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 today.

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 body.

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 breakthroughs.

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 time.

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 intestines).

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 Stomach)

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 language.

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 good.

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 it.

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 time.

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 esophagus.

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 anastamosis.

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 the stomach.

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.

SKIN FLAPS

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 new esophagus.

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 colon.

THE STOMACH
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 esophagogastrosomy.

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 JEJUNUM
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 jejunum transpleurally.

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 injury.

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 COLON

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 way.

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.