History

Most early attempts at esophagectomy were performed for esophageal cancer. Bypass operations using skin tubes were developed during the late 19th and early 20th centuries by Mikulicz1 and Garre2 for bypass or replacement of the cervical esophagus and by Bircher3 for bypass of the entire esophagus. Although these surgeons demonstrated that fluids could pass through the skin tubes they had created, successful bypass surgery was not accomplished until 1913 after a transhiatal esophagectomy.4 Most importantly, quality of life was not maintained with these operations. After >20 years of dismal outcomes of surgically addressing the issue of esophageal obstruction, the first successful transthoracic esophagectomy was performed by Torek in 1913.5 Even in this patient,

MANAGING FAILED ANTI-REFLUX THERAPY

no reconstruction was performed; instead, an extracorporeal tube connected a cervical esophagostomy to a gastrostomy to permit the patient to take enteral nutrition.

Another two to three decades were to pass before esophageal resection and reconstruction were performed routinely. Reasons for this included the slow adoption of methods for tracheal intubation for controlled ventilation, lack of understanding of requirements for fluid and electrolyte replacements, and the absence of reliable blood transfusion techniques. The large number of maxillofacial injuries that occurred during World War I stimulated the adoption of endotracheal intubation that had been developed decades earlier.6 Subsequent anesthetic advances included the introduction of intubation under direct vision, the use of positive pressure breathing apparatus, and the use of curare as a paralytic agent permitting mechanically controlled ventilation.710 Experiences during the Great War also led investigations into transfusion methods and the management of shock, both of which were vital to progress in major operations such as esophagectomy. This growth culminated in the 1930s in the performance of a transthoracic esophagectomy and, for the first time, intrathoracic reconstruction.1113

Even into the 1930s there was considerable debate over what constituted optimal methods of esophageal replacement. In 1934, Ochsner and Owens14 summarized the extant literature regarding extrathoracic esophageal reconstruction. Skin tubes (dermatoplasty), jejunoplasty, coloplasty, gastroplasty, and hybrid procedures combining two of these techniques all offered mortality rates from 20 to >50%. The procedures were completed in only about half of the patients, and overall good results were reported in only 30-40% of patients. The development of intrathoracic reconstruction techniques using the stomach in the 1930s was enthusiastically adopted, and reports of large series of patients who had undergone successful esophagectomy and reconstruction during the 1940s and 1950s began to appear.15-19

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