SUBMUCOSA ESOPHAGECTOMY IN THE TREATMENT OF THE ADVANCED MEGAESOPHAGUS
Keywords:
esophagus surgery, esophagectomy, esophageal echalasiaAbstract
Esophageal resection without thoracotomy has been used more frequently in recent years for benign conditions, especially in advanced megaesophagus. This access route, although it has the advantage of avoiding compromising pulmonary dynamics, is not free from complications. Among these, the opening of the pleura stands out, with the consequent hemopneumothorax, in addition to the potential aggression to other organs at the level of the mediastinum, with often significant postoperative morbidity. In turn, in advanced megaesophagus, stasis esophagitis predisposes to the development of carcinoma. Based on these considerations, it was previously proposed in animals and human cadavers to remove the mucosa and subnucosa of the esophagus, through complete invagination, without thoracotomy. The results, which were quite satisfactory in experimental surgery, encouraged the continuation of this line of research, beginning the experience in the clinical area. Thus, the present work aimed to demonstrate, through a detailed analysis, the technique of removing the esophageal mucosa by submucosal detachment of its muscular coat, preserving it entirely, at the level of the mediastinum. This procedure was performed via the cervicoabdominal route in 60 patients with grade III or IV megaesophagus. The gastrointestinal transit was reconstructed, transposing the stomach through the posterior mediastinum, inside the muscular coat or through the retrosternal route. This study allowed the following conclusions: 1) resection of the mucosa through the submucosal plane, through intussusception, proved to be simple and viable in 98.4% of cases; 2) there was little blood loss, intra- or immediately post-operatively, originating from the bed of the esophageal muscular layer remaining at the mediastinal level; 3) there was a low incidence of pleuropulmonary complications (5.0%); 4) the continuity of the gastrointestinal tract could be reestablished by transposition of the stomach, through the remaining esophageal muscular tube, in the majority of patients with grade IV megaesophagus.
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