OF ESOPHAGEAL REPLACEMENT
"Making a new esophagus"
The operations to replace the esophagus in babies born with
short or long gap esophageal atresia have a long history.
William Durston reported on the first documented case of
esophageal atresia in conjoined twin girls in England back
in 1670. I have not been able to find any other reported
cases before this so I cannot say if this is the only case
in print in any language other than English.
Though babies have been born with birth
defects for thousands of years the documentation is where
we have to begin. Before it was discovered that babies were
born with either esophageal atresia or esophageal atresia
with a tracheo-esophageal fistula people were having difficulty
swallowing for one reason or another such as strictures
and narrowing of the esophagus.
In the 1800's doctors had known about
and recognized cancer of the esophagus and some thought
that it would be possible to remove the esophagus and replace
the esophagus with some kind of artificial tube such as
rubber tubing or other artificial devices and by the use
of eels skin. It is because of CANCER of the esophagus and
burns of the esophagus that was found in adults and kids
that we have the operations to correct esophageal atresia
The operations that are done today to
replace the esophagus in babies born with esophageal atresia
and or injuries from acid or lye burns of the esophagus
are the same operations used to replace the esophagus in
patients who have cancer of the esophagus and who have had
to have the esophagus removed (esophagectomy) and replaced
with an artificial esophagus made out of another part of
The 20th century has been the greatest
time in history for so many of the advancements in medicine
that the world has ever seen and for that matter anytime
in history to date. Consider all of the operations that
are done on the heart, the blood vessels, kidneys and lungs,
new medicines such as antibiotics along with so many other
The use of new equipment such as Cat Scans,
magnetic resonance imaging and so many others has brought
medicine to heights that could not have been foreseen. The
20th century brought organ transplants, heart lung machine,
kidney dialysis machine and synthetic insulin for diabetes
to briefly name a few. The last 50 years have shown that
if we can think it, it can probably be done at some near
The most common operations for replacement
of the esophagus are the Gastric Pull-up (bringing the stomach
into the chest cavity), the Inter-Colon Position (using
one of three part of the large intestines), Gastric Tube
Replacement (there are two curves to the stomach the lesser
curvature on top and the greater curvature below and making
a tube out of either of these stomach curves), and Jejunal
Interposition (using the jejunum which is part of the small
The operation that is no longer used is
the ante-thoracic skin tube that the first survivor of esophageal
atresia and early survivors from Boston had done, though
it still could be used if necessary.
Another operation that could be used is
the operation that plastic surgeons use on patients who
have cancer of the esophagus where skin and muscle flaps
can be used.
I am working with a cancer patient who
had the gastric pull-up done and it didn't work and then
they used the colon and this didn't work. Then a plastic
surgeon was consulted. This doctor
used muscle and skin flaps to make a new esophagus and my
friend is doing well as of this writing.
Each replacement organ used for the operation
for esophageal replacement has proved effective and a good
substitute but not without problems. Though nothing can
truly replace the original esophagus these substitutes for
the esophagus have stood the test of time as a viable alternative
and many patients have had their substitute for almost 50
years and some for more than 50 years.
We will also talk about the methods for
stretching of the esophagus that brings the two ends of
the esophagus together and how long this has been done and
the many ways that people have stretched their esophagus
at home and under the care of a medical facility.
This is another fascinating part of esophageal
atresia that most of us don't hear about because it is not
done as much today as it was done years ago and we are not
told about this other alternative of bringing the ends of
the esophagus together by this stretching method that is
done over a long period of time.
All of the reconstructive surgeries of
the esophagus have their drawbacks as well as good points.
Please keep in mind that we are living in the time when
many of these transplants of organs used as replacements
for the esophagus have been done for at least 50 years and
many of these patients are still alive today and have gone
on to marry and have children of their own.
We have been able to document with living
proof that these operations work and that these babies go
on to eat by mouth into childhood, teenage years and adulthood.
What each surgeon has to consider before
operation is their own experience doing the operation, which
operation they are most comfortable doing and what they
have had the best long term result with and experience doing.
Other factors that are considered are
the length of required substitute organ, most importantly
is the blood supply good, will the substitute reach the
neck, and are there other birth defects to be considered
to name a few. This is a brief overview of what the surgeon
looks for to replace the esophagus and what the parents
for their own information should know.
GASTRIC TUBE (Greater Curvature of the
One of the operations for replacing the
esophagus is called a gastric tube replacement and has been
done by one surgeon with outstanding results for over 50
years. No one has more experience doing this operation than
Dan Gavriliu from Romania. He has done this operation for
cancer of the esophagus, lye burns of the esophagus, acid
burns of the esophagus, strictures of the esophagus, esophageal
replacement for babies born with esophageal atresia and
any other reason needed for replacement of the esophagus.
Dan told me that he has done over 5000
gastric tubes. I don't believe anyone comes close to that.
He has been doing this operation since the 1950's.
When I spoke with him on the phone I thought
he was quite a character. He told me I spoke terrible English
and he asked me if I was a foreigner. He said he could barely
understand me and could I communicate with him in any other
Dan said he spoke 3 languages and I should
probably learn another. After many phone calls about his
work he said that maybe the reason he couldn't understand
me was that the telephones in Romania are terrible. Remember
I still live under communism and our phones are not very
We continued talking with me asking questions
about his work and why I could find so little. He told me
that most of his written work was in other languages. He
did tell me that one reason why he never wrote about his
work in the 50's and 60's because there was no money in
He had to pay to have them written. When
he was invited to the United States many doctors asked him
this same question and he told them the same thing that
there was no money in it. They told him they would find
the money to get his papers printed in the United States.
Another doctor who made great advances
using the greater curvature of the stomach and using the
gastric tube was Dr. Henry Heimlich from Ohio. Heimlich
had vast experience using the gastric tube and he was the
first to use the gastric tube in the United States. This
Dr. Heimlich is the same Dr. that invented the procedure
for choking victims called the Heimlich maneuver.
The first doctor to use the gastric tube
in North America was Dr. James Fallis from Canada.
The use of the stomach was among the first
organs thought of to replace the esophagus. Dr. D. Biondi
in 1895 said that the stomach could be pulled up into the
chest through the diaphragm and connected (anastamosis)
to the esophagus to make a new esophagus. Dr. Gosset had
reported in 1903 on transdiaphragmatic esophagogastrostomy
was done in dogs.
The extrathoracic (outside the chest) tube
was created from the greater curvature of the stomach in
both cadavers and dogs and was reported by Drs.Carl Beck
and A.Carrell and later in the century was made popular
to replace the esophagus.
Dr. Hirsch in 1911 also suggested that
the anterior (front) surface of the stomach could be formed
to make a gastric tube to replace the esophagus. In 1920
Dr. Martin B. Kirschner wrote about his experiments and
results of an antesternal pull-up of the entire stomach
that connected to the esophagus and replaced the esophagus
that he performed in dogs and cadavers rather than the gastric
tube. The idea of using the stomach as a replacement for
the esophagus did not gain wide attention or use at this
In 1904 the use of the small intestine
called the jejunum was thought a good substitute to replace
the esophagus by a German Dr. L Wullstein. Another German
by the name of Lexer said that a skin tube could be made
the same way Dr L. Bircher described to close the gap space
between the cervical esophagus and the proximal (upper esophagus)
end of the antethoracic jejunal intestine.
Operating on the esophagus in the early1900's had so many
obstacles as did most surgeries. Opening the chest and the
chest cavity, the pleural space, lack of antibiotics and
sterile technique in the operating room were not really
understood and many surgeons were so arrogant that they
didn't believe in keeping the area that they wanted to operate
on or themselves sterile or clean. Many didn't believe Lister.
Wound infection after operations on the
chest and lack of drainage techniques and leaks if the esophagus
was operated on caused more deaths than those who survived.
Instruments and surgical special techniques were not even
known. Anesthesia was basically open drop method having
a patient breathe ether. Anesthesia was nothing close to
what we have today. So many contributions by so many people
have made surgery and survival the norm along with the great
types of anesthesia and pain relief after surgery.
In 1886 Dr. Mikulicz from Germany wrote
about the use of skin flaps to make a skin tube to replace
the esophagus He wrote of a patient who he operated on survived
3 months after resection of the cervical esophagus and making
an external esophagostomy and the fistula closed by the
use of the skin of the neck. His patient he wrote was able
to eat food by making a new esophagus this way until he
died. This is similar to the operation that Dr. William
E. Ladd performed on the first patient Millie Ladd Collins
who was the first survivor in the world back in 1939 who
had to have an esophagus made out of the skin on her chest.
Another doctor named C. Garre wrote about
using skin tubes to reconstruct the cervical esophagus in
1898. Dr. E. Bircher made an extrathoracic skin tube to
close the space between the stomach and cervical esophagus
in 1894. Bircher also made a gastrostomy to join to the
farther end of the skin tube a month and a half after he
constructed a skin tube to show that liquids could pass
from the newly constructed skin tube into the stomach. Bircher
never joined the cervical esophagus to the new skin tube
because he wasn't sure that if his patient took solids that
they would pass. His patients only survived a short time
but it showed that these techniques worked.
In 1913 an operation called a transhiatal
removal of the esophagus was done on the esophagus of a
patient of a Dr. Denk for cancer of the esophagus. Dr. Denk
also made an antethoracic skin tube to replace the cancerous
A Dr. Payr in 1917 successfully used the
technique that Dr. Bircher used in 1894. Many were not overwhelmed
with the outcome of these operations but it was a natural
progression to try other organs of the body such as the
intestines and the stomach.
Dr. A Jianu from Hungary writes in 1914
of his use of tube made from the greater curvature of the
stomach which is what Dr. C. Beck wrote about earlier in
1905. Dr. Jianu brought the new tube just under the skin
and connected it to the neck where a small stub of esophagus
is. Dr. Jianu credited Dr. Beck and the operation became
know as the Beck-Jianu operation. In 1913 a Dr. J.O. Halpern
also wrote about the gastric tube made from the greater
curvature of the stomach. Dr. Willy Meyer wrote of his use
of the greater curvature of the stomach in patients in 1913
as did Dr. G Lotheissen.
A similar operation with a different approach
was taken by Dr. F. Fink in 1913. Instead of the gastric
tube made from the greater curvature of the stomach he divided
the duodenum, stabilized the stomach, and brought the stomach
through a tunnel under the skin to the suprasternal notch
as in an antiperistalic way. The stomach and duodenum were
joined together using a skin tube.
Dr. Kirschner in 1920 wrote of doing an
isoperistalic gastric pullup in a patient who had swallowed
lye and had a stricture. Kirschner wrote of using a subcutaneous
tunnel for the pullup and a direct cervical (neck area)
connection of the stomach and esophagus called a esophagogastric
In 1907 Dr. Cesar Roux (famous for the
Roux-Y operation) described the use of part of the small
intestine called the jejunum as a substitute for the esophagus.
Dr.Roux wrote about bringing an isolated piece of the jejunum
through a subcutaneous (under the skin) tunnel joining the
stomach distally and the esophagus proximally. A similar
operation was done by Dr. P. Herzen in 1908 and a 3 staged
operation was done on his patient.
A combination of three doctor's techniques
called antethoracic jejuno-dermato- esophagosplasty was
popular for rebuilding the esophagus and was done especially
for esophageal corrosive burns. These combinations of techniques
were from Lexer, Roux and Bircher.
In 1911 Dr. G. Kelling first described
the use of the colon as a substitute. A piece of the transverse
colon was brought subcutaneously (under the skin) in an
isoperistalic method and its distal end was connected to
In 1909 Dr. Willy Meyer (1880-1952) before
the American Surgical Association spoke about the latest
methods of reconstruction. Meyer also spoke about the advances
in differential pressure in the chest when the chest was
open preventing the lungs from collapsing that was started
by Dr. Sauerbach from Germany who also was a friend of Dr.
Rudolph Nissen who developed the operation called the Nissen
Fundoplication for reflux. Dr. Meyer stated that it didn't
matter that none of the patients survived resection of the
esophagus. If 50 or 200 died maybe the next would survive
and we would look to that patient as the new beginning.
What allowed the eventual success for esophageal
reconstruction and resection was mainly due to the advances
in anesthesia, electrolyte and fluid replacement during
and after operations and the use of safe blood transfusions.
Probably the most important development
was the positive pressure ventilation with the use of an
endo-tracheal tube that allowed the safe opening of the
chest that kept the lungs inflated whereas previously when
the chest was opened the lungs would collapse and the patient
would not survive because the pressure in the chest when
opened was not equal.
Tracheal intubation was started in the
late 1700s. Many names contributed to its use such as Macewen,
O'Dwyer, and later by Fell,Matas and Tuffier. Chevalier
Jackson spoke of laryngoscopy and intratracheal use by Meltzer
and Auer and Elsberg.
The Great War (World War 1) brought about
advances in anesthesia with the injuries to the jaw (maxillofacial
injuries) and endotracheal intubation was reintroduced by
Drs Rowbotham and Magill. Dr. Gale and Dr. Waters from America
and Dr. Magill from England brought about the use of direct
vision endotracheal intubation.
In 1913 Dr. Franz Torek's successful transthoracic
esophagectomy was done with the patient under general anestheai
by the use of intratracheal ether insufflation. His patient
survived it is believed because of the adhesions in the
pleura that would not allow the lungs to collapse. Toreks
patient lived for 11 years and drank liquids by mouth that
passed from the cervical esophagostomy into the tube and
into the gastrostomy .
Dr. Ohsawa from Japan was the first to
describe his successful operation of a transthoraic esophagectomy
and the intrathoracic esophagogastrostomy or esophagojejunostomy.
After the report by Ohsawa shortly thereafter Dr. Marshall
in Boston and Drs. Adams and Phemister from Chicago reported
about their success. Dr. Yudin in Moscow also wrote about
his surgery of reconstruction of the esophagus right after
removing the esophagus (esophagectomy) and using a piece
of the jejunum (small intestine) brought through a tunnel
right under the skin (subcutaneous).
Many doctors were reporting successes with
their own operations for making a new esophagus or reconstructing
a new one.
Almost all operations for replacing the
esophagus now were done in stages. This means that the surgeon
would do one part of the operation then wait a few days
and do another part of the operation. Some could be 2or
3 staged operations.
Dr. Wookey believed that building skin-lined
tubes after treatment of cancer of the pharynx and for thoracic
(chest) inlet esophageal lesion.
Dr. William Edward Ladd used skin tubes
for antethoracic (made from the skin on the chest wall)
reconstruction in patients born with esophageal atresia
in Boston. Ladd who is believed to be the father of pediatric
surgery had the first survivor in the world of esophageal
atresia and made a skin tube on his patient Millie Collins
who had esophageal atresia. Millie is in her 60's and in
1987 her skin tube became cancerous and she went through
radiation and now has a colon interposition that is her
Skin flaps and pedicle flaps were developted
by Dr. Watson and Dr. Converse for radical resection and
reconstruction for cancer of the cervical esophagus.
In 1957 Dr. Bricker and Dr. Burford wrote
about their poor success rate of 16 patients for reconstruction.
They only had 5 survivors and only one good result with
the use of skin flaps. Skin flaps are used in rare cases
today and when all other substitutes of the esophagus fail
such as the stomach being pull-up into the chest and the
The early success of the use of the stomach pull-up to replace
the esophagus and the work of Dr. Kirschner believed that
the stomach could be used on a routine basis for cervical
esophagogastrostomy. The only concern doctors had was how
far could the stomach be stretched in the chest and would
the blood supply be viable. The blood supply was a major
concern back than as it is today. If the blood supply fails
the new esophagus will not work and will slough off and
usually die. Dr. Sweet and Churchill believed that a direct
esophagogastrostomy (connecting the stomach to the stub
of esophagus) could be done only if the esophagus could
be transected below the inferior pulmonary vein. Dr. Sweet
also believed that an anastamosis could be done as high
as the aortic arch safely by his additional experience.
In 1946 Lewis and Sweet reported in many
papers that a high intrathoracic (within the chest) anastamosis
of the stomach could be done as a routine operation with
success. It was also believed that it was safe to do a cervical
Dr. Dan Gavriliu from Romania (my friend)
in the 1950's started using the reversed gastric tube replacement
to make the new esophagus out of the stomach . The use of
the stomach became the most popular method to reconstruct
the esophagus for lye burns, cancer of the esophagus and
esophageal atresia reconstruction.
The use of the jejunum (small intestine) for reconstruction
of the esophagus was well known in the 1930s. The most common
practice for the use of the jejunim was to place the jejunum
extrathoracic (outside the chest wall).
Dr. Reinfoff did the first successful intrathoracic (within
the chest) esophagojejunostomy (connecting the jejunum to
the esophagus) in 1942 and wrote about his patient in 1946.
Dr. Reinhoff operation was a one stage procedure. Dr. Longmire
and Dr. Ravitch wrote of their experience for many years
trying to accomplish this same one stage operation in the
experimental lab and in their clinical practice.
Dr. Harrison wrote about the work of Reinhoff, Roux, Herzen
and Yudin in 1949 and based on this Dr. Harrison described
the first reconstruction of the whole esophagus using the
The substernal (under the sternum) route
for reconstruction of the esophagus was contributed by Dr.
Robertson and Dr. Serjeant in 1950 and many doctors still
use thie substernal reconstruction procedure today.
Replacement of the esophagus was primarily
done before the 1950s due to lye burns of the esophagus,
esophageal atresia, and cancer of the esophagus or a blockage
in the esophagus.
Dr. Merendino and Dr. Dillard in 1955 wrote
about the use of the jejunum for the lower esophageal sphincter
replacement that stated a short isoperistalic length of
the jejunum could protect the esophagus from acid-peptic
In Russia Dr. Androsov and some engineers
in Moscow developed a way to anastamose (join together)
small blood vessels using metal clips. They used these metal
clips to join together the blood supply from the internal
mammary vessels to an interposed piece of the intestines
in 11 patients.
Another doctor by the name of Kasai wrote
about another technique of using a short piece of the jejunum
on a long vascular pedicle and to perform an isolated reconstruction
of the cervical esophagus.
Three doctors Gunning, Allison and Wooler
followed up patients who had jejunal interposition 3 years
previously and all were able body workers and were able
to eat by mouth with the jejunum as the new esophagus.
The first survivor who had esophageal
atresia in 1935 and was a patient of Dr. George Humphreys
had an esophagus made out of the jejunum and Dr. Humphreys
patient (Bob Linsig) is alive and well as of this writing.
The use of the large intestine (ascending,
transverse,descending) or the colon was actually the last
to be used as a replacement of the esophagus. Many believe
the reason for this is the difference in the size of the
colon in reguard to the opening of the esophagus and the
opening of the colon. The two are different in size. The
colon being larger.
The idea of using the colon was not very
impressive to many because it carried waste material and
attaching that to a sterile part of the body did not seem
feasible. A major concern to surgeons was the blood supply.
There were not many attemps or written
documentation of esophagocologastrostomy (using the colon
to replace the esophagus) before 1950.
The pieces of colon that were used right colon, transversecolon
and left colon. In 1951 Dr. Rudler wrote about 28 cases
using the colon and there were 8 deaths and the out of the
20 who lived 13 had leaks at the anastamosis site.
Dr. Lemaire and Orsoni were some of the
first surgeons to write about using the descending colon
and the transverse colon along with where it was places
through the posterior mediastinal and substernal passage
Dr. Robin and Goligher studied the writings
of different surgeons and the ways reconstructive surgery
was done in 1954. They believed that the left colon was
the best organ suited to replace the esophagus and the pharynx
after the surgical removal of the pharynx. Many other surgeons
after much experience wrote later that either the right
colon or left colon was a good choice.
Dr. Belsey felt that the left colon was a better substitute
mainly because it had a better blood supply and it had a
smaller diameter to attach to the esophageal stub.
This is a short history of esophageal replacement.
There were many other doctors who contributed much to the
history and it is not intentional on my part to exclude
them. I just don't know how much people want to know or
are willing to read. I want those surgeons that I did not
include to know that I am so grateful for their work and
it has been a tremendous learning experience for me to read
their contributions by the papers they wrote about and present
to the many journals.