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Ann Thorac Surg 2003;76:989-995
© 2003 The Society of Thoracic Surgeons

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Original article: general thoracic

Challenges in reversing esophageal discontinuity operations

^a University of Michigan Medical School, Ann Arbor, Michigan, USA
^b Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA

^* Address reprint requests to Dr Orringer, Section of Thoracic Surgery, University of Michigan Medical Center, 1500 E. Medical Center Drive, 2120 Taubman Center, Box 0344, Ann Arbor, MI 48109, USA.
e-mail: morrin{at}umich.edu

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
BACKGROUND: After catastrophic esophageal or gastric disruption results in esophageal discontinuity, operations to restore swallowing are surgical challenges.

METHODS: A retrospective review and assessment of functional results was performed in 40 patients (average age 59.9 years) who had 42 operations to reverse esophageal discontinuity between 1973 and 2002.

RESULTS: Esophageal discontinuity resulted from gastric necrosis after esophagectomy and esophagogastrostomy (n = 10) or hiatal hernia repair (n = 4), esophageal perforation complicating dilatation (n = 5), failed colonic or jejunal interpositions (n = 5), caustic ingestion (n = 4), Boerhaave syndrome (n = 4), esophagogastric anastomotic leak (n = 3), and other causes (n = 6). Eighteen patients (43.9%) required prolonged mechanical ventilation. Thirty-one (75.6%) had an end cervical esophagostomy; 6, an anterior thoracic esophagostomy; 2, lateral esophagostomy and in situ native esophagus stapled and divided distally; and 1 each, a stapled, divided esophagus without esophagostomy and a stapled undivided esophagus without esophagostomy. Twenty-six patients (63.4%) had undergone partial or total gastrectomy. Ten (24.4%) had vocal cord paralysis. Operations reestablishing continuity included colonic interposition in 23 (56.1%), substernal gastric interposition in 7 (17.1%), esophagectomy and cervical anastomosis in 6, esophageal reanastomosis in 3, staged jejunal interposition in 1, and Roux-en-Y esophagojejunostomy in 1. There were no hospital deaths. Twenty-eight patients (68.3%) had postoperative complications. Length of stay averaged 20.6 days. Follow-up for 40 patients averaged 54.5 months. Functional results (39 patients) were excellent in 12 (30.8%), good in 15 (38.5%), fair in 10 (25.6%), and poor in 2 (5.1%).

CONCLUSIONS: Successful reversal of esophageal discontinuity requires individualized assessment and ingenuity. Despite appreciable morbidity, the ultimate result is generally gratifying.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
The need to establish esophageal discontinuity typically arises from complications of esophageal reconstruction, hiatal hernias or their repairs, or iatrogenic or spontaneous esophageal rupture (Boerhaave syndrome). Regardless of the etiology, life-threatening mediastinitis and sepsis drive the decision to interrupt continued mediastinal soilage. The techniques for achieving this goal vary greatly and include ligating or stapling the thoracic esophagus in continuity proximally and distally to the perforation, with or without a lateral cervical esophagostomy; ligating or stapling the thoracic esophagus after resecting the area of perforation, with or without a lateral cervical esophagostomy; dividing the cervical esophagus and constructing an end cervical esophagostomy; and resecting the damaged esophagus and stomach and performing either an end cervical esophagostomy or anterior thoracic esophagostomy. Given the urgency with which these operations are undertaken, the focus is frequently on saving the patient's life and not on what future operations will be required to restore swallowing. Little has been written about the technical aspects of reversing esophageal discontinuity, the preoperative assessment, preparation and planning of the operations, and the functional results achieved. This study was undertaken to review our experience and to define the major challenges and guidelines in reversing esophageal discontinuity.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Between 1973 and 2002, 40 patients with esophageal discontinuity underwent 42 operations by the Thoracic Surgery Service at the University of Michigan Medical Center to reestablish alimentary continuity. One patient had staged jejunal reconstruction (two separate operations), and one had two operations to reverse two separate instances of primary esophageal discontinuity. He initially had his defunctionalized esophagus resected and a cervical esophagogastric anastomosis performed, but gastric tip necrosis required takedown of the anastomosis, cervical esophagostomy, and partial gastrectomy. He subsequently had a successful substernal colonic interposition. Thus, this series includes 41 instances of primary esophageal discontinuity treated with 42 operations. A retrospective review of the medical records of these patients and assessment of functional results was undertaken. Follow-up was obtained from the University of Michigan Esophageal Resection Database, through personal interviews and examinations, and written correspondence and telephone contact with patients and their families. In assessing the functional result of repair or esophageal replacement, factors analyzed included weight status and presence and degree of dysphagia, regurgitation, and postvagotomy dumping (postprandial diarrhea, cramping, sweating, nausea). The functional result at the time of last follow-up was graded as excellent (no symptoms), good (mild symptoms not requiring treatment), fair (symptoms requiring occasional treatment, eg, an esophageal dilatation for periodic dysphagia, antispasmodics for postprandial cramping), or poor (ongoing symptoms requiring regular treatment, eg, repeated regular dilatations for dysphagia, daily antispasmodics, or antidiarrheal medication). Satisfaction was assessed by asking patients whether they were pleased with the outcome of their operation to reestablish continuity, believed that they were better than before the operation, and given what they know now, whether they would have the operation again. Difficulty with arm range of motion and function after substernal bypass (necessitating resection of the sternoclavicular joint) was also assessed. Patients available for follow-up in 2002 were contacted by mail and invited to participate in a telephone interview to further assess functional results and quality of life outcomes. Of those who agreed, the SF-36v2 Health Survey, a standardized, validated tool which provides a generic measure of physical and mental health [1], was administered by telephone, and the results were compared with United States normal values. Statistical differences were determined using a one-sample t test. A statistical comparison of the time intervals between establishment of esophageal discontinuity and its reversal in patients who had discontinuity operations at the University of Michigan and those referred to us with esophageal discontinuity was also performed utilizing an independent samples t test. Statistical analyses were performed using SPSS software (version 11.0; SPSS Inc, Chicago, IL). This study was approved by the University of Michigan Institutional Review Board.

	Results

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
The 40 patients consisted of 23 (57.5%) men and 17 (42.5%) women, ranging in age from 26 to 84 years (average 59.9 years). The etiology of esophageal discontinuity varied (Table 1). These patients had reversal of discontinuity 1 to 33 months (average 7.7 months) after establishment of esophageal discontinuity. The 14 patients who had discontinuity established at the University of Michigan underwent operations to reverse their discontinuity 1 to 12 months (average 4.6 months) later. The 27 patients who had discontinuity established at outside hospitals presented for evaluation 1 to 19 months (average 5.9 months) later and had discontinuity reversed 2 days to 14 months (average 3.5 months) after presentation. Eighteen patients (43.9%) had required mechanical ventilation for respiratory insufficiency during treatment of their esophageal injury. Ten (24.4%) had vocal cord paralysis. All were being nourished with enteral feedings; 20 had gastrostomies; 33 had feeding jejunostomies; and 12 had both. They weighed 4 to 65 pounds (average 26.4 pounds) less than their weight before their esophageal perforation (data available for 32 patients).

Postoperative follow-up in 40 patients ranged from 1 to 206.5 months (average 54.5 months). Nineteen patients were unavailable for current follow-up. A search of the Social Security Death Index indicated that fifteen had died after 5.5 to 247 months (average 73.2 months). Known causes of death for 5 included metastatic disease (n = 2), pneumonia (n = 1), myocardial infarction (n = 1), and restrictive lung disease (n = 1). In these 19 patients, functional results at last follow-up were available 1 to 105 months (average 34.6 months) and were graded as excellent in 9, good in 5, and fair in 4. None had a poor functional result, and functional outcome information was not available for one. Overall functional results at last follow-up for 39 evaluable patients were graded as excellent in 12 (30.8%), good in 15 (38.5%), fair in 10 (25.6%), and poor in 2 (5.1%). More specifically, 21 patients (53.8%) had no dysphagia; 10 (25.6%) had occasional mild dysphagia that did not require treatment; 8 (20.5%) had periodic dysphagia that required an occasional esophageal dilatation; and none had severe dysphagia that required daily or weekly dilatations. Seventeen patients (43.6%) had no regurgitation; 6 (15.4%) had mild regurgitation only when reclining or prone after eating; and 16 (41%) were sleeping with the head of the bed elevated on blocks or in a reclining chair, but none had pulmonary complications resulting from aspiration. Twenty-one patients (53.8%) had no postprandial diarrhea or cramping; 10 (25.6%) had occasional postprandial diarrhea not requiring treatment; 5 (12.8%) had moderate diarrhea requiring antidiarrheal medications; and none had severe postprandial diarrhea requiring regular medication. Four patients (10.3%) had mild postprandial cramping requiring no treatment, and 2 (5.1%) had sufficient postprandial cramping to require regular use of antispasmodics. At last follow-up, 35 patients weighed an average of 31.3 pounds less than before their esophageal perforations that resulted in discontinuity.

Twenty-one patients were available for telephone follow-up in 2002 from 4 to 206.5 months (average 72.5 months) postoperatively. These interviews included assessment of functional results, patient satisfaction, and quality of life utilizing the SF-36v2 Health Survey. Functional results were graded as excellent in 3, good in 10, fair in 6, and poor in 2. Twenty patients were satisfied with the outcome of their operations, affirming that they were better off than they were before they had the operation to restore swallowing and would have the operation again, given what they knew now. Twelve (80%) of 15 who had undergone substernal gastric or colonic interposition with concomitant resection of the sternoclavicular joint experienced some, but usually minor, difficulty with function or movement of their ipsilateral arm or shoulder; there was occasional arm numbness in 3 and restriction in reaching or lifting above their heads in 4. The SF-36v2 Health Survey yields an eight-scale profile of scores and physical and mental health summary measures that can be compared to norms in the general United States population. The eight scales assess physical function (limitation in performing physical activities due to health), role-physical (problems with work or other daily activities as a result of physical health), bodily pain, general health (patients' evaluation of personal health), vitality (energy level and fatigue), social functioning (whether patients can perform normal social activities without interference secondary to physical or emotional problems), role-emotional (problems with daily activities as a result of emotional problems), and mental health (higher scores indicating a better health state). Because the average age of our surveyed patients was 65 years, we used the norms for comparison for the 65 to 74 year old age group. Statistically significant differences (p < 0.05) were found for only two scales, vitality and mental health (Table 3). For the two summary measures analyzed, physical and mental health, our patients had lower scores (43.19 and 46.14, respectively) than age-matched normal controls (44.70 and 53.17, respectively), but the differences were not statistically significant.

	Comment

Top Abstract Introduction Patients and methods Results Comment Discussion References

Individualized assessment and treatment of these patients is required. Twenty-seven (65.9%) of our patients had undergone discontinuity operations at other hospitals and presented for reconstruction several weeks or months later. Not uncommonly, such patients have lost substantial weight, are deconditioned from sedentary existence, and have struggled with complications of tube feedings, eg, abdominal cramping, diarrhea, and inflammation or infection around tube sites. Pulmonary hygiene is often compromised by impaired swallowing associated with recurrent laryngeal nerve injury that occurred during construction of a cervical esophageal anastomosis or cervical esophagostomy. Some patients have had the intrathoracic esophagus ligated, stapled, or divided and left in situ without a proximal diverting esophagostomy, resulting in recurrent aspiration of saliva. Others with a cervical esophagostomy have excoriated adjacent skin or a stenotic esophagostomy stoma impairing swallowing and causing salivary aspiration. Discarding potassium-rich saliva that drains into a neck bag may result in hypokalemia and profound muscle weakness. Failure to replace vitamin B12 after a gastrectomy may result in pernicious anemia affecting gait.

Before reversing the discontinuity, those issues must be addressed. An experienced dietician may readjust tube feeding regimens. A stenotic esophagostomy stoma should be dilatated to a size 46F Maloney bougie, followed by daily dilatation with a gloved, lubricated finger by the patient or family. Laryngoscopic evaluation of hoarseness establishes vocal cord paralysis. The cervical esophagus should be approached through the ipsilateral side of the neck to avoid possible bilateral recurrent laryngeal nerve damage. Aggressive physical reconditioning for several weeks preoperatively is critical. Walking 1 to 3 miles a day and use of an incentive inspirometer is routinely advocated. Essential vitamin B12 is replaced. Unhealed abdominal wounds are permitted to granulate closed. Local infection and excoriated skin around feeding tube sites are treated. Reversal of esophageal discontinuity is entirely elective and should be delayed to optimize strength and pulmonary status. If a completion esophagectomy is required after prior mediastinitis, or gastric or colonic interposition is required after an upper abdominal infectious complication, discontinuity reversal is delayed for 6 months to allow resolution of the local inflammation.

The stomach is the optimal organ for esophageal replacement both for benign and malignant disease [13]. If the stomach and right gastroepiploic vessels are intact, even with a prior gastrostomy, it is the preferred esophageal substitute. The gastrostomy tube is removed and the site closed with a gastrointestinal anastomosis surgical stapler applied in the vertical axis of the stomach to minimize tension on the closure as the stomach is pulled into the mediastinum for a cervical esophagogastric anastomosis. Many patients with esophageal discontinuity have had a partial or total gastrectomy. In others, the stomach might not be usable for esophageal replacement after remobilization after multiple upper abdominal operations. The surgeon must be prepared to utilize alternative conduits. Suitability of the colon as an esophageal substitute is assessed with a barium enema. In patients with arteriosclerotic cardiovascular disease, mesenteric angiography is performed to ensure adequate blood supply for colonic interposition. When neither the stomach nor any portion of the colon is suitable, small intestine remains the only option. In one such patient of ours, a Rous-en-Y jejunal limb was positioned retrosternally as far cephalad as it would reach, and a stoma was created just above the remaining distal two thirds of the sternum. The left sternoclavicular joint and upper third of the sternum were resected to enlarge the superior opening into the superior mediastinum. After 2 months, a free jejunal graft between the cervical esophagus and the previously placed lower retrosternal jejunum was performed. Use of extended jejunal interpositions augmented by microvascular anastomosis of a second or third jejunal artery, as described more recently [14–17], obviates the need for two separate operations in such situations.

Management of the stapled or ligated thoracic esophagus in situ with or without a proximal cervical esophagostomy is problematic. With a normal esophagus before the perforation and exclusion, it is assumed at the time of discontinuity reversal that the perforation has healed. It may be possible to establish a lumen by disrupting the esophageal exclusion staple suture line(s), reconnecting the divided cervical esophagus, and avoiding the need for esophageal resection and reconstruction. With a divided cervical esophagus and a gastrostomy, retrograde disruption of an intrathoracic esophageal staple suture line is facilitated by general anesthesia and a fluoroscopic C-arm. The gastrostomy tube is removed, the stoma is dilated by passing 34F through 46F Maloney dilators through it, a flexible esophagoscope is introduced into the stomach, and the esophagus is cannulated retrograde under direct vision. Then, using a fluoroscopically positioned guidewire, progressive Savary dilators to a 46F size are used to disrupt the esophageal staple suture line. Esophageal patency is confirmed by repeat retrograde esophagoscopy. The gastrostomy tube is reinserted. Several days later, the cervical esophagostomy can be taken down and the divided cervical esophagus reanastomosed, the procedure facilitated again by retrograde esophagoscopy through the gastrostomy. The esophagoscopy light that is visible through the sutured esophageal wall in the neck aids in localizing the distal end of the divided esophagus. A partial upper sternal split may also facilitate exposure for the reanastomosis.

One of the most challenging situations for reversing discontinuity results from resecting a portion of the thoracic esophagus containing the site of the perforation and leaving the stapled or sutured proximal end of the esophagus in situ in the native esophageal bed. This approach to the management of an esophageal perforation is ill conceived. A stapled or sewn esophageal suture line in an infected mediastinum commonly disrupts, resulting in recurrent empyema and mediastinitis. Furthermore, even if healing of the divided esophagus proceeds uneventfully, when the cervical esophagus is connected to the visceral esophageal substitute, the remnant thoracic esophagus should still be resected to prevent mucocele formation. Blunt mobilization of the remnant esophagus through a cervical incision or the diaphragmatic hiatus may be impossible because of mediastinal fibrosis involving the end of the divided intrathoracic esophagus. A transthoracic completion esophagectomy is then needed before proceeding with esophageal replacement.

Positioning of the esophageal replacement in the chest can be a challenge. After a completion esophagectomy, the normal posterior mediastinal esophageal bed is the shortest, most direct, and preferred route. With obliteration of the posterior mediastinum by a prior esophagectomy, the retrosternal route is the next best option. With a retrosternal esophageal replacement, the medial clavicle and sternoclavicular joint should be resected to enlarge the anterior opening into the superior mediastinum at the thoracic inlet, thereby preventing impingement by the posterior prominence of the clavicular head [18]. Resection of the sternoclavicular joint is generally well tolerated, but the resulting early shoulder droop can cause compression of the stretched subclavian vein over the first rib and swelling of the ipsilateral arm. This arm should therefore be elevated in the immediate postoperative period, and no intravenous fluids should be administered through it. As was the case in 12 of 15 such patients we surveyed, long-term sequelae of sternoclavicular joint resection on arm function were usually minor. When neither the posterior mediastinal nor retrosternal routes are available for esophageal substitution, the esophageal substitute can be positioned in the thorax in a paramediastinal route, either posterior to the pulmonary hilum as originally described by Waterston [19] or anterior to the hilum. We do not utilize the subcutaneous antethoracic route for esophageal substitution because it is cosmetically and functionally unacceptable.

The challenges of preparing these patients and reversing esophageal discontinuity are substantial. The long-term functional outcome of these operations is poorly documented. Varghese and associates [20] described 4 patients with discontinuity from Boerhaave syndrome, 3 of whom were treated with delayed subcutaneous colonic interposition. Their discontinuity operation was transthoracic esophagectomy, feeding gastrostomy, and left cervical esophagostomy. Quality of life self-assessment (on a 1 to 10 scale) of the 3 patients whose discontinuity was reversed indicated a score of 10 before the discontinuity operation, 4 after it, and 8 after restoration of continuity. Our assessment of functional results in 39 patients followed up an average of 54.5 months and quality of life in 21 patients surveyed an average of 72.5 months after reversal of esophageal discontinutiy documents the excellent long-term results consistent with near-normal functioning and enjoyment of life which can be obtained with careful preoperative planning, reconditioning, and intraoperative and postoperative management.

	Discussion

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
DR THOMAS J. WATSON (Rochester, NY): An excellent presentation, very clear and concise. We value the leadership that Dr Orringer and the group at Michigan have provided in this complex group of patients.

I have two questions on specific circumstances. Number one, if you are in the situation where you have to reconstruct the esophagus using a substernal conduit, and if there are several organs available, the stomach, the colon, and the small bowel, which would be your organ of choice? I know that your group has previously reported a high leak rate with the substernal stomach, and I am also curious if you have any insights regarding functional results with the various conduits in this position.

DR ORRINGER: The stomach is our preferred organ with which to replace the esophagus whether in the substernal or posterior mediastinal route. The leak rate with a substernal graft, regardless of what organ is used, is higher than when the replacement is placed in the esophageal bed. This is a function of the fact that a cervical esophageal anastomosis to either substernal colon or stomach is essentially subcutaneous and unsupported during coughing or Valsalva maneuvers in the early postoperative period, whereas a conduit placed in the normal esophageal bed deep within the neck is supported by the sternocleidomastoid muscle and carotid sheath laterally, the spine posteriorly, the trachea and thyroid medially, and the overlying strap muscles anteriorly. We have found, however, that with the use of a stapled cervical esophagogastric anastomosis, the leak rate has been dramatically reduced. Whichever organ is placed substernally, we still recommend resecting the sternoclavicular joint to enlarge the opening into the anterior mediastinum.

DR WATSON: Second question. Is there ever a situation where you would electively choose to two-stage these reconstructions? In other words, suppose you have a patient whose esophagus is still intact, they may have had multiple prior operations, they may be obese, or they may be aspirating, would you ever electively do the esophagectomy, give them a spit fistula and bring them back later for the reconstruction?

DR ORRINGER: In situations in which we do not believe that we can repair a perforation, and these are few and far between, we proceed with an esophagectomy and establish discontinuity. However, when we take out the esophagus, we preserve as much of the esophagus as we can, constructing an anterior thoracic esophagostomy. The extra esophageal length may be invaluable in the subsequent reconstruction.

DR WATSON: I am talking about the case where a patient is sent to you and their esophagus is still intact. They may be stapled above and below, they may have had a failed gastric interposition for whatever reason, a gastric pull-up for whatever reason. Would you ever electively two-stage them from that point onward?

DR ORRINGER: Christina has done a beautiful job presenting a group of patients that are as disparate as you can imagine, and there are obviously some patients with just the situation you describe, with discontinuity and an excluded esophagus still in situ.

Your question cannot be answered simply. You have to take into account whether the esophagus was normal and when it was first assaulted. If, for example, a normal esophagus was perforated at the time of an endoscopy and was stapled above and below the tear, it is likely that by the time you see the patient 3 months later, the perforation has healed. Through a gastrostomy, as we described, one may carry out a retrograde dilatation and force open the staple suture line, re-establishing a normal esophageal lumen. So we try to preserve an intrinsically normal esophagus if at all possible.

Some of the worst scenarios we have encountered have been in patients whose esophagus had been stapled or partially resected in an infected mediastinum, and then 3 to 5 days later, the suture lines disrupted, and the patient had a recurrent empyema and hydropneumothorax and then required a completion esophagectomy and esophagostomy.

If you are in the desperate situation in which a patient with an esophageal perforation is virtually dying from the associated sepsis, you are just better off getting the esophagus out of the mediastinum. It gives the patient his best chance of survival and makes the subsequent reconstruction easier. We prefer not to stage later reconstruction in patients with an excluded diseased esophagus in situ and will remove the excluded esophagus and use the normal esophageal bed, if possible, for positioning of the esophageal replacement.

DR LESLIE KOHMAN (Syracuse, NY): Your long-term telephone follow-up was only in 20 patients, which is only half the patients, and they had a very high satisfaction rate. So I think the lack of 50% of your data may be very significant in terms of what happened to the other 50% of the patients. Do you have any reason to believe that they are equally as satisfied as the ones you were able to contact?

DR ORRINGER: We attempted to make all follow-up contacts as current as possible. We found, however, that only 21 were available for telephone interviews in 2002. We explained where the rest of the missing group were. A number of these patients were operated on for cancer and had succumbed to their disease. Postoperative follow-up in 40 of our patients ranged from 1 to 206.5 months and averaged 54.5 months. Nineteen were unavailable for current (2002) follow-up, and we report the functional follow-up in this group, followed up for an average of 34.6 months, separately from those who had the telephone interview and SF-36 survey last year. In general, we have complete follow-up in most patients until the time of death. I agree with the importance of complete follow-up, Dr Kohman.

DR STEPHEN C. YANG (Baltimore, MD): What influence does the advanced stage of the esophageal cancer have on your decision whether to take this down or not?

DR ORRINGER: Plenty. The question of reconstructing a patient who has undergone a discontinuity operation for complications of an esophagectomy for advanced cancer is very pertinent. These patients have such a poor life expectancy that we advise waiting 6 to 12 months before reversing discontinuity. Most do not survive long enough to be reconstructed.

In closing, I would like to commend our fourth-year medical student, Christina Barkley, for an outstanding job of collating these data, doing the real foot work in writing this paper, and carrying out the statistical analysis. Mentorship of such students needs to be a priority for our specialty and will bring new blood into our ranks. Thank you.

	References

Top Abstract Introduction Patients and methods Results Comment Discussion References

 

1. Ware J.E., Kosinski M., Dewey J.E. How to score version 2 of the SF-36 Health Survey. . Lincoln, RI: QualityMetric Incorporated, 2000.
2. Luc M, Grillo HC, Malt RA. Operative and nonoperative management of esophageal perforations. Ann Surg 1981;194:57–63.1
3. Skinner D.B., Little A.G., DeMeester T.R. Management of esophageal perforation. Am J Surg 1980;139:760-764.[Medline]
4. Bufkin B.L., Miller J.I., Jr, Mansour K.A. Esophageal perforation: emphasis on management. Ann Thorac Surg 1996;61:1447-1452.[Abstract/Free Full Text]
5. Davis E.A., Heitmiller R.F. Esophagectomy for benign disease: trends in surgical results and management. Ann Thorac Surg 1996;62:369-372.[Abstract/Free Full Text]
6. Iannettoni M.D., Vlessis A.A., Whyte R.I., Orringer M.B. Functional outcome after surgical treatment of esophageal perforation. Ann Thorac Surg 1997;64:1606-1610.[Abstract/Free Full Text]
7. Pate J.W., Walker W.A., Cole F.H., Jr, Owen E.W., Johnson W.H. Spontaneous rupture of the esophagus: a 30-year experience. Ann Thorac Surg 1989;47:689-692.[Abstract]
8. Reeder L.B., DeFilippi V.J., Ferguson M.K. Current results of therapy for esophageal perforation. Am J Surg 1995;169:615-617.[Medline]
9. Brewer L.A., Carter R., Mulder G.A., Stiles Q.R. Options in the management of perforations of the esophagus. Am J Surg 1986;152:62-69.[Medline]
10. Orringer M.B., Stirling M.C. Esophagectomy for esophageal disruption. Ann Thorac Surg 1990;49:35-43.[Abstract]
11. Sakamoto Y., Tanaka N., Furuya T., et al. Surgical management of late esophageal perforation. Thorac Cardiovasc Surgeon 1997;45:269-272.[Medline]
12. Jones W.G., Ginsberg R.J. Esophageal perforation: a continuing challenge. Ann Thorac Surg 1992;53:534-543.[Abstract]
13. Orringer M.B., Marshall B., Iannettoni M.D. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 1999;230(3):392-400.[Medline]
14. Chana J.S., Chen J., Sharma R., Gedebou T.M., Feng G. Microsurgical reconstruction of the esophagus using supercharged pedicled jejunum flaps: special indications and pitfalls. Plastic Reconst Surg 2002;110:742-748.
15. Heitmiller R.F., Gruber P.J., Swier P., Singh N. Long-segment substernal jejunal esophageal replacement with internal mammary vascular augmentation. Dis Esophagus 2000;13:240-242.[Medline]
16. Hirabayashi S., Miyata M., Shoji M., Shibusawa H. Reconstruction of the thoracic esophagus, with extended jejunum used as a substitute, with the aid of microvascular anastomosis. Surgery 1993;113:515-519.[Medline]
17. Inoue Y., Tai Y., Fujita H., et al. A retrospective study of 66 esophageal reconstructions using microvascular anastomoses: problems and our methods for atypical cases. Plast Reconst Surg 1994;94:277-284.[Medline]
18. Orringer M.B., Sloan H. Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J Thorac Cardiovasc Surg 1975;70:836-851.[Abstract]
19. Waterston D. Colonic replacement of esophagus (intrathoracic). Surg Clin North Am 1964;44:1441-1447.
20. Varghese D., Patel H., Waters R., Dickson G.H. Quality-of-life study on four patients who underwent esophageal resection and delayed reconstruction for Boerhaave's syndrome. Dis Esophagus 2000;13:314-316.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mark B. Orringer Mark D. Iannettoni John Yee Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Barkley, C. Articles by Yee, J. Search for Related Content PubMed PubMed Citation Articles by Barkley, C. Articles by Yee, J. Related Collections Esophagus - other