© Borgis - Postępy Nauk Medycznych s1/2011, s. 23-28
Paweł Lampe, Beata Jabłońska*
Krótka historia sztucznego przełyku
A brief history of the artificial oesophagus
Katedra i Klinika Chirurgii Przewodu Pokarmowego SUM w Katowicach
Kierownik: prof. dr hab. med. Paweł Lampe
Pomimo postępów w diagnostyce rak przełyku jest często rozpoznawany w późnym stadium. Ze względu na zaawansowane stadium, w którym zazwyczaj się znajduje, leczenie raka przełyku jest tylko paliatywne u ponad 70% pacjentów. Chorzy po resekcji przełyku wymagają rekonstrukcji. Zabiegi chirurgiczne składające się z przeniesienia lub wszczepienia nieuszypułowanego odcinka przewodu pokarmowego są bardzo inwazyjne. W piśmiennictwie istnieje wiele doniesień na temat ulepszeń sztucznego przełyku przy użyciu różnych materiałów biologicznych i syntetycznych. Celem niniejszej pracy było przedstawienie krótkiej historii sztucznego przełyku powołując się na najważniejsze publikacje na ten temat.
Despite the progress in diagnostics procedures, oesophageal cancer is often diagnosed in its late stages. Because of the advanced stage at which it usually presents, treatment of carcinoma of the oesophagus is just palliative in over 70% of patients The surgical treatment of the esophageal cancer is associated in the esophagectomy. Patients following esophagectomy require the esophageal reconstruction. Procedures consisting of translocation or implantation of a pedunculated segment of the alimentary canal are extremely invasive. There are numerous reports regarding improvements of the artificial esophageal using different synthetic and biological materials in the literature. The aim of this paper was to present a short history of the artificial esophagus by citing the most important publications on this topic.
Despite the progress in diagnostics procedures, oesophageal cancer is often diagnosed in its late stages. The disease is characterized by a malignant course: early infiltration of the muscular coat, and metastases to the regional lymph nodes. Because of the advanced stage at which it usually presents, treatment of carcinoma of the oesophagus is just palliative in over 70% of patients (1-4).
Nutritional gastric and enteral fistulas and oesophageal tubes have multiple disadvantages. Different sophisticated methods, i.e. cutting through the neoplasm using laser followed by irradiation and chemotherapy, cause discomfort to the patient, and do not seem to improve the quality of survival (5-7).
However, palliative procedures consisting of translocation or implantation of a pedunculated segment of the alimentary canal are extremely invasive. Besides, the intended purpose, which is enabling the patient to eat naturally and to prevent the bronchial tree from being flooded with saliva and food, is not always achieved. In the 1940s, numerous studies were carried out in order to develop alloplastic oesophageal prostheses. The tubes were easily available and convenient to use for a surgeon. The duration of the operatio was cut down, and intra- and perioperative mortality rates lowered. However, despite numerous improvements of the tube structure over the years as well as various materials and methods of anastomosing the prosthesis to the oesophagus being used, fusion between the tissues and the implant was not achieved. The attempts to use biological, usually cell-rich, implants were unsuccessful.
Non-preserved connective tissue fibrous membranes were later considered as potential material for the development of an oesophageal prosthesis. The results of those investigations were not encouranging, and thus the prostheses were not widely used.
In search of an effective palliation, which would additionally maximize the quality of survival experimental and clinical studies were launched aimed at the development of an artificial oesophageal prosthesis. In 1922, Neuhoff and Ziegler (8) used rubber tubes as experimental oesophageal prostheses in dogs. In 1947, Grindlay (9) suggested that polyethylene tubes could be used as bilairy, tracheal and colonic prostheses. In 1952, Berman (10) selected metacrylic and polyethylene tubes. Out of 20 dogs operated on with the use of the above mentioned tubes. 6 died for various reasons. However, the condition of the surviving 14 dogs was satisfactory. In the same year, Berman reported his results on 28 operations in humans. He used polyethylene tubes for thr formation of an artificial oesophagus. In 1954, Berman (11) operated on 60 patients using the same prosthetic material; mortality rate was below 10%. According to Berman, the success of the procedure might be accounted for by the elimination of the trauma resulting from the mobilized stomach being advanced upwards.
In 1952, Ruffo (12) published the results of his investigations concerning the use of plastic tubes as oesophageal prostheses. However, out of 15 dogs that were operated on, 11 died (74%) in the perioperative period. Chalnot at al. (13) replaced the thoracic segment of the oesophagus in 16 dogs. Having excised a 2-4 cm segment of the thoracic oesophagus, they implanted much longer polyvinyl tubes; the results were encouraging.
In 1953, Roth et al. (14) used metacrylic and PVC tubes as the prostheses of the thoracic oesophagus in 5 dogs, and cervical oesophagus in 15 dogs. Following the procedures they found prosthesis displacement, stomach wall perforation by a PVC prosthesis, and anastomotic leakage. Similar observations were made by Razemon at al. (15).
Shackelford and Sparkuhl (16) reported on a patient who survived 183 day with a plastic prosthesis following a plalliative surgical treatment fo oesopahgeal cancer. In 1954, More et al (17) published the results of their studies which had carried out on 36 rabbits since 1949. Like Berman, they used plastic prostheses; the results, however, were unsatisfactory. The rabbits were dying, most frequently, of suppurative inflammation within the thoracic cavity.
Although, in 1954, Battersby and King (18) submitted a paper describing advantageous features of the prosthetic tube proposed by Berman, they als pointed out some of its shortcoming, i.e. the standard size and the fact that the prosthesis could not be anastomosed to the oesophagus using standard suture technique. They developed a multi-layer prosthesis which consisted of polyethylene sheeting and nylon mesh fused together in an autoclave. The prosthesis was anastomosed to the oesophagus; various anastomoses were used for the purpose. Out of 22 dogs which were operated on using this method, 14 died. During endoscopic procedures performed 3-4 months following the operation, Battersby and King found that the prosthesis and tissues were separated. The high risk was, however, attributed to the oesophageal surgery rather to the above mentioned technique of prosthesis implantation.
In 1956, Maynard et al. (19) reported on the use of a plastic tube as and endoprosthesis for palliative treatment of oesophageal cancer, and for the replacement of an oesophageal segment in a group consisting of 5 patients (Group I) and 9 patients (group II) respectively. The endoprosthesis functioned satisfactorily in 4 patients from Group I. In 8 patients from Group II, the results were poor p the prosthesis and the oesophagel tissues did not fuse together.
In 1956, Ebner (20) described the use of Berman’s prosthesis for palliative treatment of cancer of the oesophagu.
In 1963, bearing in mind that organ pullup was too risky in the case of patients presenting with cancer cachexia, Fryfogle et al. (2) used an alloplastic oesophageal prosthesis. The prosthesis was made of rubber with silicone lining. The outer surface was covered with Dacron. In order for anastomosis not to cause ischaemia of the margins of the oesophasus, the authors suggested a complex technique. The function of the prosthesis and possible methods of anastomosing the tube to the oesophagus were first studied in experiments on dogs; afterwards the prosthesis was used in1 patient with a good result. After 6 weeks, however, the patient started complaining of dry hacking cough, most probably caused by tracheal compression by the prosthesis.
In 1968, La Guerre et al. (21) used tubed made of new material, hydron (Hadron Laboratories New Brunswick, N.J.), in a teflon or Dacron cuff, as oesophageal prostheses in 24 dogs. In the first 7 dogs died due to leakage from the upper anastomosis; two others died after about 3 weeks. The survival period of the remaining 13 dogs ranged between 1.5 and 9 months. The authors warned surgeons not to divide the vagus nerve while excising oesophageal segments. Three dogs, in which the nerve was damaged during the operative procedure, developed considerable weight loss. One dog vomited the prosthesis, and very soon stricture developed within the prosthesis canal. Microscopic examination did not reveal any ingrowth of the oesophageal wall tissuses into the prosthesis. Epithelial growth was not found either.
Stuart (22, 23) reported on 5 patients with a plastic tube as a prosthesis of a rubber segment of the oesophagus. He considered the immediate result satisfactory, and the method accepatable for palliative treatment of cancer of the oesophagus.
In 1973, Goldsmith et al. (24) described a marlex mesh prosthesis. The mesh pores were sealed up with collodion, and the whole prosthesis wrapped up in pedunculated omentum. Out od 12 dogs, 7 survived for a long period of time. The remaining 5 died of complications.
Parallel to the trials with synthetic material, were the attempts to use auto-, allo-, and xenografts for oesophageal repair procedures. Allografts were used by Skinner (25) in an experiment on 20 dogs. Nine dogs died in the early postoperative period; 11 animals which survived the first week developed strictures. In 1952, in an experiment on dogs, Fiacavento (26) transplanted oesophageal prostheses which had been first preserved in Gross solution containing penicillin. The transplants were wrapped up in the pleura. Despite numerous early complications, the long-term results were encouraging – he observed slight strictures, oesophageal strump approximation, and epithelial growth in the prosthesis canal. In 1952, allografts, fresh and formalin-preserved, were transplanted by Ruffo (27), who observed marked shortening and stricture of the transplants in dogs. Lyophilized allografts were transplanted in 1953 by Pate and Sawyer (28), who found progressive graft atrophy due to retrograde changes. The results were confirmed in 1958 by Pataky, Molnari and Jakab (29), who found cicatrical strictures within lyophilized oesophageal segments which they had transplanted.
Then, the attention of researchers was frawn to the tube-shaped blood vessels and the trachea. Some of them believed that these structures could be used as oesophageal prostheses. In 1956, Giudice and Tawano (30) published the results of their experiment on 6 dogs, in which a short oesophageal segment was excised and replaced with autogenic trachea. In 1958, Galente et al. (31) noted poor results after the transplantation of allogenic trachea. Allogenic aorta, fresh and preserved, was used by Kuntz in 1952. His experiments on dogs were unsuccessful. He found strictures resulting in cachexia.
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