Acquired benign esophagorespiratory fistula: report of 16 consecutive cases.

Sixteen cases of acquired benign esophagorespiratory fistula were treated in a 20-year period. A delay in diagnosis was usual, and most patients were first seen with a pulmonary infection already developed. Contrast esophageal x-ray studies established the diagnosis in all patients. There were seven esophagotracheal and nine esophagobronchial fistulas. A fistula between the esophageal diverticulum and a bronchus considered to be of inflammatory origin developed in 7 patients. A fistula as the consequence of trauma developed in 9 patients, and these fistulas were situated at a higher level of the respiratory tree. All patients underwent surgical treatment; in 12 it was definitive, and in 4 temporary gastrostomy was performed to improve nutrition before definite repair. The definitive repair consisted of eventual diverticulectomy, division of the fistula, and suture of both esophageal and respiratory defects. Two patients required esophageal resection and later reconstruction with colon interposition. One patient died, creating an operative mortality of 8.3% in the definitive-repair group. The remaining 11 patients had a gratifying long-term result. There were two deaths in the gastrostomy group due to an extremely poor condition of patients and debilitating pulmonary infection. Early diagnosis of this rare condition is necessary if severe pulmonary complications are to be avoided. Early direct repair gives excellent results.

[Limited or extensive surgery in gastric carcinoma?]. / Ogranicena ili ekstenzivna hirurgija karcinoma zeluca?

Although the incidence of gastric cancer has dropped it is still the most frequent carcinoma of dhe digestive tract. Surgical management of gastric carcinoma was always dependent on the stage of the disease. Contemporary knowledge of gastric lymph drainage and attempts to remove metastatic glands with the tumor gave rise to more optimism. In the beginning such and approach did not fulfill expectations, but during the past decades, especially in Japan, it became evident that more aggressive and extensive surgical procedures could benefit certain groups of patients. In order to asses this new approach it is necessary to have a unique TNM classification and to perform a rigorous and systematic identification of cancer metastasis in the lymph nodal system of the stomach. Comparison of partial gastric resection with limited standard lymphadenectomy to total gastrectomy with extensive lymphadenectomy is not possible. Nevertheless, patients with gastric cancer stages Ib, II and IIIa profit from more extensive surgery. The author present the modifications in the extent of surgical procedures for the management of gastric cancer. Special emphasis is drawn to the surgical technique and results of systemic extensive lymphadenectomy. The author has demonstrated the benefits of the new extensive surgical approach in he management of gastric cancer in his series. Operative mortality in the group of patients after systemic lymphadenectomy was 6.7% and the 5-year survival rate was 21.0%. In the group of patients where gastric resection with standard lymphadenectomy was performed postoperative mortality was 14.0% and the 5-year survival was only 5.3%.

[Reconstructive surgery of the oesophagus. Possibilities and organization]. / Rekonstruktivna hirurgija jednjaka.

For a number of anatomical and pathological reasons, reconstructive surgery of the oesophagus remains a difficult and complex surgical procedure. The vast experience of performing 1155 reconstructive surgical procedures at Prva hirurska klinika (First surgical clinic), part of Belgrade Medical Faculty, enables the author to reflect upon options and limitations of such operations. There is a considerable discrepancy between the results obtained from reconstructive surgery of the oesophagus and the cardia affected by malignant growths, and form treatment of benign strictures of the oesophagus--the latter producing significantly better results. Digestive tract tissue used in the reconstructive surgery, is applicable depending on the pathological condition, its location, the possibility of isolating a sufficiently long section, and its adequate vascularization. Best results were achieved when a segment of thejejunum was used, but only for distal lesions of the oesophagus. Good results were achieved also when segments of the colon were used, the left colon proving more useful than the right one. Stomach tissue produced the worst results in a series of reconstructions, because it was used primarily in cases where the oesophagus was affected by malignant growths. When comparing the data from this series with the findings from the world literature, we come to almost identical results as in cases of reconstructive surgery of the oesophagus affected with carcinoma. Our experience in reconstructive surgery treatment of benign lesions of the oesophagus produced consistently better results that those shown in reputable foreign statistics.

[Surgical treatment of achalasia]. / Operativno lecenje ahalazije.

A total of 356 patients were treated for achalasia during a thirty eight years period, ranging from 1955 to 1993 the author presents his results and therapeutic recommendations. Since 1970, patients were treated in a standardized manner, using the transabdominal approach in 85,71% patients and the transthoracic approach in 14,29% pts. The operative technique for cardiomiotomy is described in detail for both approaches. To achieve good postoperative result it is necessary, to perform complete miotomy in a length of 6-8 cm. The miotomy should extend no less than 2 cm onto the stomach. All circular muscle fibers of the esophageal muscular layer should be severed. Antireflux procedure was added in all 294 patients operated since 1970. The demonstrated Dor fundoplication was done for a transabdominal approach and the Belsey mark IV antireflux procedure for the transthoracic approach. Reflux esophagitis was found in 12,82% of patients postoperatively while esophageal stricture in only 1,5% patients. In another group of 49 patients operated prior to 1970 postoperative check-up demonstrated the reflux esophagitis in 35,13% and an esophageal stricture in 5,4%. Antireflux procedure is an additional but important procedure in the treatment of achalasia. Inappropriate indications and an inadequate technique result in severe complications. Different approaches in the surgical management of achalasia are discussed.

[Overview of reconstructive surgery and functional compensation in the digestive tract]. / Osvrt na rekonstrukciju i kompenzaciju funkcije digestivnog trakta.

This paper represents a short and overall overview of the reconstructive procedures of the esophagus, stomach, colon and rectum. Optimal reconstructive procedure has not been chosen only for the reconstruction of the digestive system. Precise selection of the patients and reconstructive methods must enable the correction of the possible functional disadvantages. Usage of adaptional and reserve possibilities of other organs and tissues will help the functional compensation of the lost segments of the digestive system. The understanding of the importance of the physiological approach to the reconstruction of the digestive system using the segments of stomach, jejunum or colon is of the most importance so that in this difficult segment of surgery adequate improvements can be achieved.

Modification of the Merendino procedure.

The jejunal interposition operation after resection of distal esophagus and cardia, designed by Merendino and Dilard, has not been widely employed until now. The complexity of the procedure, demanding high performance, and still unacceptable postoperative mortality, were limiting factors and a challenge for many surgeons. The aim of this paper is to present three modifications of the original technique, without changing the basic concept of the Merendino procedure. These modifications differ from the original technique in three main ways: the longer isoperistaltic jejunal segment, the terminolateral mechanical esophagojejuno anastomosis, and the placement of the lower jejunogastric anastomosis on the posterior wall of the stomach. This report comprises an experience in 29 patients operated on in period 1972 through 1995. There were two postoperative deaths and long-term results were excellent in all except one patient who had an ischemic stenosis of the transplanted jejunal segment. Despite this, the Merendino procedure, simplified by these modifications, deserves to be more frequently used in the treatment of undilatable or recurrent strictures and other benign lesions which require resection of the distal esophagus and cardia.

[The Collis-Nissen operation in the treatment of reflux due to esophageal stenoses associated with brachioesophagus]. / Collis-Nissen-ova operacija u lecenju refluksnih stenoza jednjaka udruzenih sa brachioesophagus-om.

Eight patients with esophageal reflux strictures and brachioesophagus were treated by endoscopic dilatation and the Collis-Nissen procedure between 1986 and 1990 at the Institute of Digestive Diseases, Belgrade University Clinical Center. Dilatation of the esophageal stricture was performed by the Eder-Puestow system. All strictures were dilated preoperatively to in average 45 Fr without any complications recorded. The average duration of the Collis-Nissen operation was 3.5 hours and it was hastened by the usage of GIA surgical stapler for construction of the Collis gastroplasty tube. Postoperative course was uneventrful in all eight patients and by dismissal all of them had satisfactory relief of dysphagia and barium esophagogram. Postoperative hospital stay averaged 13.0 days. Satisfactory symptomatic control of gastroesophageal reflux (no symptoms, no treatment) was achieved in 5 patients at a long-term follow-up. Two patients required periodic dilatations and antireflux therapy during the first postoperative year to achieve resolution of the dysphagia and no need for medical therapy. One patient had objective failure of reflux control and progression of stricture formation requiring reoperation. This patient underwent esophagectomy and esophagocoloplasty with a subsequent good result. The combined Collis gastroplasty-Nissen funduplication has become the operation of choice in patients with dilatable reflux stricture and esophageal shortening and a reasonable alternative to a formidable resectional procedures. This report evaluates the first experiences with a Collis-Nissen procedure in our country.

[Drug therapy of chronic tissue ischemia with improvement of microcirculation]. / Nasa iskustva u medikamentoznom lecenju hronicnih tkivnih ishemija poboljsanjem mikrocirkulacije.

In this study the experience in treating 213 patients suffering from chronic ischemia with improvement of the microcirculation has been discussed. Medicamental treatment of chronic ischemia in patients with various pathologiic alterations of the circulation is indicated in cases which do not indicate reconstructive surgery. In the abundance of measures adopted in the treatment of these pathologic conditions the authors summarize their experience with the use of Pentoxyphyllin (Trental). During 1976 theyy treated 213 patients with this drug: 142 patients with pathologically altereed arterial circulation 51 patients with pathologically altered venous circulation 20 patienst on whom transplantations using various tissue transplants were used. The plan of administration of the drug, its undesireable side effects and the manifesting vasoactive effects of trental at the microcirculatory level especially on the microcirculation in tissue with pathologicaly altered perfusions has been discussed. Based on the shortlasting and limeted experiences the authors conclude that this drug can be recommended in therapy for various conditions of pathologicaly altered tissues circulation.

Atrophic chronic gastritis and esophagogastric anastomotic leak after resection and reconstruction for esophageal carcinoma.

The incidence of anastomotic leakage after esophagectomy for cancer and reconstruction with the stomach was analyzed with respect to the presence of coexistent atrophic chronic gastritis (ACG). Of a total of 28 operated esophageal cancer patients with ACG, 6 patients developed an anastomotic leak at the cervical esophagogastrostomy (21%). Of a total of 8 operated esophageal cancer patients none of the patients developed an anastomotic leak. The ACG positive and the ACG negative patients were found to be well matched for age, sex, type of operation, transplant route, level of the anastomoses, and suture technique, and all were operated on by the same surgeons. The difference in leakage rate did not reach statistical significance.

Paraoesophageal hernia repair with and without concomitant fundoplication.

There is currently no consensus as to whether an antireflux procedure should accompany surgical repair of paraoesophageal hernia. Forty consecutive patients with paraoesophageal hernia were studied. Surgery routinely included transabdominal hernia reduction, excision of the sac and crural repair. The addition of fundoplication was based on the presence of preoperative endoscopic evidence of oesophagitis. Twenty-three patients without endoscopic oesophagitis had no antireflux procedure whereas 17 with oesophagitis underwent concomitant antireflux surgery. Thirty-six patients were followed for 1-7 years. Patients without endoscopic oesophagitis had no postoperative reflux problems. All patients with oesophagitis who underwent fundoplication were improved or cured of reflux. The selection of patients for antireflux repair can satisfactorily be based on preoperative endoscopic findings.

[Correction of failed primary surgical interventions in benign lesions of the esophagus]. / Korekcija neuspelih primarnih hirurskih intervencija kod benignih lezija jednjaka.

In an retrospective analysis of documentation and printed paper in period between 1964-1998 168 patients required reoperations in benign esophageal lesions. Failed initial interventions were found in 66 (39.28%) pts. operated in our clinic and 102 (60.71%) pts operated in other institutions in our country. The corrective procedure was possible in 140 (83.33%) pts and impossible in 11 (6.54%). Post-operative mortality was 7.73% so the definitive failed corrections were 14.27%. The main cause of failure were: Defective operative technique, wrong preoperative diagnosis and indications including inadequate initial procedure. Among the 168 pts undergoing corrective surgery, more than a half of pts had obstructive lesions requiring resections and reconstructions. Dilatation of the stricture was possible in 16% followed by total diversion, particularly in previous gastric surgery. Malignant degeneration of benign lesions were found in 10.71%. Only 4 pts (2.3%) refused suggested operations. Satisfactory long-term results especially in patients undergoing esophageal corrective reconstructions for benign diseases were good to excellent in regular yearly postoperative routine control examination.

[Esophagus preserving surgery--eversion and mucosal stripping]. / Postedna hirurgija jednjaka--everzioni i mukozni stripping.

The eversional stripping and esophageal mucosal stripping methods as standard procedures in the preserving esophageal surgery are presented in this paper. These procedures have indication limit and results are excellent in selected risk dependent group of patients. This review describes technique, indications and advantages of these techniques in comparision with conventional finger esophageal dissection.

[Primary suture of the esophagus with reinforcement using autologous tissue in the therapy of perforation of the thoracic esophagus]. / Primarna sutura jednjaka sa pojacanjem autolognim tkivom u terapiji perforacije torakalnog jednjaka.

Perforations of the esophagus are the serious problem and only promptly diagnosis and treatment with effective operation can change the fatal destiny of this patients. The most effective operations of early diagnosed perforations are the primar suture with buttresses with circumferential wrap of parietal pleura. Authors discuss 15 patients with perforations of thoracic esophagus. In six patients the perforation was only sutured, and in nine patients the suture line was buttressed with Grillo pleural wrap. In this group one patient had a leak at the suture line and died after reoperation. This data indicate that the pleural wrap should be used routinely.

[Anastomosis suture technic and complications of esophagocoloplasty in corrosive lesions]. / Tehnika sivenja anastomoza i komplikacije kod ezofagokoloplastika zbog korozivnih lezija.

For the reconstruction of the esophagus due to a corrosive stenosis a colon transplant is usually used. In all esophagocoloplastics three anastomosis are necessary: anastomosis that continues the alimentary tract, anastomosis of the distal part of transplant with the stomach or duodenum, and the most important proximal anastomosis of the esophagus (or pharynx) with the transplant. In the period of 29 years (from January 1, 1964 until December 31, 1993) on the Institute for digestive diseases in Belgrade 250 esophagocoloplastics were performed with 750 anastomosis, in the patients with corrosive stenosis of the esophagus. All the anastomosis are sewn in two layers with the interrupted or continuous stitch, except for the anastomosis with the pharynx where due to a structure of the wall a one layer continuous stitch was only possible. From 750 anastomosis in 30 patients or 4% an anastomotic leakage occurred and in only 4 patients or 0.5% it ended lethaly. Stenosis of the anastomosis occurred in 18 patients or 2.4%.

Esophagocoloplasty in the management of postcorrosive strictures of the esophagus.

The clinical data, technical considerations, early and late post-operative complications, and long-term follow-up results of esophagocoloplasty in the management of 176 patients with postcorrosive stricture of the esophagus are presented. All 176 colon segments were placed in the isoperistaltic position. Left colon transplants were used in 66.47% and the right colon with terminal ileum was used in 33.52% of patients. The postoperative mortality rate in the entire series was 5.68%. In the past 10 years the postoperative mortality rate was reduced to 1.96%. Long-term follow-up examinations were done for 144 patients (81.81%). Excellent results were noted in 87.50%, satisfactory results in 10.41%, and poor results in 2.08% of surgically treated patients at regular yearly check-ups during a follow-up period ranging from 1 to 24 years after operation.

Prevalence and clinicopathologic features of multiple squamous cell carcinoma of the esophagus.

BACKGROUND: The occurrence of independent synchronous esophageal carcinoma in patients with grossly invasive esophageal cancer (GEC) is well known. Although multiple primary carcinoma of the esophagus is not uncommon, the exact prevalence is controversial, and its clinicopathologic features remain relatively unknown. METHODS: Fifty-four patients with squamous cell GEC who underwent transthoracic esophagectomy with systematic lymphadenectomy between 1987 and 1991 at the Institute for Digestive Diseases, Belgrade University Clinical Center, were included in the study. RESULTS: Detailed histopathologic examination of the esophagus resected for squamous cell carcinoma was performed in 54 patients and revealed 17 patients (31%) with associated cancer independent of the main tumor. The second lesion was significantly less invasive than the main tumor. There was no significant difference (P = 0.06) in sex, age, main tumor site, tumor differentiation, tumor diameter, lymph node involvement, or tumor stage between patients with multiple cancer and patients with solitary cancer, but there was a significant difference in the depth of invasion (P < 0.01). The tumor stage in patients with multiple cancer was determined by the main tumor stage and was not influenced by the associated lesion. The prevalence of multiple primary cancer of the esophagus is lower in other reports than in this series. CONCLUSIONS: The patients in this study had significantly more invasive main tumors. It seems likely that a higher prevalence of multiple cancer may be expected in patients with advanced main tumor penetration. These results support the concept that the entire esophagus may be considered as one entity of field cancerogenesis.

[Paraesophageal hiatal hernia of the diaphragm]. / Paraezofagealne hernije hijatusa dijafragme.

Paraesophageal hernia (type II hiatal hernia) accounts for less than 5-10% of all herniation through the esophageal hiatus. Anatomically, it is distinguished from the more common sliding variety (type I hiatal hernia) by the position of the gastroesophageal junction. The management of paraesophageal hiatal hernia is influenced by the tendency of the herniated stomach to develop volvulus, which potentiates life-threatening complications that include complete gastric obstruction, bleeding, infarction and perforation. In a cases with gastroesophageal reflux one of the antireflux procedures had to be done. In the Institute of Digestive Diseases, in the 16 years period from 1980-1996, 37 patients had treated of paraesophageal hernia. Authors discuss their management strategies, especially the using of antireflux procedures.