Ann Thorac Surg 2001;72:1141-1143
© 2001 The Society of Thoracic Surgeons
Original article: general thoracic
Pharyngo-enteral anastomosis for esophageal reconstruction in diffuse corrosive esophageal stricture
Jae K. Park, MDa,
Sung B. Sim, MDa,
Sun H. Lee, MDa,
Hae M. Jeon, MDb,
Moon S. Kwack, MDa
a Departments of Thoracic and Cardiovascular Surgery, St. Mary’s Hospital, Catholic University of Korea, Seoul, South Korea
b Department of General Surgery, St. Mary’s Hospital, Catholic University of Korea, Seoul, South Korea
Accepted for publication May 29, 2001.
Address reprint requests to Dr Park, Department of Thoracic and Cardiovascular Surgery, St. Mary’s Hospital, 62 Youido-dong Youngdungpo-gu Seoul, Korea 150-713
e-mail: jaekpark{at}cmc.cuk.ac.kr
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Abstract
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Background. Diseases involving the entire esophagus usually require extensive surgical procedures to accomplish functional reconstruction. These procedures are extremely stressful for undernourished patients. We have utilized a simpler procedure for total esophageal reconstruction.
Methods. This retrospective report reviews the experience in 8 patients who underwent esophageal reconstruction by pharyngo-colo-gastrostomy or jejunostomy without any resection of bony structures.
Results. There was no operative or hospital death. Complications included anastomotic stenosis, transient leak from the ileal stump, and late enterocutaneous fistula, each in 1 patient. Laryngeal function was maintained without special treatments. After swallowing training for approximately 1 week, oral feeding was resumed. All patients have gained 7 to 21 kg at 35 to 67 months after surgery.
Conclusions. Our surgical procedure is shown to be safe and effective in undernourished patients with diffuse esophageal stricture.
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Introduction
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Despite good initial management, approximately 5% of patients who ingest caustics develop severe and diffuse esophageal stricture [1, 2]. There is much controversy about the techniques available to prevent this complication once the burn has occurred. Steroids, stents, and prophylactic dilatation all have been employed [3, 4]. However, endoluminal techniques have not proved effective when stricture formation involves the upper portion. Esophageal reconstruction in the form of pharyngo-enteral anastomosis is an option in such situations [5]. Patients with longstanding esophageal stricture are usually malnourished and often have immune deficiency. Conventional pharyngo-enteral reconstruction procedures are extensive and stressful, and often poorly tolerated in this group of patients. Therefore, we tried a simpler procedure to reduce surgical invasiveness.
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Material and methods
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From May 1995 to January 1998, 8 patients underwent pharyngo-colo-enteral anastomosis for diffuse esophageal corrosive stricture in our department. Seven of them were transferred from another hospital for operation. The age of these patients ranged from 20 to 63 years old, with an average of 38 years. Seven were female and 1 was male. The corrosive agents were acid in 7 patients and alkali in 1 patient (Table 1).
Time interval from swallowing the corrosive agent to reconstructive surgery ranged from 6 months to 50 years. All patients required gastrostomy, jejunostomy, or both for enteral feeding before reconstructive surgery. Body weight ranged from 31 to 55 kg. Six patients weighed less than 50 kg. Two patients were also diagnosed with depression.
Through an upper midline laparotomy, the right colon and a 3-inch-long segment of terminal ileum was mobilized using a pedicle of the middle colic vessels.
A collar incision was made on the left side of the neck, and the sternohyoid, sternothyroid, omohyoid, and the sternal head of sternomastoid muscles were divided. The intestinal segment was pulled up to the neck through the substernal space. After exposing the posterolateral surface of the hypopharynx (left piriform sinus), the left inferior constrictor and cricopharyngeal muscles were vertically incised about 2.5 cm (Fig 1). A side-to-side hypopharyngo-ileal anastomosis was made using 4-0 absorbable monofilament suture (Fig 2).
The lower end of intestinal segment was anastomosed to the anterior wall of the stomach in 3 patients and to the jejunum in 5 patients. Pyloroplasty was performed in 5 patients.
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Results
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There was no incidence of postoperative death or anastomotic disruption (Fig 3). Postoperative complications consisted of one anastomotic stenosis, one transient disruption of ileal stump, and one enterocutaneous fistula (Table 2). The ileal stump leak was detected on the 12th postoperative day, was drained, and subsided in 3 weeks. The anastomotic stenosis improved after several dilatations, and the enterocutaneous fistula that occurred at 7 months after surgery was managed by laparotomy.
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Fig 3. Postoperative esophagogram does not show aspiration, leakage, or any passage disturbance (arrows indicate anastomotic site).
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Normal diet was possible in 7 cases, and the increase in body weight ranged from 7 to 21 kg at 35 to 67 months after the operation.
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Comment
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A wide variety of methods for total esophageal reconstruction has been described, however, no universally acceptable method for reconstruction of the cervical esophagus is available [6, 7]. This type of esophageal reconstruction requires a substitute with considerable length. Thus, the colon has been used in preference to the reverse gastric tube or the jejunum. The ileocolic segment can be made longer by including more ileum based on the ileocolic artery. This makes it possible to bring the graft for substitution much higher into the neck.
Thomas and associates [9], Gupta [10], and Kim and associates [11], have described enteral anastomoses in the posterior portion of the hypopharynx. In an attempt to make space for the transplant, they resected the left half of sternal manubrium, the proximal third of the clavicle, and the first costal cartilage. Beon and associates [12] performed pharyngo-enterostomy after resection of the left-side thyroid cartilage. We used the terminal ileum for the pharyngeal anastomosis and positioned the right colon in the substernal space. As a result, we could preserve all bony structures.
Laryngeal functions was preserved well in all cases and, with training of swallowing according to the rehabilitation schedule for approximately 1 week, there was no significant problem in oral feeding.
Regurgitation occurred in the recumbent position, and worsened with coughing and liquid intake. However, it was mild and was easily prevented by upper torso elevation.
One question that remains unanswered is whether the damaged esophagus should be removed. If the esophagus is left in place, complications due to secretions or infection in the segment might occur, and the possibility of carcinoma arising on the basis of the injured tissue must be considered. The incidence of malignant change is uncertain, and estimates range from 1% to 5% [13–16]. The average reported interval between the initial injury and malignancy is 40 years [17]. However, esophageal resection may not fully protect the patient against cancer [18]. Moreover, the extensive dissection necessary to remove it, particularly when marked periesophagitis has occurred with adherence to contiguous structures, presents considerable risks for damage. Some authors believe the danger of cancer justifies resection of the esophagus, while others state that the morbidity of resection is greater than the risk of malignancy [17, 19, 20]. Under ideal conditions it is desirable that esophageal resection be performed during reconstructive surgery. However, we feel that the procedure described in this series of malnourished chronically ill patients represents an effective and safer alternative [8].
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References
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Noirclerc M.J., Costanzo J.D., Sastre B., et al. Surgical management of caustic injuries to the upper gastrointestinal tract. In: Demeester T.R., Matthews H.R., eds. Benign esophageal disease. International trends of general thoracic surgery, Vol. 3. St. Louis, MO: Mosby, 1987:261-265.
-
Borja M.R., Ransdell H.T., Jr, Thomas D.V., Johnson W. Lye injuries of the esophagus: analysis of ninety cases of lye ingestion. J Thorac Cardiovasc Surg 1969;57:533-538.[Medline]
-
Hill J.L., Norberg H.P., Smith M.D., Young J.A., Reyes H.M. Clinical technique and success of the esophageal stent to prevent corrosive stricture. J Pediatr Surg 1976;11:443-450.[Medline]
-
Webb W.R., Koutras P., Ecker R.R., Sugg W.L. An evaluation of steroids and antibiotics in caustic burns of the esophagus. Ann Thorac Surg 1970;9:95-102.[Medline]
-
Holinger P.H., Johnston K.C., Potts W.J., daCunha F. The conservative and surgical management of benign strictures of the esophagus. J Thorac Surg 1954;28:345-366.
-
Ranger D. The problems of repair after pharyngolaryngectomy. Proc R Soc Med 1964;57:1099-1103.[Medline]
-
Endo M., Yoshino K., Takiguchi T., Yamazaki S. Surgical procedures for cervical esophageal cancer. In: Ferguson M.K., Little A.G., Skinner D.B., eds. Diseases of the esophagus, Vol. 1: Malignant diseases. Mount Kisco, NY: Futura Publishing Company, 1990:171-176.
-
Grimes O.F. Surgical reconstruction of the diseased esophagus. II. Interposition of the ileocolon and colon. Surgery 1967;61:487-494.[Medline]
-
Thomas A.N., Dedo H.H., Lim R.C., Steele M. Pharyngoesophageal caustic stricture: treatment by pharyngogastrostomy compared to colon interposition combined with free bowel graft. Am J Surg 1976;132:195-203.[Medline]
-
Gupta S. Total obliteration of esophagus and hypopharynx due to corrosive: a new technique of reconstruction. J Thorac Cardiovasc Surg 1970;60:264-268.[Medline]
-
Kim H.K., Lee S.Y., Choi J.B. Surgical treatment for acute caustic injury of the hypopharynx, esophagus, and stomach. Korean J Thorac Cardiovasc Surg 1995;28:935-938.
-
Beon J.U., Ku B.I., Oh S.J. Esophageal reconstruction for hypopharyngeal stricture after severe corrosive injury. Korean J Thorac Cardiovasc Surg 1997;30:48-54.
-
Hollinger P.H., Hara H.J. Cancer of the esophagus: study of 100 consecutive cases. Laryngoscope 1942;52:968-982.
-
Hopkins R.A., Postlethwait R.W. Caustic burns and carcinoma of the esophagus. Ann Surg 1981;194:146-148.[Medline]
-
Benedict E.B. Carcinoma of the esophagus developing in benign stricture. N Engl J Med 1942;224:408-412.
-
Ti T.K. Oesophageal carcinoma associated with corrosive injury: prevention and treatment by oesophageal resection. Br J Surg 1983;70:223-225.[Medline]
-
Belsy R.H.R. Corrosive injury-late management. In: Pearson F.G., Hiebert C.A., Deslauriers J., McKneally M.F., Ginsberg R.J., Urschel H.C., Jr, eds. Esophageal surgery, 1st ed. New York: Churchill Livingstone Inc, 1995:474-478.
-
Csikos M., Horvath O., Petri A., Petri I., Imre J. Late malignant transformation of chronic corrosive oesophageal stricture. Langenbecks Arch Chir 1985;365:231-238.[Medline]
-
Anderson K.D. Corrosive injury-early management. In: Pearson F.G., Hiebert C.A., Deslauriers J., McKneally M.F., Ginsberg R.J., Urschel H.C., Jr, eds. Esophageal surgery, 1st ed. New York: Churchill Livingstone Inc, 1995:465-474.
-
Siewert J.R., Bartels H. Oesophagus veratzung-"prophylaktische" Oesophagektomie?. Langenbecks Arch Chir 1985;365:227-229.[Medline]
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Abstract
Introduction
