Peptic Ulcer in Children With Gastric Tube Interposition By Kathryn
D. Anderson,
Judson G. Randolph,
and John R. Lilly
R
ECENT REPORTS have described the use of a gastric tube for esophageal substitution.‘4 The principal advantages of this interposition procedure are uniformly excellent vascular supply and assurance of good length. Furthermore, it is the technique of choice when there are coexisting anorectal anomalies that preclude the use of the colon. From a technical standpoint, the operation is relatively simple and especially well tolerated in children. The gastric tube has proved to be a highly satisfactory conduit, allowing adequate oral intake for normal nutrition and growth. Recently, however, we have encountered two cases in which frank ulceration of the tube occurred, one of which necessitated its abandonment. These cases will be reviewed in detail in this report in an attempt to identify those conditions that may have contributed to ulcer formation. CASE
REPORTS
Case 1 A 3-yr-old female was hospitalized after ingesting liquid lye. Esophagoscopy confirmed the presence of a severe esophageal burn. Intensive initial treatment with steroids and antibiotics failed to prevent stricture, in spite of the usual efforts at dilatation. Attempts to preserve the esophagus were not fruitful and a reverse gastric tube, positioned behind the root of the left lung, was constructed to bypass the strictured esophagus. The child restmILd oral feedings and rapidly gained weight. Postoperative barium studies, 1 and 8 mo after surgery, showed some redundancy of the tube in the chest above the diaphragm, but there was unimpeded flow of barium into the stomach. Another contrast study was obtained I yr after surgery when the patient developed persistent vomiting of coffee-ground material, which was proven to be blood. An ulcer crater with radiating edematous folds in the posterior, redundant portion of the gastric tube (Fig. I) as well as delayed emptying of the tube through the diaphragm were demonstrated radiographically: Direct endoscopic visualization confirmed the presence of the ulcer crater and demonstrated marked edema and’inflammation of the adjacent mucosa. She was treated with a standard antacid regimen and elevation of the head of the bed. Her symptoms had resolved 1 mo later, and the ulcer could not be seen by esophasgoscopy although it was still detectable on barium study. She remained asymptomatic and a study done I yr later showed complete radiologic resolution. She remains well 4 yr after surgery.
Case
2
An IS-mo-old boy developed to swallow liquids, a gastrostomy
an esophageal stricture after was done 2 mo after injury.
ingesting Feedings
lye. Because of inability through the gastrostomy
From the Department ofSurgery, Children’s Hospital National Medical Center, Washington, D. C.. and the Department of Surgery. University of Colorado Medical Center, Denver, Colo. Presented bejore the 6th Annual Meeting of the American Pediatric Surgical Association, San Juan, Puerto Rico, April 10-12, 1975. Supported in part by Grant RR284 from the General Clinical Research Center of the National Institutes of Health. Address for reprint requests: Kathryn D. Anderson, M.D., Center. 2125 13th St.. N. W.. Washington, D.C. 20009. 0 1975 by Grune & Stratton, Inc. Iournaf of Pediatric Surgery, Vol. 10, No. 5 (October), 1975
Children’s
Hospital
National
Medical
701
702
ANDERSON,
RANDOLPH,
AND
LILLY
Fig. 1. Ulcer cmter in gastric tube with md
edematous folds. Note dancy of tube in chest.
Iredun-
esophagram showed a tracheoesophageal fistula just tube refluxed into the mouth. A retrograde above the carina. The esophagus was diverted, therefore, as a cervical esophagostomy, and the esophagogastric junction was transected and oversewn. Subsequently, a retrosternal gastric tube was constructed to bypass the destroyed esophagus. Two months after this operation he experienced hemorrhage from the tube through a persistent cutaneous fistula at the cervical anastomosis. This anastomosis was stenotic and refractory to dilatation. A barium study obtained through the cervical cutaneous fistula showed narrowing of the gastric tube at the diaphragm (Fig. 2A). It was reasoned that this distal stricture might be causally related to ulceration and hemorrhage within the tube, further perpetuating the cervical salivary fistula. Therefore, the gastric tube was removed from its substernal position and the narrowing was corrected at the diaphragmatic hiatus. The gastric tube bypass was replaced beneath the sternum and reanastomosed in the neck. The patient did relatively well for 6 mo; at that time a routine follow-up esophagram showed stricture and ulceration in the midportion of the gastric tube. Despite intensive treatment with a regimen of antacids and milk, the ulcer failed to heal. Repeated dilatations did not result in improvement in the stricture (Fig. 2b). The cervical fistula recurred during treatment. The pH of the cervical fistula drainage was acidic (pH, IS), suggesting reflux from the stomach or distal gastric tube. The gastric tube was abandoned, and a colon interposition was carried out through the chest. The patient has done well. Pathologic examination of the gastric tube showed extensive inflammatory ulceration and fibrosis (Fig. 3A and II).
DISCUSSION
The use of the gastric tube has been developed by Beck and Carrel,5 Jianu,6 Gavriliu,’ and Heimlich* and adapted by Burrington and Stephens in 196g2 for use in children. In 1974, Heimlich reported on a 20-yr experience with more than 60 adult patients who had gastric tube interposition for a variety of esophageal lesions. 9 The rate of complications was minimal and, in particular,
PEPTIC
ULCER
Fig. 2. (A) Substernal gastric tube with marked narrowing at exit through the diophmgm. (8) Stricture in midportion of gastric tube shows no improvement after seveml weeks of conservative therapy.
Fig. 3. (A) Histologic examination fiammation and fibrosis (B).
of area of ulcer and stricture showing submucosal in-
704
ANDERSON,
RANDOLPH,
AND
LILLY
ulceration of the gastric tube was never observed. Several investigators have confirmed Heimlich’s observations.3*4*‘0 From the outset, it has been appreciated that the gastric tube as an esophageal substitute potentially was susceptible to ulcer formation. In the standard formation of the tube, the gastric antrum is brought up to the cervical esophagus where it is subjected intermittently to chemicals in food and distended by the passage of food. Both of these stimuli in the intact stomach are known to result in the release of antral gastrin, which stimulates acid production in the fundus.“s’2 This hormonal pathway is intact in the gastric tube in spite of its altered position. Mechanical factors that impede emptying and produce distension such as narrowing or redundancy of the gastric tube would, at least hypothetically, tend to intensify these stimuli with consequent acid hypersecretion, thus predisposing to ulcer formation. These mechanical factors were present ‘in the two cases just described. This hypothesis for ulcer formation was studied in the first patient (case 1) in the following manner. The antrum was stimulated while simultaneous samples were obtained from the fundic portion of the tube for acid analysis. A Foley catheter was placed in the high thoracic part of the gastric tube and collection of secretions was obtained from the lower part of the tube before, and for 1 hr after, inflation of the Foley balloon. Prompt acid secretion in the lower portion (fundic) of the tube consistently occurred after distension of the upper (antral) portion of the tube. After pressure stimulation, the quantity of secretion increased from a base line of 50 ml/hr to over 70 ml/hr. The free acid was zero in the base-line collection, whereas it increased to a maximum of 48.4 meq/liter after stimulation. Peptic ulceration of the colon bypass when used for esophageal substitution has been documented both as an early and late complication.‘3-‘5 The etiology of this ulceration is thought to be related to reflux of gastric acid into the interposed colon. An entirely different mechanism of ulcer formation is probably operating in the gastric tube. In the latter situation, the gastric mucosa is normally subjected to acid secretion and is normally protected by its mucous barrier.16 Therefore, reflux into the gastric tube would not be expected to produce ulceration. However, in the presence of inadequate drainage of the gastric tube, hypersecretion may ensue, which, in time, could lead to breakdown of the mucous barrier and consequent ulceration (Fig. 4). Peptic ulceration of the gastric tube, although infrequent, is not an inconsequential complication. It necessitated abandonment of the tube in one of the two patients reported here. In the case described by Henry,” penetration into the pericardium and perforation 10 yr after surgery required emergency removal of the gastric tube as a life-saving procedure. It is, therefore, imperative that children subjected to esophageal replacement by gastric tube bypass be studied carefully by endoscopic and radiologic techniques regularly, as well as when hematemesis or delayed transit occur. It is noteworthy that most cases of peptic ulceration in a colon bypass were associated with pain as a main feature. In neither of our children with gastric tube ulcer was pain noted. Early diagnosis of an ulcer within the tube may permit healing by treatment with appropriate antacids and diet, whereas long-standing unrecognized ulceration may lead to abandonment of the tube.
PEPTIC
ULCER
Fig. 4. Proposed mechanism for hypersecretion and ulcerogenesir in gastric tube.
SUMMARY
AND CONCLUSIONS
An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary. ACKNOWLEDGMENT The authors wish to thank John D. Burrington, M.D., for permission to include this report, and Robert H. Shikes for preparation and interpretation of Fig. 3.
his case in
REFERENCES 1. Heimlich HJ: Elective replacement of the esophagus. Br J Surg 58:913, 1966 2. Burrington JD, Stephens CA: Esophageal replacement with a gastric tube in infants and children. J Pediatr Surg 3:246, 1968 3. Anderson KD, Randolph JG: The gastric tube for esophageal replacement in children. J Thorac Cardiovasc Surg 66:333, 1973 4. Cohen DA, Middleton AW, Fletcher J: Gastric tube esophagoplasty. J Pediatr Surg 9: 451,1974 5. Beck AR, Carrel A: A demonstration of
specimens illustrating a new method of formation of a prethoracic esophagus. Ill Med J 7: 463, 1905 6. Jianu A: Gastronstime u oesophagoplastik. Btsch. 2. Chir. 118:383, 1912 7. Gavriliu D, Georgescue L: Esophagolastie direction a material gastric. Rev Sti-Intelor Med (Bucharest) 3:33, 1955 8. Heimlich HJ: The use of a gastric tube to replace or bypass the esophagus. Surgery 37: 549, 1955 9. Heimlich HJ: Esophagus replacement with
ANDERSON,
704
reversed gastric tube. Presented at the Postgraduate Course in Thoracic Surgery, American College of Surgeons, Miami, Fla, October, 1974 IO. Ein SH, Shandling B, Simpson JS, et al: A further look at the gastric tube as an esophageal replacement in infants and children. J Pediatr Surg 8859, 1973 I I. Edkins IS: The chemical mechanism of gastric secretion. J Physio134: 133, 1906 12. Grossman MI, Robertson CR, Ivy AC: Proof of a hormonal mechanism for gastric secretion-The hormonal transmission of distension stimulus. Am J Physiol 153:I, 1948 13. Battersby JS: Cited by Sherman CD Jr, Waterston D: Oesophageal reconstruction in
RANDOLPH,
AND
LILLY
children using intrathoracic colon. Arch Dis Child 32: I I, 1957 14. Nardi GL, Glotzer DJ: Anastomotic ulcer of the colon following colonic replacement of the esophagus. Ann Surg 152:IO, 1960 15. Malcolm JA: Occurrence of peptic ulcer in colon used for esophageal replacement. J Thorac Cardiovasc Surg 55:763, 1968 16. Glass GBJ: Proteins, mucosubstances, and biologically active components of gastric secretion. Adv Clin Chem 7:235, 1964 17. Henry J: Discussion of Anderson KD, Randolph JG. The gastric tube for esophageal replacement in children. J Thorac Cardiovasc Surg 66341, 1973
Discussion Dr. S. Ein (Toronto): 1 have talked with the three other gastric tubers from Toronto: Drs. Stevens, Simson, and Shandling. We think it is important that you have presented a problem in a fairly new operation. We have not had any problems with ulceration in the gastric tubes in our 22 gastric tubes performed to date. I think that you may well have put your finger on the cause of this problem by showing that there is, in fact, stasis of the gastric tube as it passes through the hiatus. We are still very old-fashioned in Toronto, and we bring our tubes, for the most part, through the retrosternal space, and we stage them. We bring the gastric tube out next to the esophagostomy and in 2-3 wk we do a neck anastomosis. We have a follow-up of over IO yr in these patients, and the tubes are very satisfactory. We have nothing that sounds like ulceration. One tube did have a mild midtube narrowing that was asymptomatic and did not affect the neck anastomosis in any way and disappeared without any specific treatment. Maybe that narrowing was, in fact, an ulceration, but if it was, we did not appreciate that. It seems a shame to have abandoned what looked like a good gastric tube. I wonder why this patient could not have been dilated, rather than to have abandoned this tube and to go to colon replacement. Our main problem continues to be the neck anastomosis, in that it leaks and strictures. Eventually, within 6 mo to 1 yr, after three to eight dilations, the anastomosis eventually is stretched up to an adequate size. We will continue to use the gastric tube. We hope ulcers will not develop. One patient had a stress gastric remnant ulcer on the first postoperative day, bled and perforated, but it was in no way related to the gastric tube, per se. Dr. G. Holcomb (Nashville): I wish to report an experience that I personally had with a patient, which illustrates my concern about the development of an ulcer. This was a boy that I operated on 12 yr ago and for creation of a gastric tube. I did not have any problems thereafter with a stricture, as a matter of fact I created the tube perhaps a little large and the major problem he had was reflux. He did fairly well for 10 yr, until one night he appeared in the emergency room with severe substernal pain. He was cyanotic, had marked tachycardia, and obviously was very sick. He did have an ulcer in the midportion of the gastric tube that had penetrated the pericardium. This tube was then removed, and following a stormy course, he did survive. This was mentioned in a discussion by Dr. Henry at the American Thoracic Society meeting 2 yr ago. I have subsequently done a colon interposition successfully, and he now swallows well and has had no problems. I think that attention should be given to stasis at the pylorus, as well as stasis in the gastric tube, because a similar problem may develop. I therefore feel that doing a pyloroplasty is also very important. I think that the authors are correct in calling attention to the need for close follow-up an these patients with periodic GI series to avoid these complications. Dr. T. Holder (Kansas C&J): Although we still prefer colon interposition, I would like to indicate that it is not free of complications either. Jn our experience with 45 colon interpositions for esophageal replacement, we have had 6%. or three patients, who have had ulcers in their interposed colon, one of whom responded to nonoperative treatment, and two required operative treatment. While the gastric tube has its problems, the colon is not immune to it.
PEPTIC
Dr.
ULCER
K.
Anderson
707
(closingi:
Dr. Ein, the tube
was abandoned
in the second
patient
because
conservative therapy with repeated dilatations had failed. This had been done over many weeks and months. Dr. Holcomb, I would like to thank you for emphasizing the long-term follow-up. This is not a panacea and we realize that. We are going to continue to use it. We don’t know whether we’ll wind up using it in preference to the colon or as an alternative. Dr. Holder, I think that the mechanism of ulcer formation in the colon is probably more related to reflux. All the gastric tubes reflux, and I don’t think that this is necessarily a problem for the gastric tube. because the gastric mucosa is ordinarily subject to acid and protected by its mucous barrier. which the colon is not. I think that we do have to be extremely careful about its exit through the diaphragm, whether we put it substernally or retropleurally. as we did in one of each of the cases.
D. Anderson,
Judson G. Randolph,
and John R. Lilly
R
ECENT REPORTS have described the use of a gastric tube for esophageal substitution.‘4 The principal advantages of this interposition procedure are uniformly excellent vascular supply and assurance of good length. Furthermore, it is the technique of choice when there are coexisting anorectal anomalies that preclude the use of the colon. From a technical standpoint, the operation is relatively simple and especially well tolerated in children. The gastric tube has proved to be a highly satisfactory conduit, allowing adequate oral intake for normal nutrition and growth. Recently, however, we have encountered two cases in which frank ulceration of the tube occurred, one of which necessitated its abandonment. These cases will be reviewed in detail in this report in an attempt to identify those conditions that may have contributed to ulcer formation. CASE
REPORTS
Case 1 A 3-yr-old female was hospitalized after ingesting liquid lye. Esophagoscopy confirmed the presence of a severe esophageal burn. Intensive initial treatment with steroids and antibiotics failed to prevent stricture, in spite of the usual efforts at dilatation. Attempts to preserve the esophagus were not fruitful and a reverse gastric tube, positioned behind the root of the left lung, was constructed to bypass the strictured esophagus. The child restmILd oral feedings and rapidly gained weight. Postoperative barium studies, 1 and 8 mo after surgery, showed some redundancy of the tube in the chest above the diaphragm, but there was unimpeded flow of barium into the stomach. Another contrast study was obtained I yr after surgery when the patient developed persistent vomiting of coffee-ground material, which was proven to be blood. An ulcer crater with radiating edematous folds in the posterior, redundant portion of the gastric tube (Fig. I) as well as delayed emptying of the tube through the diaphragm were demonstrated radiographically: Direct endoscopic visualization confirmed the presence of the ulcer crater and demonstrated marked edema and’inflammation of the adjacent mucosa. She was treated with a standard antacid regimen and elevation of the head of the bed. Her symptoms had resolved 1 mo later, and the ulcer could not be seen by esophasgoscopy although it was still detectable on barium study. She remained asymptomatic and a study done I yr later showed complete radiologic resolution. She remains well 4 yr after surgery.
Case
2
An IS-mo-old boy developed to swallow liquids, a gastrostomy
an esophageal stricture after was done 2 mo after injury.
ingesting Feedings
lye. Because of inability through the gastrostomy
From the Department ofSurgery, Children’s Hospital National Medical Center, Washington, D. C.. and the Department of Surgery. University of Colorado Medical Center, Denver, Colo. Presented bejore the 6th Annual Meeting of the American Pediatric Surgical Association, San Juan, Puerto Rico, April 10-12, 1975. Supported in part by Grant RR284 from the General Clinical Research Center of the National Institutes of Health. Address for reprint requests: Kathryn D. Anderson, M.D., Center. 2125 13th St.. N. W.. Washington, D.C. 20009. 0 1975 by Grune & Stratton, Inc. Iournaf of Pediatric Surgery, Vol. 10, No. 5 (October), 1975
Children’s
Hospital
National
Medical
701
702
ANDERSON,
RANDOLPH,
AND
LILLY
Fig. 1. Ulcer cmter in gastric tube with md
edematous folds. Note dancy of tube in chest.
Iredun-
esophagram showed a tracheoesophageal fistula just tube refluxed into the mouth. A retrograde above the carina. The esophagus was diverted, therefore, as a cervical esophagostomy, and the esophagogastric junction was transected and oversewn. Subsequently, a retrosternal gastric tube was constructed to bypass the destroyed esophagus. Two months after this operation he experienced hemorrhage from the tube through a persistent cutaneous fistula at the cervical anastomosis. This anastomosis was stenotic and refractory to dilatation. A barium study obtained through the cervical cutaneous fistula showed narrowing of the gastric tube at the diaphragm (Fig. 2A). It was reasoned that this distal stricture might be causally related to ulceration and hemorrhage within the tube, further perpetuating the cervical salivary fistula. Therefore, the gastric tube was removed from its substernal position and the narrowing was corrected at the diaphragmatic hiatus. The gastric tube bypass was replaced beneath the sternum and reanastomosed in the neck. The patient did relatively well for 6 mo; at that time a routine follow-up esophagram showed stricture and ulceration in the midportion of the gastric tube. Despite intensive treatment with a regimen of antacids and milk, the ulcer failed to heal. Repeated dilatations did not result in improvement in the stricture (Fig. 2b). The cervical fistula recurred during treatment. The pH of the cervical fistula drainage was acidic (pH, IS), suggesting reflux from the stomach or distal gastric tube. The gastric tube was abandoned, and a colon interposition was carried out through the chest. The patient has done well. Pathologic examination of the gastric tube showed extensive inflammatory ulceration and fibrosis (Fig. 3A and II).
DISCUSSION
The use of the gastric tube has been developed by Beck and Carrel,5 Jianu,6 Gavriliu,’ and Heimlich* and adapted by Burrington and Stephens in 196g2 for use in children. In 1974, Heimlich reported on a 20-yr experience with more than 60 adult patients who had gastric tube interposition for a variety of esophageal lesions. 9 The rate of complications was minimal and, in particular,
PEPTIC
ULCER
Fig. 2. (A) Substernal gastric tube with marked narrowing at exit through the diophmgm. (8) Stricture in midportion of gastric tube shows no improvement after seveml weeks of conservative therapy.
Fig. 3. (A) Histologic examination fiammation and fibrosis (B).
of area of ulcer and stricture showing submucosal in-
704
ANDERSON,
RANDOLPH,
AND
LILLY
ulceration of the gastric tube was never observed. Several investigators have confirmed Heimlich’s observations.3*4*‘0 From the outset, it has been appreciated that the gastric tube as an esophageal substitute potentially was susceptible to ulcer formation. In the standard formation of the tube, the gastric antrum is brought up to the cervical esophagus where it is subjected intermittently to chemicals in food and distended by the passage of food. Both of these stimuli in the intact stomach are known to result in the release of antral gastrin, which stimulates acid production in the fundus.“s’2 This hormonal pathway is intact in the gastric tube in spite of its altered position. Mechanical factors that impede emptying and produce distension such as narrowing or redundancy of the gastric tube would, at least hypothetically, tend to intensify these stimuli with consequent acid hypersecretion, thus predisposing to ulcer formation. These mechanical factors were present ‘in the two cases just described. This hypothesis for ulcer formation was studied in the first patient (case 1) in the following manner. The antrum was stimulated while simultaneous samples were obtained from the fundic portion of the tube for acid analysis. A Foley catheter was placed in the high thoracic part of the gastric tube and collection of secretions was obtained from the lower part of the tube before, and for 1 hr after, inflation of the Foley balloon. Prompt acid secretion in the lower portion (fundic) of the tube consistently occurred after distension of the upper (antral) portion of the tube. After pressure stimulation, the quantity of secretion increased from a base line of 50 ml/hr to over 70 ml/hr. The free acid was zero in the base-line collection, whereas it increased to a maximum of 48.4 meq/liter after stimulation. Peptic ulceration of the colon bypass when used for esophageal substitution has been documented both as an early and late complication.‘3-‘5 The etiology of this ulceration is thought to be related to reflux of gastric acid into the interposed colon. An entirely different mechanism of ulcer formation is probably operating in the gastric tube. In the latter situation, the gastric mucosa is normally subjected to acid secretion and is normally protected by its mucous barrier.16 Therefore, reflux into the gastric tube would not be expected to produce ulceration. However, in the presence of inadequate drainage of the gastric tube, hypersecretion may ensue, which, in time, could lead to breakdown of the mucous barrier and consequent ulceration (Fig. 4). Peptic ulceration of the gastric tube, although infrequent, is not an inconsequential complication. It necessitated abandonment of the tube in one of the two patients reported here. In the case described by Henry,” penetration into the pericardium and perforation 10 yr after surgery required emergency removal of the gastric tube as a life-saving procedure. It is, therefore, imperative that children subjected to esophageal replacement by gastric tube bypass be studied carefully by endoscopic and radiologic techniques regularly, as well as when hematemesis or delayed transit occur. It is noteworthy that most cases of peptic ulceration in a colon bypass were associated with pain as a main feature. In neither of our children with gastric tube ulcer was pain noted. Early diagnosis of an ulcer within the tube may permit healing by treatment with appropriate antacids and diet, whereas long-standing unrecognized ulceration may lead to abandonment of the tube.
PEPTIC
ULCER
Fig. 4. Proposed mechanism for hypersecretion and ulcerogenesir in gastric tube.
SUMMARY
AND CONCLUSIONS
An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary. ACKNOWLEDGMENT The authors wish to thank John D. Burrington, M.D., for permission to include this report, and Robert H. Shikes for preparation and interpretation of Fig. 3.
his case in
REFERENCES 1. Heimlich HJ: Elective replacement of the esophagus. Br J Surg 58:913, 1966 2. Burrington JD, Stephens CA: Esophageal replacement with a gastric tube in infants and children. J Pediatr Surg 3:246, 1968 3. Anderson KD, Randolph JG: The gastric tube for esophageal replacement in children. J Thorac Cardiovasc Surg 66:333, 1973 4. Cohen DA, Middleton AW, Fletcher J: Gastric tube esophagoplasty. J Pediatr Surg 9: 451,1974 5. Beck AR, Carrel A: A demonstration of
specimens illustrating a new method of formation of a prethoracic esophagus. Ill Med J 7: 463, 1905 6. Jianu A: Gastronstime u oesophagoplastik. Btsch. 2. Chir. 118:383, 1912 7. Gavriliu D, Georgescue L: Esophagolastie direction a material gastric. Rev Sti-Intelor Med (Bucharest) 3:33, 1955 8. Heimlich HJ: The use of a gastric tube to replace or bypass the esophagus. Surgery 37: 549, 1955 9. Heimlich HJ: Esophagus replacement with
ANDERSON,
704
reversed gastric tube. Presented at the Postgraduate Course in Thoracic Surgery, American College of Surgeons, Miami, Fla, October, 1974 IO. Ein SH, Shandling B, Simpson JS, et al: A further look at the gastric tube as an esophageal replacement in infants and children. J Pediatr Surg 8859, 1973 I I. Edkins IS: The chemical mechanism of gastric secretion. J Physio134: 133, 1906 12. Grossman MI, Robertson CR, Ivy AC: Proof of a hormonal mechanism for gastric secretion-The hormonal transmission of distension stimulus. Am J Physiol 153:I, 1948 13. Battersby JS: Cited by Sherman CD Jr, Waterston D: Oesophageal reconstruction in
RANDOLPH,
AND
LILLY
children using intrathoracic colon. Arch Dis Child 32: I I, 1957 14. Nardi GL, Glotzer DJ: Anastomotic ulcer of the colon following colonic replacement of the esophagus. Ann Surg 152:IO, 1960 15. Malcolm JA: Occurrence of peptic ulcer in colon used for esophageal replacement. J Thorac Cardiovasc Surg 55:763, 1968 16. Glass GBJ: Proteins, mucosubstances, and biologically active components of gastric secretion. Adv Clin Chem 7:235, 1964 17. Henry J: Discussion of Anderson KD, Randolph JG. The gastric tube for esophageal replacement in children. J Thorac Cardiovasc Surg 66341, 1973
Discussion Dr. S. Ein (Toronto): 1 have talked with the three other gastric tubers from Toronto: Drs. Stevens, Simson, and Shandling. We think it is important that you have presented a problem in a fairly new operation. We have not had any problems with ulceration in the gastric tubes in our 22 gastric tubes performed to date. I think that you may well have put your finger on the cause of this problem by showing that there is, in fact, stasis of the gastric tube as it passes through the hiatus. We are still very old-fashioned in Toronto, and we bring our tubes, for the most part, through the retrosternal space, and we stage them. We bring the gastric tube out next to the esophagostomy and in 2-3 wk we do a neck anastomosis. We have a follow-up of over IO yr in these patients, and the tubes are very satisfactory. We have nothing that sounds like ulceration. One tube did have a mild midtube narrowing that was asymptomatic and did not affect the neck anastomosis in any way and disappeared without any specific treatment. Maybe that narrowing was, in fact, an ulceration, but if it was, we did not appreciate that. It seems a shame to have abandoned what looked like a good gastric tube. I wonder why this patient could not have been dilated, rather than to have abandoned this tube and to go to colon replacement. Our main problem continues to be the neck anastomosis, in that it leaks and strictures. Eventually, within 6 mo to 1 yr, after three to eight dilations, the anastomosis eventually is stretched up to an adequate size. We will continue to use the gastric tube. We hope ulcers will not develop. One patient had a stress gastric remnant ulcer on the first postoperative day, bled and perforated, but it was in no way related to the gastric tube, per se. Dr. G. Holcomb (Nashville): I wish to report an experience that I personally had with a patient, which illustrates my concern about the development of an ulcer. This was a boy that I operated on 12 yr ago and for creation of a gastric tube. I did not have any problems thereafter with a stricture, as a matter of fact I created the tube perhaps a little large and the major problem he had was reflux. He did fairly well for 10 yr, until one night he appeared in the emergency room with severe substernal pain. He was cyanotic, had marked tachycardia, and obviously was very sick. He did have an ulcer in the midportion of the gastric tube that had penetrated the pericardium. This tube was then removed, and following a stormy course, he did survive. This was mentioned in a discussion by Dr. Henry at the American Thoracic Society meeting 2 yr ago. I have subsequently done a colon interposition successfully, and he now swallows well and has had no problems. I think that attention should be given to stasis at the pylorus, as well as stasis in the gastric tube, because a similar problem may develop. I therefore feel that doing a pyloroplasty is also very important. I think that the authors are correct in calling attention to the need for close follow-up an these patients with periodic GI series to avoid these complications. Dr. T. Holder (Kansas C&J): Although we still prefer colon interposition, I would like to indicate that it is not free of complications either. Jn our experience with 45 colon interpositions for esophageal replacement, we have had 6%. or three patients, who have had ulcers in their interposed colon, one of whom responded to nonoperative treatment, and two required operative treatment. While the gastric tube has its problems, the colon is not immune to it.
PEPTIC
Dr.
ULCER
K.
Anderson
707
(closingi:
Dr. Ein, the tube
was abandoned
in the second
patient
because
conservative therapy with repeated dilatations had failed. This had been done over many weeks and months. Dr. Holcomb, I would like to thank you for emphasizing the long-term follow-up. This is not a panacea and we realize that. We are going to continue to use it. We don’t know whether we’ll wind up using it in preference to the colon or as an alternative. Dr. Holder, I think that the mechanism of ulcer formation in the colon is probably more related to reflux. All the gastric tubes reflux, and I don’t think that this is necessarily a problem for the gastric tube. because the gastric mucosa is ordinarily subject to acid and protected by its mucous barrier. which the colon is not. I think that we do have to be extremely careful about its exit through the diaphragm, whether we put it substernally or retropleurally. as we did in one of each of the cases.
