing of a cervical esophagogastric anastomosis 2 months after operation could be transient and spontaneously subside parallel to disappearance of the surgery-related inflammatory changes at the suture line, so as not to require any endoscopic dilatation at follow-up. <BR> Alimentary comfort after esophageal replacement also requires a substitute of appropriate capacity to accommodate a meal of normal volume without producing early satiety. Studies on stomachs from fresh cadavers and brain-dead organ donors showed that the capacity of the gastric transplant increased by 10% on average following denudation and unfolding of the lesser curvature of the whole stomach whereas it was reduced by 33% on average after gastric tubulisation with resection of the lesser curvature. […]
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Collard, J.-M. (1997). The stomach as an esophageal substitute after total or subtotal esophagectomy : comparison between the gastric tube and the whole stomach. https://hdl.handle.net/2078.5/111429