Intrathoracic esophageal replacement in the dog with the use of an artificial esophagus composed of a collagen sponge with a double-layered silicone tube

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Intrathoracic esophageal replacement in the dog with the use of an artificial esophagus composed of a collagen sponge with a double-layered silicone tube Yasumichi Yamamoto, MDa, Tatsuo Nakamura, MDa, Yasuhiko Shimizu, MDa, Kazuya Matsumoto, MDa, Yukinobu Takimoto, MDa, Tetsuya Kiyotani, MDa, Takashi Sekine, MDa, Hiroki Ueda, MTecha, Yu Liu, MDa, Nobushige Tamura, MDb The Journal of Thoracic and Cardiovascular Surgery Volume 118, Issue 2, Pages 276-286 (August 1999) DOI: 10.1016/S0022-5223(99)70218-7 Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 1 An overview of the artificial esophagus composed of an inner silicone tube, 18 mm in diameter and 0.5 mm thick, covered with an outer collagen sponge layer 5 mm thick. The material was exposed to dehydrothermal treatment. ST, Silicone tube; CS, collagen sponge. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 2 Operative findings. Top, The oral anastomosis is completed. Bottom, The anal anastomosis is completed. A 5-cm length of the intrathoracic esophagus was excised, and both ends of the prosthesis were inserted for about 1 cm into the resulting stumps. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 3 Esophagogram taken 3 months after the operation in dog 8. Left, Plain right anterior oblique view. Center, Right anterior oblique view. Right, Anteroposterior view. The contrast medium passed through the regenerated esophagus smoothly. Stenosis in the middle portion of the regenerated esophagus and prestenotic dilatation were evident. The anastomoses were confirmed by the metal markers in the plain right anterior oblique view. Arrows, Anastomosis. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 4 Esophagogram at 24 months in dog 8. Left, Plain right anterior oblique view. Center, Right anterior oblique view. Right, Anteroposterior view. Stenosis in the middle portion of the regenerated esophagus and prestenotic dilatation are still evident. Metal markers were about 3.5 cm of the distance, which indicated the distance of the anastomosis, and they had not changed compared with the distance at 3 months. Arrows, Anastomosis. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 5 Endoscopic findings in dog 8. Left, 1 month; middle, 3 months; right, 12 months. Upper half, Oral side; lower half, anal side. At 1 month, the internal surface was covered by granulation tissue, although stenosis was not observed. Stenosis was evident in the middle of the regenerated esophagus at 3 and 12 months. The anastomoses were confirmed by residual sutures. The degree of stenosis at 3 months was similar to that at 12 months. The stenosis did not worsen after 3 months. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 6 Macroscopic appearance of the internal surface of the regenerated esophagus at 1 month. The surface is covered with granulation tissue, and stenosis is hardly evident (stenosis degree = 13%, shrinkage degree = 34%). Arrow, Anastomosis; A, anal side; O, oral side. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 7 Macroscopic appearance of the internal surface of the regenerated esophagus at 10 months. The surface is completely covered by mucosa. Stenosis and shrinkage are observed (stenosis degree = 47%, shrinkage degree = 41%). Arrow, Anastomosis; A, anal side; O, oral side. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 8 Microscopic findings in the middle of the regenerated esophagus at 1 month. The top is the luminal side. The inner amorphous collagen layer (A) is composed of inflammatory cells with neovascularization, and the outer fibrous collagen layer (F) consists of collagen fiber bundles aligned along the longitudinal axis of the esophagus (Masson’s trichrome stain, original magnification ×80, arrowhead: area of interest in Fig 9). The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 9 Immunofluorescence histologic study of the middle of the regenerated esophagus at 1 month after staining with anti-alpha–smooth muscle actin antibody (original magnification ×400). A large number of cells positive for alpha–smooth muscle actin are observed (arrow). These are considered to be myofibroblasts. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 10 TEM appearance at 1 month of spindle cells that were positive for alpha–smooth muscle actin. The round nuclei are divided into 2 parts owing to the deep fold. The well-developed microfilaments (arrow) with dense bodies (arrowhead) are arranged parallel to the long axis of the cell. Rough endoplasmic reticulum (thin arrow) is also evident. The cells have characteristics intermediate between those of smooth muscle cells and fibroblasts. Therefore they are considered to be myofibroblasts. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 11 Microscopic findings near the anal anastomosis at 3 months. Top side is the luminal side. Stratified squamous epithelium covers the regenerated esophagus. The skeletal muscle layer has lost its inner circular and outer longitudinal original structure at the stumps (Masson’s trichrome stain, original magnification ×50). E, Mucosa; M, lamina muscularis mucosae; G, gland; SC, inner circular skeletal muscle layer; SL, outer longitudinal skeletal muscle layer. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 12 Microscopic appearance of the middle of the regenerated esophagus at 12 months. Ten layers or more of the stratified squamous epithelium have formed, beneath which islets of smooth muscle or esophageal glands have regenerated. The islets of smooth muscle are considered to be the interrupted lamina muscularis mucosae. The location of the mucosa, smooth muscle, and glands is similar to that in the normal esophagus (Masson’s trichrome stain, original magnification ×200). E, Mucosa; M, islets of smooth muscle; G, gland. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions

Fig. 13 Immunohistologic findings near the regenerated esophagus at 12 months, stained with anti-alpha–smooth muscle actin antibody (original magnification ×100). The smooth muscle has regenerated at the tip of the skeletal muscle layer. These smooth muscle bundles are connected with the lamina muscularis mucosae in the middle of the regenerated esophagus. E, Mucosa; M, lamina muscularis; G, gland; S, skeletal muscle; B, smooth muscle bundle. The Journal of Thoracic and Cardiovascular Surgery 1999 118, 276-286DOI: (10.1016/S0022-5223(99)70218-7) Copyright © 1999 Mosby, Inc. Terms and Conditions