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The purpose of this study was to investigate the effects of esophagotomy closure techniques on the esophageal bursting pressure.
Altogether, 122 freshly dead sheep esophagi received from the local slaughterhouse were prepared for manual closure. After esophagotomy, the specimens were divided into four groups. An interrupted mucosal suture pattern (...
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Context 1
... 2 cm longitudinal esophagotomy incision was carried out in the distal one-third of the esophagus. Esophagoto- my closure was accomplished in group 1 (n = 30) using an interrupted mucosal suture pattern (Fig. 1), in group 2 (n = 30) with an interrupted mucosal-submucosal suture pattern ( Fig. 1), in group 3 (n = 32) with an interrupted mucosal- submucosal and over-over continuous muscular suture pattern (Fig. 2), and in group 4 (n = 30) with an inter- rupted mucosal-submucosal suture and reinforcement with a piece of diaphragm with a ...
Context 2
... 2 cm longitudinal esophagotomy incision was carried out in the distal one-third of the esophagus. Esophagoto- my closure was accomplished in group 1 (n = 30) using an interrupted mucosal suture pattern (Fig. 1), in group 2 (n = 30) with an interrupted mucosal-submucosal suture pattern ( Fig. 1), in group 3 (n = 32) with an interrupted mucosal- submucosal and over-over continuous muscular suture pattern (Fig. 2), and in group 4 (n = 30) with an inter- rupted mucosal-submucosal suture and reinforcement with a piece of diaphragm with a full-thickness interrupted U suture pattern that included the diaphragm, muscularis, and ...
Context 3
... 2 cm longitudinal esophagotomy incision was carried out in the distal one-third of the esophagus. Esophagoto- my closure was accomplished in group 1 (n = 30) using an interrupted mucosal suture pattern (Fig. 1), in group 2 (n = 30) with an interrupted mucosal-submucosal suture pattern ( Fig. 1), in group 3 (n = 32) with an interrupted mucosal- submucosal and over-over continuous muscular suture pattern (Fig. 2), and in group 4 (n = 30) with an inter- rupted mucosal-submucosal suture and reinforcement with a piece of diaphragm with a full-thickness interrupted U suture pattern that included the diaphragm, muscularis, and mucosal-submucosal layers (Fig. 3); 4-0 silk suture was used in all specimens. The sutures were spaced 2 mm from the cut edge. After the primary esophageal repair was completed, specimens were mounted on a sphygmo- manometer (Riester, Germany); the distal end of the esophagus was clamped and subsequently placed under water. Measurements were recorded with visual observa- tion by a person who was blinded to the study. The insufflation rate was adjusted as one total restriction of the insufflator per second. The bursting pressure level at which we detected air bubbles indicated the limits of the ...
Context 4
... 2 cm longitudinal esophagotomy incision was carried out in the distal one-third of the esophagus. Esophagoto- my closure was accomplished in group 1 (n = 30) using an interrupted mucosal suture pattern (Fig. 1), in group 2 (n = 30) with an interrupted mucosal-submucosal suture pattern ( Fig. 1), in group 3 (n = 32) with an interrupted mucosal- submucosal and over-over continuous muscular suture pattern (Fig. 2), and in group 4 (n = 30) with an inter- rupted mucosal-submucosal suture and reinforcement with a piece of diaphragm with a full-thickness interrupted U suture pattern that included the diaphragm, muscularis, and mucosal-submucosal layers (Fig. 3); 4-0 silk suture was used in all specimens. The sutures were spaced 2 mm from the cut edge. After the primary esophageal repair was completed, specimens were mounted on a sphygmo- manometer (Riester, Germany); the distal end of the esophagus was clamped and subsequently placed under water. Measurements were recorded with visual observa- tion by a person who was blinded to the study. The insufflation rate was adjusted as one total restriction of the insufflator per second. The bursting pressure level at which we detected air bubbles indicated the limits of the ...
Citations
... In the air leak test, complete inverted closure was observed only in the OTSC group. The principle of surgical suturing is traditionally based on inverted suturing of the serosa-muscle layer, such as the Albert-Lembert suture technique [28,29]. However, even if endoscopic closure using hemoclips (as in PSS) appears endoluminally to be complete defect closure, the state of the serosal side is not well known. ...
Background
The recently developed endoscopic full-thickness resection technique requires reliable closure. The main closure methods are the purse-string suture (PSS) technique and over-the-scope clip (OTSC) technique; however, basic data on the closure strength of each technique are lacking. This study was performed to compare the closure strengths of these two methods in an ex vivo porcine model.
Methods
In the traction test, a virtual 5-cm full-thickness closure line was closed by the following six methods three times each: conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture. The primary endpoint was the tension at the starting point of dehiscence, measured in Newtons (N) by an automatic traction machine. In the leak test, a 15-mm gastric full-thickness defect was closed by PSS or OTSC six times each, and the closed stomach was then pressurized in a water container. The primary endpoint was the leak pressure when air bubbles appeared. The secondary endpoints were the procedure time and presence of complete inverted closure.
Results
The mean tension was 2.16, 3.68, 5.15, 18.30, 19.30, and 62.40 N for conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture, respectively. Complete inverted closure was observed for seromuscular PSS, seromuscular OTSC, and surgical suture. The mean leak pressure was 13.7 and 24.8 mmHg in the PSS and OTSC group, respectively (P < 0.01). The mean procedure time was 541 and 169 s in the PSS and OTSC group, respectively (P < 0.01). Complete inverted closure was observed in OTSC alone.
Conclusion
The OTSC, which allows complete inverted closure, showed greater closure strength than PSS. Considering the size limitation suitable for single OTSC, a therapeutic strategy for closing the larger size is further warranted.
... In the air leak test, complete inverted closure was observed only in the OTSC group. The principle of surgical suturing is traditionally based on inverted suturing of the serosa-muscle layer, such as the Albert-Lembert suture technique [22] , [23]. However, even if endoscopic closure using hemoclips (as in PSS) appears endoluminally to be complete defect closure, the state of the serosal side is not well known. ...
Background The recently developed endoscopic full-thickness resection technique requires reliable closure. The main closure methods are the purse-string suture (PSS) technique and over-the-scope clip (OTSC) technique; however, basic data on the suture strength of each technique are lacking. This study was performed to compare the suture strengths of these two methods in an ex vivo porcine model.
Methods In the traction test, a virtual 5-cm full-thickness suture line was closed by the following six methods three times each: conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture. The primary endpoint was the tension at the starting point of dehiscence, measured in Newtons (N) by an automatic traction machine. In the leak test, a 15-mm gastric full-thickness defect was closed by PSS or OTSC six times each, and the sutured stomach was then pressurized in a water container. The primary endpoint was the leak pressure when air bubbles appeared. The secondary endpoints were the procedure time and presence of complete inverted closure.
Results The mean tension was 2.16, 3.68, 5.15, 18.30, 19.30, and 62.40 N for conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture, respectively. Complete inverted closure was observed for seromuscular PSS, seromuscular OTSC, and surgical suture. The mean leak pressure was 13.7 and 24.8 mmHg in the PSS and OTSC group, respectively (P < 0.01). The mean procedure time was 541 and 169 seconds in the PSS and OTSC group, respectively (P < 0.01). Complete inverted closure was observed in OTSC alone.
Conclusion The OTSC, which allows complete inverted closure, showed greater suture strength than PSS.
... The polymerized collagen present in normal esophageal tissue is replaced by immmature and mechanically weaker newly formed collagen hence the probability of dehiscence and leakage increases at days 4 to 7 following surgery. 18 To minimize the incidence of wound dehiscence and esophageal leakage, patching of the suture line with various tissues has been recommended. Apart from the periesophageal muscles, greater omentum has been used for this purpose by several investigators. ...
Objective-This study aimed to evaluate the feasibility of using platelet rich fibrin membrane as a novel on-lay patching biomaterial in canine esophagotomy and its effects on esophageal wound healing. Design-Experimental study. Animals-Eight adult mixed breed dogs of both sexes equally allocated to control and treatment groups. Procedures-Longitudinal incisions measuring 3 cm were made in the cervical esophagus of all dogs (2 incisions in each dog). All incisions were sutured and on-lay patching was performed in four dogs using platelet rich fibrin. After 28 days, wound healing was assessed by macroscopic, histological and biochemical methods Results-Patching resulted in less adhesion formation (18.24 vs. 61.67 mm, p<0.05) and increase in tissue hydroxyproline content (91.31 vs. 74.31 mg, p>0.05). Histologically, platelet rich fibrin membrane mostly influenced wound healing in the outer layers of the esophagus particularly the muscular layer although a slightly better wound healing was observed overall. Conclusion and Clinical Relevance-Platelet rich fibrin membrane could be used as an alternative patching biomaterial in esophageal surgery although further investigations needs to be carried out particularly in clinical cases.
... 10,30,31 In this in vivo study, we examined the sheep esophagus because of its similarities to the human esophagus with respect to thickness and histological structure. 20,22,34 We investigated the possible morphological, structural, and histopathological changes that may occur in the esophagus during and after anterior cervical spine surgery, with an emphasis on the potential for retraction injury during anterior cervical approach and discectomy. ...
Postoperative dysphagia is a well-recognized complication of the anterior surgical approach to the cervical spine. However, its incidence and etiology remain unknown. The aim of this study was to investigate the impact of automatic retractor use on the esophagus and to describe the related pathological changes that might occur during cervical spine surgery.
A single-level cervical discectomy was performed via an anterior approach in 16 skeletally mature female sheep. Continuous retraction was applied with an automatic retractor system during surgery. The sheep model was chosen because of anatomical similarities to the human esophagus. The esophageal tract in every animal was examined using contrast radiographic examination. Eight animals were killed 3 days after the operation (Group 1). The remaining sheep were killed 4 weeks after the operation (Group 2). The esophagi were removed for histopathological study, which was performed using H & E and Masson trichrome staining. The changes in esophageal innervation were examined with nicotinamide adenine dinucleotide diphosphate-diaphorase histochemical staining.
Only 1 animal (a Group 1 sheep) demonstrated any postoperative radiographic abnormality. In Group 1 sheep, histopathological study of the esophagi at the treated level revealed edema between the muscular fibers in the outer longitudinal and inner circular layers of the muscularis propria. At some points, obvious signs of vascular congestion, vascular damage, and inflammation were observed. In the Group 2 animals, there was mild-to-moderate fibrosis extending from the outer surface of the esophagus to the longitudinal layers of the muscularis propria in the area to which retraction had been applied. Enzyme-histochemical staining revealed the presence of normal myenteric plexus and ganglion cells, and nitrergic innervation in all parts of the esophagus wall.
The results of this study demonstrate that direct pressure induced by the medial retractor blade on the esophagus wall leads to local injury. Postoperative dysphagia in human patients who have undergone anterior cervical spine surgery could be a clinical manifestation of this phenomenon.
An adult, female, captive ostrich (Struthio camelus domesticus) was referred to a veterinary teaching hospital for a 2-week history of lethargy and a mass effect in the proximal cervical region. Physical examination revealed a fistula in the middle cervical esophagus surrounded by devitalized and necrotic tissue; feed material was found leaking from the site. Cervical radiography identified an esophageal stricture with anterior dilation due to the accumulation of feed. After receiving supportive care for 48 hours, the patient's overall status improved, allowing partial esophagectomy and resection of the affected tissues with end-to-end anastomosis. Postoperative management included fasting for 24 hours, followed by the administration of a liquid hand-rearing formula prepared with commercially available ostrich feed and administered via a feeding tube for 15 days. Proper healing of the surgical site was confirmed by esophagoscopy using a flexible endoscope 17 days after surgery. The ostrich was discharged after 27 days, with no complications recorded within the 180 days of the follow-up period. Partial cervical esophagectomy with end-to-end anastomosis along with pre- and postoperative management provided a successful outcome for the treatment of a fistulated esophageal stricture in a captive ostrich, resulting in full recovery without surgical complications.
Iatrogene Ösophagusperforationen sind eher klein (1–3 cm) und können überwiegend mit einer konservativ-interventionellen Therapie behandelt werden. Begleitend finden sich häufig thorakale Flüssigkeitsansammlungen, sodass hier Thoraxdrainagen oder ggf. radiologisch-interventionell Drainagen platziert werden müssen. Bei Versagen der initial begonnenen konservativen Behandlung mit Zeichen einer Mediastinitis und oder Sepsis müssen umgehend operative Verfahren zur Anwendung kommen. Entscheidend für das Outcome der Patienten ist ein Therapiebeginn innerhalb der ersten 24 h. Als chirurgische Optionen stehen die Übernähung und Deckung des Defekts oder die Ösophagektomie mit Rekonstruktion oder Diskontinuitätsresektion zur Verfügung. Das Ziel aller Therapieformen ist die Behandlung der mediastinalen Infektion und die Verhinderung einer Sepsis mit fortschreitenden Organsystemausfällen.
Objective: Esophageal perforation during anterior spine surgery is a rare but serious complication that may lead to death, if not managed properly. Optimal management of these injuries is still debated, which varies from conservative approach to different types of surgical repair. The purpose of this study was to evaluate and compare the healing process following various surgical techniques to repair experimentally induced esophageal injury in rodents. We hypothesized that repair techniques that involve flap rotation along with primary suture was superior to primary suture alone. Material and Methods: Fifty male Sprague-Dawley rats were used for this study. Esophageal injury was induced by a vertical incision through all layers of its wall. Groups were determined according to the repair techniques used, i.e., Group-1 (sham, no injury), Group-2 (primary suture), Group 3 (primary suture plus muscle flap), Group 4 (primary suture omental flap) and Group 5 (untreated). Esophageal segments repaired were obtained fourteen days after the injury/repair surgery for histopathological evaluation. Results: Total histopathological damage scores were highest in Group 5. Lower total scores were obtained in Group 3 than in Group 2 and 5, whereas total scores between Groups 2 and 4, 2 and 5, and 3 and 4 were similar. Infiltration and submucosal/muscular healing scores were higher in Group 2 than in 3. There was no difference in any of the parameters between groups 2 and 4, 2 and 5, and 3 and 4. Conclusions: Primary suture closure reinforced by a muscle flap provides better healing in a rat model of iatrogenic esophageal injury. Primary suture reinforced by omentum, or primary suture alone may be considered as second options for repair.
Atresia and Barrett's esophagus are diseases in which the esophageal tissue is compromised. It has been shown that the extracellular matrix of the porcine small intestinal submucosa (SIS) serves as a scaffold for tissue repair and remodeling. This project aims to generate an organic scaffold that resembles the tensile properties of esophageal tissue through SIS modifications. First, the mechanical properties of three segments of a porcine esophagus were characterized using biaxial tensile strength tests. To emulate the esophageal natural properties, SIS was modified using two different methods: i) the crosslinking of single hydrated SIS laminae with varying crosslinking durations, and ii) trilaminar constructions using different orientations amongst the layers. The resulting modified tissues were compared to the esophagus tensile data. Mechanical properties differed along the esophageal tract studied, and both SIS modification procedures showed mechanical properties similar to the different esophagus segments.
The incidence of esophageal perforation (EP) has raised with the increasing use of endoscopic procedures, which are currently the most frequent causes of EP. Despite decades of clinical experience, innovations in surgical technique and advances in intensive care management, EP still represents a diagnostic and therapeutic challenge. EP is a devastating event and mortality remains close to 20%. Ambiguous presentations leading to misdiagnosis and delayed treatment, and the difficulties in management are responsible for the high morbidity and mortality rates. A high variety of treatment options is available ranging from observational medical therapy to radical esophagectomy. The potential role of interventional endoscopy and the use of stents for the treatment of EP seem interesting but remain to be evaluated. Surgical primary repair, with or without reinforcement, is the preferred approach in patients with EP. Prognosis is mainly determined by the cause, the location of the injury and the delay between perforation and initiation of therapy.
The incidence of esophageal perforation (EP) has risen with the increasing use of endoscopic procedures, which are currently the most frequent causes of EP. Despite decades of clinical experience, innovations in surgical technique and advances in intensive care management, EP still represents a diagnostic and therapeutic challenge. EP is a devastating event and mortality hovers close to 20%. Ambiguous presentations leading to misdiagnosis and delayed treatment and the difficulties in management are responsible for the high morbidity and mortality rates. A high variety of treatment options are available ranging from observational medical therapy to radical esophagectomy. The potential role of interventional endoscopy and the use of stents for the treatment of EP seem interesting but remain to be evaluated. Surgical primary repair, with or without reinforcement, is the preferred approach in patients with EP. Prognosis is mainly determined by the cause, the location of the injury and the delay between perforation and initiation of therapy.
