Surgeon's Day

Mrs. Harley Stansberry of Sterling, Colo., did some heavy washing in her basement two months ago, and she was extra careful to empty her tub of lye water well away from little Mike, who was playing on the floor near by. But Mike, 28 months, found the drain hose, and some of the lye solution was still in it. Mike swallowed and screamed. His mother rushed him to a doctor, who gave him mineral oil and kept him on soothing milk and ice cream for three weeks. But one morning Mike could no longer swallow: scar tissue had closed his esophagus (gullet). He was driven 124 miles through a snowstorm to Denver's Colorado General Hospital. There, Mike was fed intravenously and through a tiny plastic tube forced through his esophagus, to build him up for surgery.

At 8:30 one morning last week, Chief Surgeon Henry Swan II began a daring and radical operation. Its aim: to give Mike an artificial esophagus, made from a part of the intestine.

To the Hiatus. With the small patient under ether, Dr. Swan made a huge incision to open chest and abdomen. He pulled out a loop of the jejunum (uppermost part of the small intestine) and cut it off near the duodenum. Carefully he worked the long, free end upward to the diaphragm. For a time Dr. Swan had to turn his attention back to the dangling duodenum (see chart): he made a T-junction by stitching its attached bit of jejunum into the intestinal tract a couple of feet below the original cut (making a natural outlet for digestive juices).

Next, Dr. Swan spread Mike's ribs and began probing for the esophagus. He found that its lower end, where it joins the stomach, was unburned. He kept going until he found the upper end; it was also unburned. But in between was a 4-in. length of scarred, closed pipe. He cut that out.

Now it was time to use the replacement tube, i.e., the severed jejunum. Dr. Swan cut a slit in the diaphragm beside the hiatus (where the esophagus normally passes through the diaphragm). Then, through the slit he pulled up the jejunum with its trailing tentacles of arteries and veins. Four and a half hours after operation's start, he was able to begin the fine sewing necessary to join the jejunum to the upper end of the esophagus. This gave Mike a short-circuited digestive tract: throat to gullet to jejunum, with the stomach and duodenum as spectators. Dr. Swan now had a choice. He could close Mike up, as originally planned, and finish the operation after jejunum and esophagus had grown together. Or he might go right ahead and make the necessary connection with the stomach. "How's your patient?" Dr. Swan asked the anesthesiologist for the dozenth time. "Doing fine," came the answer. Dr. Swan decided that Mike was strong enough to let him go ahead at once.

Two-Way Digestion. At the hiatus. Dr. Swan pulled the jejunum over, made an opening in its side, and stitched it to the mouth of the stomach. What distinguished his technique from similar opera tions for this purpose was that he was careful to hook up with the cardia, part of the valve which keeps acid stomach juices from percolating back up toward the mouth. (Without a cardia, he is convinced, the patient would later have ulcers or other upsets.) This stitching done. Mike had two digestive tracts, beginning with the inverted "Y" at the hiatus.

At 3:30, Dr. Swan at last began sewing up membranes and muscles to close the wound.* When Mike came to, he had a plastic tube running through his mouth and his new substitute esophagus into his stomach. He would be fed that way for several days, to allow the tissue to heal undisturbed.

Dr. Swan plans to operate again in a few weeks, after the new esophagus and its unions have grown firmly together and their blood supply is assured. This time, the knifework will be relatively easy: simply to cut away the bypass stretch of jejunum--then no longer needed--from the top of the stomach to the bottom of the duodenum. Then Mike's food will have no choice but to travel the conventional course it always took, before he got inquisitive about the black hose on the washtub.

*A similar operation was developed in Russia, where an open jar of concentrated sulphuric acid is often set between the inner and outer panes of storm windows to keep the glass from frosting. Children sometimes get at the jar. Thanks to such accidents, Russian surgeons have had a lot of practice in building artificial gullets. But their technique was to lead the tube under the skin from the neck to the stomach, so that it bulged like a hose under a carpet, and could easily be injured.

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