Ann Thorac Surg 2005;80:1122-1124
© 2005 The Society of Thoracic Surgeons
Case report
Esophageal Replacement by Lexer’s Esophagoplasty: Adenocarcinoma as Late Complication
Alexander R. Novotny, MD
*
,
Gerd Florack, MD,
Karen Becker, MD,
Jorg-Rudiger Siewert, MD, PhD
Departments of Surgery and Pathology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
Accepted for publication March 17, 2004.
* Address reprint requests to Dr Novotny, Department of Surgery, Klinikum rechts der Isar der TU-München, Ismaninger Str 22, 81675 Munich, Germany; (Email: novotny{at}nt1.chir.med.tu-muenchen.de).
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Abstract
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The most successful method for esophageal reconstruction in the early 20th century was the jejunodermatoesophagoplasty after Lexer, involving the presternal formation of a skin tube for passage reconstruction. A 59-year-old patient presented to our hospital with adenocarcinoma at the dermatojejunostomy 47 years after undergoing a Lexer procedure. The neoesophagus was removed, and the passage was reconstructed by a retrosternal colonic interposition. Although squamous cell carcinoma is known as a late complication of dermatoesophagoplasties, this is a reported case of adenocarcinoma formation.
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Introduction
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Esophageal surgery in the early 1900s was associated with a very high mortality as a result of insufficient experience in thoracic surgery, infection problems, and the lack of methods that allowed for adequate ventilation of the patient while performing surgery on the open chest. At that time benign esophageal strictures caused by acid or lye ingestion were quite frequent [1, 2].
In those days the most successful method of passage reconstruction was the antethoracic jejunodermatoesophagoplasty developed by Lexer [1, 3], involving the creation of an antethoracic skin tube as an esophageal bypass.
Several cases have been reported in the literature in which squamous cell carcinoma developed in the skin tube decades after esophagoplasty [4–7]. We report herein a case of adenocarcinoma formation in a skin-tube esophagus.
A 59-year-old female patient was admitted to our hospital with biopsy-proven diagnosis of esophageal adenocarcinoma. The history received from the referring hospital indicated that in 1956 the patient had undergone a presternal reconstruction of the food passage for esophageal stricture as a result of an accidental acid burn she had suffered at the age of 13 years (1955).
During routine endoscopy a biopsy sample had been taken at the aboral anastomosis of the neoesophagus that contained malignant tissue.
After a barium study it became clear that a presternal bypass of the occluded esophageal segment had been achieved by the operation (Fig 1). The barium study, as well as an additional endoscopy, showed no signs of intraluminal tumor growth. Nevertheless extensive biopsy samples were taken at the site of the anastomosis, which however failed to show tumor on histologic examination. The computed tomography and positron-emission tomography scans likewise could not detect any signs of tumor or distant metastases. Tumor markers carcinogenic embryonic antigen, CA 19-9, and CA 72-4 were within the normal range. The biopsy specimen in question was reevaluated independently by two experienced gastrointestinal pathologists and found to definitely show adenocarcinoma.
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Fig 1. Barium study of the presternal esophageal bypass. Cranial portion with esophagodermatostomy (left); caudal portion with esophagojejunostomy (right).
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The decision was made to remove the tumor-bearing neoesophagus and reconstruct the food passage by retrosternal colonic interposition. During the course of the operation and macroscopic examination of the specimen it became clear that the occluded esophagus had been bypassed by a presternal skin tube that was cranially connected to the prestenotic cervical esophagus and to the gastric antrum by means of retrocolic interposition of a jejunal segment (Fig 2).
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Fig 2. (A) Schematic illustration of Lexer’s jejunodermatoesophagoplasty. End-to-side anastomosis of the skin tube with the prestenotic esophagus, end-to-end dermatojejunostomy, side-to-side jejunogastrostomy and side-to-side jejunojejunostomy. (B) Creation of the skin-tube (from left to right): presternal placement of rubber-drain and skin-incisions, formation of skin-tube around rubber-drain, closure of skin-flaps above the newly formed skin-tube.
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After removal of the neoesophagus, the food passage was reconstructed by retrosternal interposition of a transverse colon segment between the cervical esophagus and the stomach. The colon was connected with the anterior wall of the stomach by means of an end-to-side anastomosis. The postoperative course was uncomplicated, and swallowing function was good. The patient could be discharged 20 days after the operation and is doing well up to the time of this report.
Close histologic examination of the specimen showed a small remnant of adenocarcinoma right in the area of the anastomosis between the skin tube and the jejunal segment invading the submucosa. Most of the tumor had been removed by the biopsy that led to the diagnosis (Fig 3). Cytokeratin 7 negativity and positive staining for cytokeratin 20 in the immunohistochemical analysis confirmed the origin of the carcinoma from the jejunal epithelium.
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Fig 3. Microscopic view of the jejunodermatostomy (hematoxylin & eosin staining). Biopsy site right at the transition-zone between squamous epithelium and jejunal mucosa. Jejunal glands with atypia (different magnifications).
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Comment
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The operation performed on the patient in the present case is known as Lexer’s jejunodermatoesophagoplasty. The method was first described by Erich Lexer at the Congress of the German Surgical Association in 1911 and was basically a combination of earlier methods developed by Roux and Wullstein [1].
The operation was usually performed as a three-step procedure. In the first step a mobilized bowel loop was connected side-to-side to the stomach antrum in its aboral portion, and the oral end was transposed under the mobilized skin of the chest. In the second session the skin tube and an esophagostomy were created. The antethoracal skin tube was later connected to the bowel loop at its caudal end and joined with the esophagostomy cranially. A schematic illustration of the resulting anatomy and creation of the skin tube is shown in Figure 2.
The history of the patient in the reported case exemplifies the way benign esophageal strictures were treated around the turn of the last century and well into the 1900s. The esophageal stricture that developed after the acid burn was first treated by oral bougienage. Nevertheless it progressed until finally a gastrostomy had to be created to feed the patient. During the subsequent 9 months, "endless bougienage" was performed, which also only temporarily improved swallowing function.
In the years 1956 and 1957 the esophagoplasty according to Lexer was performed by a German surgeon named Anton Rill in the city of Sombor (Serbia). Overall nine operations were needed, including skin autotransplants and the final closing of the gastrostomy after 6 months. It was typical of this operation that it needed multiple steps to reach a satisfying result, as it frequently caused fistulas and skin necroses because of the tension at the wound edges [3].
From thereon the patient lived with the esophageal replacement for 46 years without any problems and good swallowing function.
In most of the reported cases skin-tube esophagoplasties yielded good functional results for years. There are a couple of reports in the literature in which precancerous lesions or squamous cell carcinoma in the skin tube has developed [4–7]. The time between esophagoplasty and development of squamous cell carcinoma has been reported to be approximately 30 to 40 years [4–6]. The lesions occurring in the antethoracal skin tube have been seen as results of the chronic physical and chemical irritation by food and gastroneoesophageal reflux [6]. Interestingly, malignant changes of the epithelium in the middle part of the skin tube were rare, although they were frequently found at or in the ultimate vicinity of the anastomoses. The formation of little diverticula or blind sacs is quite frequently found in these areas for technical reasons. Because of retention of neoesophageal contents, these areas would be especially exposed to chemical irritations by saliva, food, or reflux. Similar conditions are encountered in cases of esophageal diverticula or achalasia, both of which are associated with a higher risk for the development of squamous cell carcinoma [8, 9]. Adenocarcinoma is, however, comparably rare in these conditions [8–10].
Considering the parallels in potential mechanisms involved in cancer development, squamous cell carcinoma seems to occur frequently in patients with dermatoesophagoplasty, whereas the formation of adenocarcinoma is obviously a rare event.
Because of the known risk of malignant transformation in the skin tube Petri and colleagues [6] advocate endoscopic surveillance of patients with skin-tube esophagus on a regular basis, starting 10 years after esophagoplasty. It is also known that an esophagus injured by lye or acid is subject to an increased risk of malignant transformation. Inasmuch as endoscopic surveillance of the remnant esophagus is not possible in the presented case, an elective esophagectomy has to be discussed with the patient.
The described method of esophageal reconstruction by the creation of a presternal skin tube is no longer in use today, as methods with much better functional and also cosmetic results have been developed. Therefore the method has been widely forgotten. This paper is a historic review for the interested reader and may be of special interest to doctors specializing in esophageal diseases and surgery, who may once in a while encounter patients with skin-tube replacement of the esophagus.
In the further treatment of patients with dermatoesophagoplasties the increased risk of malignant transformation within the skin tube should be kept in mind and endoscopies should be performed on a regular basis. Thus, special attention should be paid to the anastomotic sites.
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References
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- Killian H. Die Chirurgie der SpeiseroehreIn: Kirschner M, Nordmann O, editors. Die Chirurgie der Brust. 2 ed. Berlin: Urban & Schwarzenberg; 1941.
- Heindl A. Klinische Beobachtungen an 137 Gutartigen Oesophagusstenosen Der I. Chirurg Universitaetsklinik Wien 1901–1925 Dtsch Z Chir 1926;199:252-268.
- Kuettner H. Die Operationen im Mediastinum und am thorakalen OesophagusIn: Sauerbruch F, Schmieden V, editors. Operationen an Hals und Brustkorb. 6 ed. Leipzig: Johann Ambrosius Barth; 1934.
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Abstract
Introduction
