BROOKS : COLON BY-PASS FOR CARCINOMA O F OESOPHAGUS 705

SUMMARY I . Two hundred and four patients with pancrea-

titis admitted to St. George’s Hospital from 1947 to 1962 were analysed.

2. The incidence, age and sex incidence, aetio- Logical factors, and the course of the disease were determined.

3. From the natural history of the disease a possible clinical pattern was evolved.

4. The results of sphincterotomy and partial pancreatcctomy were analysed.

I wish to thank the surgeons at St. George’s Hospital for permission to study their patients, in particular Mr. Rodney Smith, under whose care the majority of these patients were admitted.

REFERENCES AVERY JONES, F., and GUMMER, J. W. P. (1960), Clinical

Gastroenterology, p. 506. Oxford : Blackwell.

BARTLETT, M. K., and NARDI, G. L. (1960), N e w Engl. 3. Med. , 262. 643.

BLUMENTHAL, H. T., and PROBSTEIN, J. G. (1959a),

CATTELL, R. B., and WARREN, K. W. (1953), Surgery of

COMFORT, M. W., GAMBILL, E. E., and BAGGENSTOSS,

GAMBILL. E. E.. COMFORT. M. W.. and BAGGENSTOSS.

Pancreatitis, p. 16. Springfield, Ill. : Thomas.

the Pancreas. Philadelphia: Saunders.

A. H. (1946), Gastroenterology, 6, 239, 376.

(1959b), Ibid., p. 312.

A. H. ?1948), ibid., I I, I: HOWARD, J. M., and JORDAN, G. L. (1960), Surgical Dis-

eases of the Pancreas. London: Pitman. MACKENZIE, W. C., and WILLCOX, G. L. (1956), British

Surgical Practice: Surgical Progress (ed. CARLING, Sir E. R., and Ross, Sir J. P.), p. 249. London: Butter- worths.

POLLAK, A. V. (1959), B r . med. J., I, 6. SMITH, R. (ed.) (1961), Progress in Clinical Surgery,

Series 2, p. 204. London: Churchill. THOMPSON, J. A., HOWARD, J. M., and VOWLES, K. D. J.

(1957), Surgery Gynec. Obstet., 105, 706.

RIGHT COLON BY-PASS FOR INOPERABLE CARCINOMA OF THE OESOPHAGUS

BY VIVIAN BROOKS LECTURER I N SURGERY, UNIVERSITY OF THE WEST INDIES, KINGSTON, JAMAICA

‘THE natural history of squamous-cell carcinoma of rhe oesophagus is such that the disease is seldom seen at a time when a cure can be effected. In most instances the tumour has already metastasized beyond the limit of resection.

The experience in Jamaica was recorded by Anna- munthodo in 1959. His report, covering 73 patients, presented the dismal prognosis and emphasized the high mortality associated with resections which in no instance resulted in a cure.

The fact that almost all cases of cancer of the toesophagus are inoperable should, of course, in no way deter us from attempting some degree of pallia- rion which is usually equated with the restoration of rhe ability to swallow. Palliation can be achieved in many ways, but is probably best obtained by com- pletely by-passing the tumour. In this way infection, which inevitably accompanies the extension of the malignant process in the mediastinum, can be mini- mized or eliminated and the life expectancy of the patient may be prolonged.

The use of the retrosternal right colon for oeso- phageal by-pass was first reported by Rudler and Monod-Broca (1951), who described one successful case. Since that time Scanlon and Staley (1958) have recorded their experience with 19 cases in which 2 deaths occurred. Gordon (1963) reported 4 deaths in 16 cases and observed that ‘little justification for the procedure can be found’.

MATERIAL Since July, 1962, I have had the opportunity to

study and by-pass 9 inoperable carcinomata of the oesophagus utilizing the right colon.

There were 4 women and 5 men, and they ranged in age from 40 to 70 years. The duration of symp- toms varied from 2 weeks to 27 months. Only I patient complained of complete oesophageal obstruc- tion and this was precipitated by oesophagoscopy. All the patients presented in an advanced state of malnutrition-the average weight being 108 lb. Two had significant cardiac disease and 2 had chronic pulmonary disease. There was no instance of pre- operative tracheo-oesophageal fistula or supraclavi- cular metastasis. The diagnosis of inoperability was made in five instances on bronchoscopy where widening and fixation of the carina andlor segmental spurs were seen. In addition, infiltration, partial obstruction, and ulceration of the trachea or main stem bronchi were also encountered. In one instance left recurrent laryngeal nerve paralysis was recog- nized. All 9 lesions were squamous-cell carcinomata of the thoracic oesophagus--a being at the upper third, 5 at the middle third, and 2 in the lower third of this organ. All tumours were unusually long- the average length, as judged by barium-swallow examination, being 12 cm.

OPERATIVE PROCEDURE The technique used has previously been well

documented in the literature and was substantially the same as that described by Gordon (1963). Essentially, the right hemicolon was mobilized through a midline epigastric incision, and, based on the mid-colic and occasionally the right colic vessels, was transplanted into a retrosternal position, the vascular pedicle being brought through the gastro- hepatic omentum. Intestinal continuity was restored

706 BRIT. J. SURG., 1966, Vol. 53, No. 8, AUGUST

by end-to-end ileotransverse colostomy. An incision along the anterior border of the left sternomastoid muscle was then followed by low transection of the strap muscle and exposure of the cervical oesophagus. This organ was divided at the thoracic outlet-the distal end being closed and allowed to retract into the posterior mediastinum. The caecum was then delivered into the neck and anastomosed to the transected proximal oesophagus. The lower end of the transplanted colon was then anastomosed to the stomach and a pyloroplasty performed. A tube gastrostomy was also carried out-being used initially for decompression and later in I patient for feeding until reconstruction could be completed.

The duration of this operation ranged from 4 to 5; hours using one team. Blood-loss averaged 900 ml. In all instances the mid-colic vessels were preserved and in 5 cases it was also possible to preserve the right colic vessels. In 4 instances it was considered advisable to enlarge the thoracic out- let, and this was done by wedging out the manubrium and by resecting the left sternoclavicular joint.

COMPLICATIONS One might expect that an operative procedure of

this type could be associated with a great variety of complications and this has been repeatedly recorded in the literature. The complications of gastric reten- tion, peptic ulcer of the transplanted colon, anasto- motic stenosis, and leaking from the intra-abdominal suture lines were not encountered in this series of 9 cases.

Prolonged ileus was seen on z occasions. One of these was associated with an adhesion and required lysis on the eighth postoperative day. The other was associated with the necrosis of the transplanted colon. This was recognized 7 days postoperatively when the patient became febrile and ‘toxic’, and an offensive discharge came from the cervical wound. This patient had thrombosed the vascular pedicle to the transplant and required removal of the colon, exteriorization of the cervical oesophagus, and anterior mediastinal drainage. Subsequently he was reconstructed with a tube fashioned from the greater curvature of the stomach. He then survived a further 12 months.

RESULTS All 9 patients survived the operation and experi-

enced relief of dysphagia and improvement of nutri- tion. Two patients are currently alive 3 months and 20 months after operation. The other 7 patients survived an average of 11 months.

DISCUSSION Several points of interest emerge from a review of

this limited experience:- I. It would seem that the diagnosis of inoperability

of the middle and upper third lesions can often be made by careful bronchoscopic survey.

2. Inoperability of the lower third lesions can sometimes be determined at laparotomy-either by the finding of intra-abdominal metastasis or by medi- astinal exploration through the diaphragm. In this way unnecessary thoracotomy can often be avoided.

3. Once the decision is made to do a colon by- pass, the length of the mobilized vascular arcade and not the length of the right colon determines its feasibility. If additional length is needed, the terminal ileum can be included in the transplant.

4. In performing the proximal anastomosis it is preferable to transect the oesophagus as low in the neck as is possible, so that when the oesophagocaecal anastomosis is completed the caecum will fall back below the thoracic outlet, thus minimizing the possi- bility of strangulating the caecum. If this can be done it will seldom be necessary to enlarge the thoracic outlet.

5. Great care has to be exercised in order to avoid angulation or torsion of the vascular pedicle to the transplant-the mid-colic vein being particularly susceptible to occlusion.

6. Complications can be minimized by meticulous attention to technical detail in order that suture lines can be completed between well-vascularized tissue and without tension.

7. The complication of necrosis of the colon has been reported in almost all series and appears to be associated with a high mortality. One of the reasons for this mortality seems to be the delay in making the diagnosis. There are seldom any localizing signs until gangrenous changes are established. The patient who experienced this complication complained of no pain or discomfort, and the diagnosis was not suspected until an offensive brown discharge issued from the cervical drain site. He did have, however, an abrupt rise in temperature and a marked increase in pulse-rate, and appeared ‘toxic’ at this time. If at the time of the oesophagocaecal anastomosis the viability of the caecum is in doubt, it might be safer to leave the cervical wound open for inspection and to close it only when this doubt no longer exists.

SUMMARY Nine cases of inoperable carcinoma of the oeso-

phagus were treated by right colon by-pass. The clinical features associated with inoperability, the technique used, and the results obtained are recorded. In the series presented this operation appears to have satisfied the generally acceptable criteria for a palliative operation in that it afforded these patients temporary relief of symptoms without undue morbi- dity and without operative mortality.

REFERENCES ANNAMUNTHODO, H. (1959), W. Indian med. J., 8, 92. GORDON, W. (1963), Ann. Surg., 158, 47. RUDLER, J. C., and MONOD-BROCA, P. (1951), MLm. Acad.

Chir.. 77. 747. , ,7,- SCANL~N, E. F., and STALEY, C. J. (1958), Surgery Gynec.

Obstet., 107, 99.