30-Day Outcomes Following Esophageal Replacement in Children: A National Surgical Quality Improvement Project Pediatric Analysis.

INTRODUCTION: The optimal method of esophageal replacement remains controversial. The aim of this study was to evaluate 30-d outcomes of children in the National Surgical Quality Improvement Project Pediatric (NSQIP-P) database who underwent esophageal replacement from 2012 to 2018. METHODS: Demographics, comorbidities, and procedural technique was identified in NSQIP-P and reviewed. Thirty-day outcomes were assessed and stratified by gastric pull-up or tube interposition versus small bowel or colonic interposition. Categorical and continuous variables were assessed by Pearson's chi-square, Fisher's exact, and Wilcoxon rank-sum tests, respectively. Multivariate logistic regression was performed to estimate the effects of procedure technique and clinical risk factors on patient outcomes. RESULTS: Of the 99 cases of esophageal replacement included, 52 (52.5%) utilized a gastric conduit, whereas 47 (47.5%) involved small bowel/colonic esophageal interposition. Overall risk of complications was 52.5%, the most common of which were perioperative transfusion (30.3%), surgical site infection (11.1%), and sepsis (9.1%). Risk of unplanned reoperation was 17.2%, and risk of mortality was 3.0%. Risk for complications, reoperation, and readmission did not differ significantly between those who underwent gastric esophageal replacement and those who underwent small bowel or colonic interposition. Median operative time was shorter in the gastric esophageal replacement group (5.2 versus 8.1 h, P = 0.009). CONCLUSIONS: Among children in NSQIP-P who underwent esophageal replacement from 2012 to 2018, the risk of 30-d complications, unplanned reoperation, and mortality was relatively frequent and was similar across operative techniques. Opportunities exist to improve preoperative optimization, utilization of blood transfusion services, and infectious complications in the perioperative period irrespective of operative technique. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Outcomes for Correction of Long-Gap Esophageal Atresia: A 22-Year Experience.

BACKGROUND: Long-gap esophageal atresia (LGEA) precludes immediate primary repair. When delayed primary esophagoesophagostomy (DPE) is not feasible, a reverse gastric tube (RGT) is a potential salvage option. The purpose of this study was to determine if DPE and RGT had both similar short-term and long-term outcomes. METHODS: A retrospective review of all EA patients from 1994 to 2016 was undertaken. Data were stratified by surgical management (DPE versus RGT). Baseline demographics, operative information, postoperative management, and complications were analyzed. Descriptive statistics were used and P-values <0.05 were considered statistically significant. RESULTS: Two hundred and eighteen patients with EA were treated during this period; 37/218 (17%) had LGEA. Mean gap length was 3.3 ± 1.2 cm. Thirty-three patients underwent some form of repair, all of which were managed initially with a gastrostomy tube feeds. Twenty-five patients underwent DPE with 89% of these never requiring revision, and 86% having excellent function with long-term follow-up. In eight patients, esophageal length was never adequate for DPE; therefore, six were reconstructed with RGT, and two underwent gastric transposition. There were no significant differences in complications, revisions, ventilator days, overall length of stay, weight percentiles, or conduit function between children undergoing RGT compared with DPE at a mean follow-up of 5.5 years. CONCLUSIONS: Surgical treatment of LGEA is complex, and controversy exists regarding the optimal repair method when DPE is not feasible. In this series, DPE after gastrostomy tube feeds often allowed for sufficient esophageal lengthening with satisfactory long-term esophageal function. However, when adequate length for DPE was not attainable, these data suggest that RGT is a viable conduit with favorable postoperative outcomes.

Surgical treatment and major complications Within the first year of life in newborns with long-gap esophageal atresia gross type A and B - a systematic review.

BACKGROUND: The surgical repair of long-gap esophageal atresia (LGEA) is still a challenge and there is no consensus on the preferred method of reconstruction. We performed a systematic review of the surgical treatment of LGEA Gross type A and B with the primary aim to compare the postoperative complications related to the different methods within the first postoperative year. METHODS: Systematic literature review on the surgical repair of LGEA Gross type A and B within the first year of life published from January 01, 1996 to November 01, 2016. RESULTS: We included 57 articles involving a total of 326 patients of whom 289 had a Gross type A LGEA. Delayed primary anastomosis (DPA) was the most applied surgical method (68.4%) in both types, followed by gastric pull-up (GPU) (8.3%). Anastomotic stricture (53.7%), gastro-esophageal reflux (GER) (32.2%) and anastomotic leakage (22.7%) were the most common postoperative complications, with stricture and GER occurring more often after DPA (61.9% and 40.8% respectively) compared to other methods (p < 0.001). CONCLUSION: The majority of patients in this review were managed by DPA and postoperative complications were common despite the surgical method, with anastomotic stricture and GER being most common after DPA. LEVEL OF EVIDENCE: Systematic review of case series and case reports with no comparison group (level IV).

Innovations for Cervical Esophagogastrostomy in Thoracic Esophageal Cancer Operations.

Three-field lymph node dissection is now performed in operations for advanced thoracic esophageal cancer, with an associated improvement in outcomes. However, reconstructive surgery following resection of the esophagus is frequently associated with the occurrence of anastomotic leakage. Once it occurs, major problems can arise such as decreased quality of life, protracted hospitalization, or even death. This is why there has been a large number of innovations in and modifications to reconstructive surgery. The standard procedures in our Department for advanced thoracic esophageal cancer are subtotal esophagectomy and three-field lymph node dissection. The thin gastric tube along the greater curvature is used as the reconstructed organ in reconstructive surgery, performing a cervical esophagogastrostomy. Innovations have been made to reconstructive surgery in order to prevent anastomotic leakage. This procedure markedly reduces anastomotic leakage, and also reduces anastomotic stricture, which likely makes it an extremely useful procedure that any surgeon can perform.

Long-term functional outcomes after replacement of the esophagus in pediatric patients: A systematic literature review.

BACKGROUND: The indications of esophageal replacement (ER) in pediatric patients include long gap esophageal atresia (LGEA), intractable post-corrosive esophageal strictures (PCES), and some rare esophageal diseases. Various conduits and procedures are currently used worldwide with a lack of consensus regarding the ideal substitute to replace the esophagus replacement. The short-term outcomes of these advanced procedures are well known; there are few data available describing long-term functional outcomes of these patients with long life expectancy. OBJECTIVES: The objective of this study is to investigate the long-term functional outcomes of the most widely used techniques for ER in pediatric patients based on a comprehensive literature search covering the last 10years. METHODS: Eligible were all clinical studies reporting outcomes after esophagectomy in pediatric patients, which contained information on at least 3years of follow-up after the operation. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic web-based search using MEDLINE, the Cochrane Library and EMBASE databases was performed, reviewing all medical literature published between January 2006 and December 2015. RESULTS: The scientific quality of the data was generally poor, converging toward only 14 full-text articles for the final analysis. The stomach was the preferred organ for esophageal replacement, where the tubulization of the stomach resulted in significant gastroesophageal reflux. Dysphagia symptoms were more seldom reported, but several authors presented growing figures with the length of follow-up. Dumping syndrome and delayed gastric emptying were only scarcely reported upon. Following colonic graft, chronic gastrocolic reflux affects these patients, in the range of 35-70.8%, while 4 studies reported any dysphagia from 2.7% to 50% of the children. Only one study reported the outcome of the use of a long jejunal segment, where presence of symptoms of functional obstruction was mentioned in 46% of cases. Very few if any data were available on a structured assessment of postprandial dumping and disturbed bowel functions. CONCLUSIONS: Available data in pediatric patients, on the long-term functional outcomes after esophageal replacement with a gastric tube, colonic graft or a long jejunal segment, are of poor scientific quality. Although symptoms are frequently reported currently no conclusions can be drawn regarding potential advantages of one graft over another. TYPE OF STUDY: Treatment study, systematic review. LEVEL OF EVIDENCE: IV.

Multicentre survey on the current surgical management of oesophageal atresia in Belgium and Luxembourg.

INTRODUCTION: The surgical management of oesophageal atresia (OA) differs between pediatric surgical teams without consensus. We aimed to describe the current practice of OA treatment in Belgium and Luxembourg and compare this to the literature. MATERIALS AND METHODS: A questionnaire was created and sent to all 18 hospitals (14 pediatric surgical units) performing OA surgery in Belgium and Luxembourg. The results were compared to the literature. RESULTS: Most units treat an average of 2-5 OA+TOF (71%) and ≤1 pure OA (pOA) per year (86%). The preferred surgical approach for OA+TOF is thoracotomy (86%), mostly extra-pleural (75%). Thoracoscopic OA repair is performed in 21%. All centers perform an end-to-end anastomosis (interrupted sutures), and all leave a transanastomotic tube. A chest drain is routinely used in 8units (57%). In pOA the preferred surgical approach is gastrostomy formation with delayed primary anastomosis (77%). The timing for delayed anastomosis is 2 to 24months. Intra-operative lengthening is mostly attempted with Foker technique (46%). If oesophageal replacement is needed, gastric interposition is mostly used (75%). A postoperative contrast study is routinely performed in 86% for OA+TOF and in 100% for pOA. Anti-reflux medication is routinely prescribed by all units but one. CONCLUSION: There are still many differences and controversies in the perioperative management of OA. Part of this is based on habits and is difficult to change without scientific evidence. There is a need for prospective (inter)national registries to further identify the existing differences, leading to a more widely accepted consensus. LEVEL OF EVIDENCE: Level III.

Esophageal reconstruction: posterior mediastinal or retrosternal route.

BACKGROUND: Although posterior mediastinal (PM) route and retrosternal (RS) route have been used for reconstruction after minimally invasive esophagectomy (MIE), the optimal route remains controversial. This study reviewed our experiences with McKeown MIEs for esophageal cancer and aimed to investigate which route was better for esophageal reconstruction. MATERIALS AND METHODS: From December 2011 to December 2013, 103 patients who underwent McKeown MIE and esophageal reconstruction by PM or RS routes were reviewed. The decision regarding which approach was appropriated mainly depended on the first surgeon's preference and experience. Baseline demographics, operative, and postoperative data of the patients were analyzed. RESULTS: Fifty-six and forty-seven patients receiving PM and RS route reconstruction were reviewed, respectively. Shorter operation time (P = 0.001), less blood loss (P = 0.029), and longer route length (P < 0.001) were observed in PM route compared with RS route. No difference was observed in the resection type, harvested lymph node, intensive care unit and hospital stay, postoperative complications, and in-hospital mortality between the two routes (all P > 0.05). CONCLUSIONS: Both RS route and PM route were safe and effective. PM route was associated with shorter operation time, less blood loss, but longer route length compared with RS route.

[Esophagoplasty in combined scarry lesions of the esophagus, laryngopharynx and the trachea in children].

The experience of plasty of the pharynx and esophagus with graft of the free small intestine segment was presented in 12 children after burn stricture by the potassium permanganate. The technical aspects of operation using methods of the reconstructive vascular surgery were described. Good short-term result was obtained in all the patients. The long-term results were investigated during 15 years. It was observed, that the graft diverticulum developed by 4-7 years in 3 patients, whom repeated operation should be performed. According to the authors, the regional plasty of the esophagus by free revasculizated small intestine graft was really effective surgical supply and could be considered as the method of choice in limited scarry lesions of the pharynx and cervical esophagus, but the method should be improved.

Learning curve of thoracoscopic repair of esophageal atresia.

BACKGROUND: Thoracoscopic repair of esophageal atresia is considered to be one of the more advanced pediatric surgical procedures, and it undoubtedly has a learning curve. This is a single-center study that was designed to determine the learning curve of thoracoscopic repair of esophageal atresia. METHODS: The study involved comparison of the first and second five-year outcomes of thoracoscopic esophageal atresia repair. RESULTS: The demographics of the two groups were comparable. There was a remarkable reduction of postoperative leakage or stenosis, and recurrence of fistulae, in spite of the fact that nowadays the procedure is mainly performed by young staff members and fellows. CONCLUSIONS: There is a considerable learning curve for thoracoscopic repair of esophageal atresia. Centers with the ambition to start up a program for thoracoscopic repair of esophageal atresia should do so with the guidance of experienced centers.

The development of cardiac surgery in West Africa--the case of Ghana.

West Africa is one of the poorest regions of the world. The sixteen nations listed by the United Nations in this sub-region have some of the lowest gross domestic products in the world. Health care infrastructure is deficient in most of these countries. Cardiac surgery, with its heavy financial outlay is unavailable in many West African countries. These facts notwithstanding, some West African countries have a proud history of open heart surgery not very well known even in African health care circles. Many African health care givers are under the erroneous impression that the cardiovascular surgical landscape of West Africa is blank. However, documented reports of open-heart surgery in Ghana dates as far back as 1964 when surface cooling was used by Ghanaian surgeons to close atrial septal defects. Ghana's National Cardiothoracic Center is still very active and is accredited by the West African College of Surgeons for the training of cardiothoracic surgeons. Reports from Nigeria indicate open-heart surgery taking place from 1974. Cote D'Ivoire had reported on its first 300 open-heart cases by 1983. Senegal reported open-heart surgery from 1995 and still runs an active center. Cameroon started out in 2009 with work done by an Italian group that ultimately aims to train indigenous surgeons to run the program. This review traces the development and current state of cardiothoracic surgery in West Africa with Ghana's National Cardiothoracic Center as the reference. It aims to dispel the notion that there are no major active cardiothoracic centers in the West African sub-region.

Reflux esophageal stricture--a review of 30 years' experience in children.

PURPOSE: Strictures of the esophagus in children may have multiple etiologies including congenital, inflammatory, infectious, caustic ingestion, and gastroesophageal reflux (peptic stricture [PS]). Current literature lacks good data documenting long-term outcomes in children. This makes it difficult to counsel some patients about realistic treatment expectations. The objective of this study is to evaluate our institutional experience and define the natural history and treatment outcomes. METHODS: A retrospective review of clinical data obtained from children who underwent dilation for PS was performed. RESULTS: Over the past 30 years, 114 children and adolescents received 486 dilations. The most common indications for stricture dilation were PS (42%) and esophageal atresia (38%). Other lesser indications included congenital, foreign body, corrosive, cancer, radiation, allergic, and infectious. This review focuses on the 48 children with PS. Of the children with PS, a congenital anomaly was identified in 23 children; and 12 had neurologic impairment. Average age at presentation was 10.2 years (range, 0.5-18.3 years). Most patients had had symptoms for many months before diagnosis. Peptic stricture was most common in the lower esophagus (n = 39). However, middle (n = 8) and upper (n = 1) strictures were occasionally identified. Noncompliance with medical therapy was a challenge in 12% (n = 5) of children. Children with a PS received a median of 3 dilations, but a subset of 5 patients with severe strictures underwent up to 48 dilations (range, 1-48). Repeated dilations were required for a median of 20 months (range, 1-242 months). Among patients receiving esophageal dilation for PS, 94% required an antireflux procedure (19% required a second antireflux surgery). A subgroup of patients (n = 10) was identified who required extended dilations, multiple surgeries, and esophageal resection. This subgroup had a significantly longer period of symptomatic disease and increased risk of esophageal resection compared with those patients requiring fewer dilations. Surgical resection of the esophageal stricture was ultimately required in 3 children with PS after failure of more conservative measures. CONCLUSION: Children and adolescents presenting with reflux esophageal stricture (PS) frequently require antireflux surgery, redo antireflux surgery, and multiple dilations for recurrent symptoms. We hope that these data will be of use to the clinician attempting to counsel patients and parents about treatment expectations in this challenging patient population.

National trends in outcomes for esophageal resection.

BACKGROUND: Case-series reports from tertiary centers report improved outcomes for esophageal resection in recent years. The objective of the current study was to determine trends in short-term outcomes after esophageal resection in a representative sample of United States (US) hospitals. METHODS: Observational study of all adult patients in the Nationwide Inpatient Sample who underwent esophageal resection from 1988 to 2000 (N = 8,657). Temporal trends of in-hospital mortality and prolonged length of stay were determined. Analyses were performed for all hospitals after stratifying by hospital volume. The proportion of patients having surgery at high volume hospitals was used to assess changes in referral patterns. RESULTS: The overall mortality rate was 11.3% and revealed a modest but significant decline from 13.6% to 10.5% during the study period (p = 0.001). Low volume hospitals had markedly higher mortality rates and showed no improvement over time (15.3% vs 14.5%). In contrast, high volume hospitals indicated significant reduction in mortality over time (11.0% vs 7.5%, p = 0.003). Referral patterns changed over time with the proportion of esophageal resections performed at high volume hospitals increasing from 40% (1988 to 1991) to 57% (1997 to 2000). CONCLUSIONS: The operative mortality rate for esophageal resection has declined over the past 13 years, particularly at high volume hospitals. Efforts should be made to understand the processes of care underlying this improvement.

Techniques and results of esophageal cancer surgery in Germany.

AIMS: This study evaluated the techniques and short-term results of surgical treatment for esophageal cancer in Germany by a nationwide representative survey. METHODS: In 2000 a questionnaire including 63 structured items concerning indication, technique, number of procedures, complications, and hospital mortality was sent to 308 randomly selected general, gastrointestinal, and thoracic surgeons and all university hospitals in Germany (20% of all surgeons). The response rate was 76% ( n=234). RESULTS: In 1999 the 56 participating hospitals performed approximately 370,000 procedures, including 1,677 operations for esophageal diseases, including 891 esophagectomies, 706 for esophageal cancer, 285 for cancer of the cardia. Gastric interposition was the most common technique to restore alimentary tract continuity (86%). Interposition of the colon (ascending colon 64%) is a common procedure only in 22 centers, indicating that experience with this means of esophageal reconstruction is limited. There were no significant differences in complication and mortality rates between gastric transposition and colon interposition. The overall complication rate was 61%, with 36% after gastric interposition and 42% after colon interposition. Anastomotic leakages occurred in 12% and 15%, respectively, and the rate of graft necrosis was 3% in both groups. Hospital mortality was 8% with gastric transposition and 11% with colon interposition. Mean postoperative hospital stay was 24 days. CONCLUSIONS: This study indicates that gastric transposition is frequently used for reconstruction after esophageal resection for malignant disease. It appears that the colon is not as accepted as the stomach for reconstruction, although the reported complication rates compare well with those reported after gastric transposition. This study allows a realistic evaluation of the overall risk of these surgical techniques.

Using the Veterans Health Administration inpatient care database: trends in the use of antireflux surgery.

Context. In the private sector, the use of surgery to treat gastroesophageal reflux disease has increased substantially since the development of minimally invasive laparoscopic techniques. However, trends in the use of antireflux surgery in the Veterans Affairs (VA) health care system have not been explored. Objective. To compare secular trends in the use of antireflux surgery in VA hospitals and the private sector. Data Sources. VA data are from the 1991-1999 medical SAS datasets for inpatient care (commonly known as patient treatment files); private sector data are from the 1991-1997 Nationwide Inpatient Sample and the U.S. census. Calculations. We compared secular trends in the use of antireflux surgery in the VA and private sector with each group's baseline rate in 1991. For the VA, we calculated annual rates of antireflux surgery among active users of the VA health care system by dividing the number of procedures (based on the appropriate procedure codes from the International Classification of Diseases, ninth revision, clinical modification) by the number of veterans who had at least two hospital or clinic visits in a given year. For the private sector, we calculated true population rates by dividing procedure counts by the total U.S. population. Results. From 1991 to 1995, the annual rate of antireflux surgery among active users of VA hospitals increased by 64%, then decreased over the next 4 years to almost baseline rates. In contrast, rates of antireflux surgery in the private sector increased 185% from 1991 to 1995, then appeared to reach a plateau thereafter. Among patients undergoing antireflux surgery, those in the VA were less likely than those in the private sector to undergo laparoscopic surgery (29% vs. 65%, respectively, in 1997). Conclusions. With the development of laparoscopic surgery, rates of antireflux surgery in VA hospitals increased only modestly compared with the private sector and have decreased in recent years. Both patient and provider factors may explain the substantially higher use of this procedure in the private sector.

Intestinal bypass of the oesophagus: 117 patients in 28 years.

This study includes 117 patients operated upon in the period from 1970 to 1999. Indications, surgical techniques, complications, and results are reviewed. Indications included: long-gap oesophageal atresia with or without fistula in 81 patients; peptic stenosis in 19; caustic stenosis in 12; oesophageal varices in 2; and 1 case each of oesophageal epidermolysis bullosa, total oesophageal leiomyomatosis, and a non-functioning antiperistaltic retrosternal colic graft operated upon in another hospital. A retrosternal bypass was performed 106 times: 98 first operations and 8 redos; the intrathoracic technique was used 19 times. The left transverse colon was used in 107 cases (85.6%), the right transverse colon in 8 (6.4%), and the ileocecum in 10 (8%). All the intestinal bypasses were placed in the isoperistaltic direction. There were 5 deaths in the first 11 years of our experience; no patient died from 1982 on. Ten complications were treated conservatively (8%): 2 wound infections healed with medical treatment, and 8 leaks of the cervical anastomosis closed spontaneously. The major surgical complications were 8 gangrenous bypasses (6.4%), removed and reoperated about 1 year later utilizing an ileocolic retrosternal graft. Three cases of peptic disease of the colic bypass (2.4%) were successfully treated with the author's technique. Nine patients had minor surgical complications (7.2%): 3 strictures of the oesophagocolic anastomosis in a retrosternal bypass (resected and reoperated) and 6 cases of adhesive occlusion. In our opinion, the best substitute of the oesophagus is the colon, particularly the left transverse segment, which may be placed behind the sternum or in the oesophageal bed, always in the isoperistaltic direction. The low mortality (4%), restricted to the early period of our experience, and few major surgical complications (6.4%) are acceptable considering the importance of the operation, and the long-term results may be considered very satisfactory.

Band ligation or sclerotherapy as endoscopic treatment for oesophageal varices in schistosomotic patients: results of a randomized study.

Endoscopic sclerotherapy and banding ligation are the two preferred methods to treat oesophageal variceal bleeding. There are many reports dealing with such treatment in cirrhotic patients but we do not know how good they are to treat varices secondary to other forms of portal hypertension. Schistosomiasis mansoni is the main cause of portal hypertension and oesophageal varices in Brazil. We performed a prospective randomised study to compare: 1) the efficacy of both treatments in eradicating oesophageal varices, and 2) complications secondary to both treatments. Forty patients were divided in two groups. Both sclerotherapy and banding ligation were performed until variceal eradication. There were no severe complications. Variceal eradication was faster obtained with banding ligation than sclerotherapy although there was no statistical difference (mean number of sessions 3.05 vs 3.72, p = 0.053). Benign complications were equally frequent in both groups, although additional sedation was more common in the sclerotherapy group. We concluded that both treatments are equally effective in the eradication of oesophageal varices, although banding ligation is better tolerated by the patient and probably faster.

[The experience of 1100 esophagoplasties]. / Opyt 1100 plastik pishchevoda.

The experience of esophagoplasties in various benign diseases (566) and cancer (534) of the esophagus is outlined. The operation of choice now is extirpation of the esophagus by cervico-abdominal approach with one-state posterior-mediastinal esophagoplasty by the stomach or (in case of impossibility to form the graft from the stomach)--large bowel. If there are contraindications to such operation or in case of necessity of one-stage reconstruction of the pharynx the optimal operation is sub- and total bypass esophagoplasty by the large bowel.

[The morphofunctional status of the isoperistaltic gastric transplant for esophagoplasty]. / Morfofunktsional'noe sostoianie izoperistal'ticheskogo zheludochnogo transplantata dlia plastiki pishchevoda.

Thirteen patients with carcinomas of the esophagus underwent one-stage operations--extirpation of the esophagus without thoracotomy with simultaneous esophagoplasty using isoperistaltic gastric tube made of the greater curvature of the stomach, in posterior mediastinum with esophagogastrostomy in the neck. The morphofunctional state of the gastric transplants was investigated at early and late periods (for 8 months) after operations. The reduction of blood in the transplants to 40% of the initial, deterioration of acid production, depression of the motility, ischemic atrophy of mucosa and increased fibrosis in submucosa were revealed. Nevertheless satisfactory results of the isoperistaltic tubular esophagoplasty were obtained in 77% of patients in early periods and in 54% of the patients during the first year after operation.

[The importance of esophagojejunogastroplasty in the surgical treatment of cancer of the proximal stomach]. / O znachenii ézofagoeiunogastroplastiki pri khirurgicheskom lechenii raka proksimal'nogo otdela zheludka.

The study discusses the efficacy of a new method of esophagojejunogastroplasty during subtotal and maximum subtotal proximal resections of the stomach. The surgical technique is described in detail. Seventeen patients aged 47-70 years were operated on for stage II-III cancer of the cardia, subcardia and fundus of the stomach. Extensive sagittal diaphragmotomy was performed in 15 cases whereas two patients were operated on through the combined abdomino-thoracic access. Pancreonecrosis and unrecognized microperforation of the gallbladder accounted for two fatalities whereas the other 15 patients were discharged from the clinic in good condition. They were followed for 1-30 months and, within this period, no postresection disorders such as reflux-esophagitis, cicatricial stricture of esophageal anastomosis or dumping syndrome were observed.

Reemplazos de esófago; casuística y resultados / Esophagic replacement; results and casuistical

Presentamos los resultados obtenidos en reemplazos esofágicos, ya sea por elevación retroesternal del estómago o por interpolación de diversos sectores colónicos ascendidos por la misma vía. Las operaciones mencionadas se efectuaron en enfermedades benignas y malignas luego de esofagectomía toracoabdominal total y como "by-pass" sin resección esofágica. En todos los casos la anastomosis superior fue cervical. Son 118 casos (102 cánceres, 8 megaesófagos, 5 esofagitis cústica y 3 perforaciones del esófago torácico). En dicha serie se efectuó esofagectomía toracoabdominal total por toracotomía derecha y elevación gástrica retrosternal con anastomosis esofagogástrica en el cuello en 92 oportunidades, igual resección con interpolación ileocolónica derecha en 16, usando el colon transverso en 3 y el colon izquierdo en 1 y "by-pass" retroesternal con ileocolon sin resección esofágica en 6 casos. En los enfermos portadores de enfermedades benignas (megaesófago y esofagitis caústica), no se registró mortalidad inmediata y los resultados funcionales fueron excelentes a largo plazo. En el cáncer, la mortalidad global del 20% bajó en el último quinquenio al 8%; el 60% de los enfermos llegó al año de sobrevida; el 22,5% a los 3 años y sólo el 6,8% superó los 5 años. Para alcanzar mejores resultados es absolutamente necesario lograr el diagnóstico en la etapa de cáncer temprano.