Cervical Esophagostomy Research Articles

魚骨誤飲により２か所の長大な食道穿孔をきたし縦隔膿よう，頚部皮下膿ようを合併した１症例

Esophageal perforation is a serious acute disease. In this paper, a case of esophageal perforation by a fish-bone with severe mediastinitis and a cervical abscess is reported.For a 50-year-old male, the diagnosis was made 15 days after he had swallowed a fish-bone, because the symptoms were slight before severe chest pain began. Two esophageal perforations (19-21 cm and 24-31 cm from his initial tooth line) were confirmed by endoscopy. Moreover, mediastinitis and a huge cervical abscess were recognized perioperatively. Most of his esophagus was resected due to the two long perforations, and mediastinal drainage, cervical esophagostomy and gastrostomy were also performed. After the operation, the patient suffered from a severe pyothorax, but he fortunately recovered. 10 months later, an esophageal reconstraction by gastric tube was done. Since fish-bones sometimes cause esophageal perforations and severe complications are often seen, strict follow-up is needed for patients who accidentally swallow them.

Functional Outcome After Surgical Treatment of Esophageal Perforation

Background. The functional results after treatment of intrathoracic esophageal perforations have been poorly documented. Methods. A retrospective review of 42 patients who underwent treatment of intrathoracic esophageal perforation associated with benign esophageal disease was performed. Results. Of 42 patients treated for esophageal perforation, 25 underwent primary repair, 15 underwent esophagectomy and reconstruction, 1 underwent cervical esophagostomy and drainage followed by esophageal resection, and 1 had drainage alone followed by primary repair. Among the patients treated with primary repair, at least one additional operation was required in 13 patients. Of the 15 patients treated with esophagectomy and reconstruction, none required further operative treatment. Follow-up averaged 3.7 years, and of the 36 survivors available for follow-up, 18 (50%) required at least one esophageal dilation postoperatively, and 3 (8.3%) have required regular dilations. Subjectively, 19 of 36 patients (53%) indicate that their swallowing is better than before perforation, it was the same in 12 (33%), and worse in 4 (11%). Conclusions. In conclusion, approximately one third of patients surviving primary repair of esophageal perforations have continued difficulty with swallowing, which often requires esophageal dilations or esophageal reconstructive procedures, or a combination of both. Optimal long-term results are achieved when primary repair is performed in patients with motor disorders or a “normal” esophagus. Esophagectomy is a better option in those patients with strictures or diffuse esophageal disease.

Repair of Aortoesophageal Fistula After Aortic Grafting

This report describes repair of an aortoesophageal fistula caused by a previously placed thoracic aortic graft. The diagnosis was made by esophagoscopy. The repair consisted of femoral-to-femoral cardiopulmonary bypass, excision of the old graft, placement of a new graft, esophagectomy, cervical esophagostomy, gastrostomy, and later reconstruction by cervical esophagogastrostomy.

Bilateral Thoracotomy and Inferior Sternotomy for Bypass Grafting After Esophagostomy

In the presence of a cervical esophagostomy, a median sternotomy may jeopardize the stoma, risk mediastinal or sternal infection, and potentially compromise future esophageal operations. Coronary artery bypass grafting was performed using a modified bilateral thoracotomy before esophageal reconstruction in a patient with cervical esophagostomy. The surgical technique is described with a review of the relevant literature.

Esophageal 'stars': a sinister foreign body ingestion.

This paper describes an "epidemic" of foreign body ingestion in six consecutive prisoners from the same jail. The resulting esophageal perforations won all patients "temporary vacations" from prison. The nature of the ingested foreign body (hypodermic needles fashioned into a "star") guaranteed perforation of the esophagus. All six patients had emergency esophagotomy for foreign body removal. In the only case of significant morbidity, suture line disruption with mediastinitis and empyema led to esophagectomy, cervical esophagostomy, and tube gastrostomy. This patient survived and subsequently had uncomplicated esophagocoloplasty. Foreign objects of this type have not been described in the literature. Because of their specific design, they necessitate immediate and aggressive surgical management.

Gastric tube as the primary procedure for pure esophageal atresia

Long gap esophageal atresia occurs in approximately 5% of patients with tracheoesophageal anomalies. A small group of such patients have a rudimentary or diverticular distal esophagus that is not amenable to primary repair. These children usually require staged procedures and esophageal replacement using other parts of the intestinal tract. to circumvent the morbidity and delayed repair associated with cervical esophagostomy, colon interposition, or delayed gastric tube interposition, the authors propose the use of a primary gastric tube for early establishment of esophageal continuity in the neonate. Three cases of early esophageal replacement using a gastric tube are described. All three patients were born prematurely, with comorbid conditions, and had a rudimentary distal esophagus. The results of the operation were successful. The authors believe that primary repair of the esophagus, when possible, is the gold standard.

Save the child's esophagus: Management of major disruption after repair of esophageal atresia

Purpose: Given the bias that the native esophagus is the best conduit between the oropharynx and the stomach, the authors report a “conservative” approach to massive esophageal leak, which may be considered “radical” by others. Major disruption of the anastomosis after primary repair of esophageal atresia is a recognized and feared complication. Historically, management has been the performance of cervical esophagostomy and gastrostomy. The aim of this report is to describe the authors' approach to this difficult and serious complication. Methods: A 15-year retrospective analysis was performed of all patients having esophageal atresia. Data collection focused on the management of all patients with clinically significant esophageal disruption. Radiographically detected (clinically asymptomatic) leaks were managed by continuation of drainage by thoracostomy tubes already in place and are not included. Reoperative thoracotomies were performed, which included primary repair (2), placement of pleural patch alone (2), pleural patch with intercostal muscle flap buttress (2), and operative debridement and drainage alone (1). Results: It was noted that seven patients had clinically significant esophageal disruption requiring reoperation, with circumferential disruptions ranging from 15% to 85%. Presentation included persistent pleural collection (4) and pneumothorax (3). Both patients who underwent primary repair had no evidence of leakage on follow-up esophagograms, neither did one with a pleural patch alone and one with an intercostal muscle flap. Five of the seven patients were tolerating oral feedings at the time of follow-up (range, 6 months to 8 years). One of the two others (both currently inpatients), has a recurrent leak associated with mediastinitis, and the other (who had primary repair) has a presumed neurological impairment of eating. Conclusion: Clinically significant disruption of primary esophageal repair should not warrant a cervical esophagostomy and placement of a gastrostomy tube, thus precluding eventual use of the native esophagus. The authors have shown that management by reoperation with primary repair, intercostal muscle flap with or without pleural patch, and/or drainage allows the patient to maintain the native esophagus and yields a generally good outcome after a prolonged healing time.

Catastrophic complications of the cervical esophagogastric anastomosis

Recent enthusiasm for the cervical esophagogastric anastomosis has arisen because of its perceived low morbidity. Although catastrophic complications of a cervical esophagogastric anastomosis are unusual, they can and do occur, and prevention is possible if the potential for them is recognized. Among 856 patients undergoing a cervical esophagogastric anastomosis after transhiatal esophagectomy, catastrophic cervical infectious complications occurred in 11 patients (1.3%): vertebral body osteomyelitis (1), epidural abscess with neurologic impairment (2), pulmonary microabscesses from internal jugular vein abscess (1), tracheoesophagogastric anastomotic fistula (1), and major dehiscence necessitating anastomotic takedown (6). These complications became manifest from 5 to 85 days after the esophageal resection and reconstruction (mean 19 days). Leakage from a gastric suspension stitch placed in the anterior spinal ligament over the vertebral bodies resulted in a posterior gastric leak and either osteomyelitis or an epidural abscess in three patients, none of whom had evidence of extravasation on the routine barium swallow 10 days after operation. Cervical exploration for a presumed anastomotic leak led to the unexpected discovery of an abscess formed by the stomach and the adjacent wall of the internal jugular vein, which was ligated and resected. One patient without symptoms who was discharged from the hospital with a contained anastomotic leak on the postoperative barium swallow was readmitted 7 days later with a cervical tracheoesophagogastric anastomotic fistula of which he ultimately died. In 6 patients (7% of those who had anastomotic leaks) there was sufficient gastric ischemia or necrosis, or both, to necessitate takedown of the anastomosis and intrathoracic stomach, cervical esophagostomy, and insertion of a feeding tube. As a result of this experience, it is recommended that cervical gastric suspension sutures either be omitted entirely or placed in the fascia over the longus colli muscles anterior to the spine, but not directly into the prevertebral fascia overlying the vertebral bodies or cervical disks. All but minute cervical anastomotic leaks, even if apparently contained, are best drained rather than treated expectantly. Patients who remain febrile and ill after bedside drainage of a cervical esophagogastric anastomosis leak should undergo cervical reexploration in the operating room; major gastric ischemia or necrosis, or both, may warrant takedown of the anastomosis and intrathoracic stomach. ( J THORAC CARDIOVASC SURG 1995;110:1493-1501)

An active esophageal prosthesis

Resection of carcinoma of the esophagus may be curative or palliative and usually results in either total esophagectomy or esophagogastrectomy. Continuity of the upper gastrointestinal tract is maintained via a gastric pull-up procedure or, when feasible, by primary reanastomosis of the gastric remnant to the proximal esophagus. 1 If a large part of the stomach has been previously resected or is unsuitable for use, colonic or jejunal interposition may be utilized to maintain continuity. However, these operations are associated with substantial surgical morbidity and mortality and a myriad of postoperative complications, including luminal narrowing caused by edema or ischemia, anastomotic leaks, formation of fistulae and strictures, and development of graft ischemia. 2, 3 These procedures may be precluded in the elderly or in patients with complex medical problems who are poor surgical risks. In these patients and in those with unresectable esophageal carcinoma, palliative cervical esophagostomies are sometimes performed to reduce the discomfort of dysphagia and lessen the at tendant risk for aspiration pneumonia. Nutrition is maintained through surgically placed gastrostomies or jejunostomies and, in rare instances when feeding tube place: ment is not possible or the distal gastrointestinal tract is obstructed, total parenteral nutrition. 2 Although these procedures are palliative, patients usually remain uncomfortable, are unable to eat, and have the extra burden of repeatedly emptying the esophagostomy bag, in which saliva accumulates. They also have the problem of administering enteral feedings and fluids to replace the salivary losses. We have developed an active esophageal prosthesis (AESOP) that, via a small pneumatically driven extracorporeal pump, can maintain a functioning conduit between a cervical esophagostomy and the remainder of the gastrointestinal tract in a closed circuit.

Cholecystokinin and nitric oxide in transient lower esophageal sphincter relaxation to gastric distention in dogs

Background/Aims: Transient lower esophageal sphincter relaxations have been found to be involved in gastroesophageal reflux. The purpose of this study was to determine whether cholecystokinin (CCK) and nitric oxide are involved in the occurrence of these relaxations. Methods: Pharyngeal, esophageal, lower esophageal sphincter, and gastric pressures were monitored in five dogs through a cervical esophagostomy. Gastric distentions with air, at a constant pressure of 1.56 kPa, were performed for 30-minute sessions using a barostat. Results: During gastric distention at 1.56 kPa, transient relaxations occurred at a mean rate of 7.2 ± 0.6 every 30 minutes. CCK-8 infused intravenously (0.1–1 μg·kg−1·h−1) dose dependently increased the occurrence of relaxations while it was reduced by the CCK-A receptor antagonist devazepide but not the CCK-B antagonist L365260, both administered intravenously in a dose range of 0.1–100 μg/kg. The two antagonists administered intracerebroventricularly (1 μg/kg) did not modify the occurrence of relaxations. Both devazepide and L365260 (10 μg/kg) reduced the CCK-induced relaxations, but devazepide was more potent. The nitric oxide synthase inhibitor NG-nitro-l-arginine-methyl ester (20 mg/kg) reduced the number of relaxations during gastric distention in the presence or absence of CCK infusion. This effect was reversed by l-arginine but not d-arginine (200 mg/kg). Conclusions: CCK is involved in the occurrence of transient lower esophageal sphincter relaxations through peripheral CCK-A receptors and an l-arginine nitric oxide pathway.

Comparison of Postoperative Mortality and Morbidity in VA and Nonfederal Hospitals

We compared postoperative mortality and morbidity rates in the Veterans Health Administration (VA) to those in nonfederal hospitals, using multivariate analysis to adjust for the patient characteristics of age, diagnosis, comorbidity, and severity of illness. We used a total of 544,000 patient discharge records (330,000 nonfederal and 214,000 VA) from 1987 through 1988 and compared 118 surgical procedures or procedure groups composed of 314 individual surgical procedures. We found no significant differences in postoperative mortality rates between the VA and nonfederal hospital systems for 110 of 118 surgical procedures or procedure groups. Endarterectomy, cervical esophagostomy, and esophageal anastomosis or esophagocolostomy showed significantly lower postoperative mortality in the VA hospitals compared to nonfederal hospitals (P = 0.05). VA postoperative mortality rates that were higher than those in nonfederal hospitals and could not be entirely explained by adjusting for patient characteristics were found for suture of ulcer, cholecystostomy, colon surgery, small intestine surgery, and reopening of recent thoracotomy site (P = 0.05). Respiratory, gastrointestinal, and urinary postoperative morbidity were generally lower in the VA hospitals than in nonfederal hospitals (P = 0.05). Infections were generally higher in the VA hospitals than in nonfederal hospitals. Pulmonary embolism, deep venous thrombosis, shock due to surgery or anesthesia, mediastinitis, hemorrhage, cardiac, and central nervous system morbidity showed no significant differences. These data demonstrate that VA postoperative mortality and morbidity in 118 surgical procedures or procedure groups is comparable to those in nonfederal hospitals.

Near-Total Esophageal Exclusion in the Treatment of Late-Diagnosed Esophageal Perforation: Two Case Reports

Two cases of late-diagnosed esophageal perforation were successfully treated with near-total esophageal exclusion, using cervical T-tube esophagostomy with circumferential suture fixation of the lower arm of the T-tube. Esophageal stricture developed at the site of catgut or dexon tie. This complication can be managed with esophageal dilation. Drainage-tube gastrostomy proved to be unnecessary.

Management of delayed esophageal perforation with mediastinal sepsis: Esophagectomy or primary repair?

Ninety patients with esophageal perforations were operated on at our institutions between 1970 and 1992. Thirty-four of them were seen after delayed diagnosis (> 24 hours) with mediastinal sepsis caused by perforation of the thoracic esophagus. There were 18 patients with spontaneous ruptures, 11 with instrumental perforations (including one caused during laparotomy), and 3 perforations caused by foreign bodies. One patient had perforation of an esophageal ulcer into the pericardium and another had perforation of an esophageal diverticulum into the mediastinum. Nineteen patients underwent primary repair of the perforation with cleansing and drainage of the mediastinum and the pleural cavity. The remaining 15 had primary extirpation of the thoracic esophagus, irrigation of the mediastinum with antibiotics, cervical esophagostomy, gastrostomy, and drainage of the mediastinum and pleural cavity. Nineteen of the 34 patients survived (hospital mortality 44%). Of patients with primary repair, only six survived (in-hospital mortality 68%), whereas only two patients treated with esophagectomy died (in-hospital mortality 13%). The difference was highly significant (p = 0.001). The most common cause of death was multiorgan failure resulting from sepsis. Postoperative complications developed in four patients treated with primary repair (two sepsis, one empyema, and one anuria) and in seven patients treated with esophagectomy (two empyema, two sepsis, one pneumonia, one mediastinal abscess, and one brain abscess). After healing of the mediastinitis, the esophagogastric continuity was reconstructed with colon in 11 patients and stomach in two patients. In the management of delayed esophageal perforation with mediastinal sepsis, esophagectomy is superior to primary repair alone, which often leads to mediastinal leakage, continued sepsis, and death.

Development of a technique for jejunal interposition in long-gap esophageal atresia

Primary anastomosis is the treatment of choice in esophageal atresia. There remains a small number of infants in whom establishment of primary esophageal continuity fails or is unrealistic due to a long gap. Esophageal reconstruction then necessitates an interposition/transposition procedure. The most widely used tissues are colon and stomach but each has significant limitations. Jejunum is theoretically the ideal esophageal substitute being of appropriate diameter and having good peristaltic activity. Its use in the past has been limited by the precarous blood supply and restricted length which result from the short mesenteric pedicle. We have attempted to resolve these limitations by using a microvascular anastomosis to augment the blood supply to the proximal jejunum in a series of 5 cases (2 pure atresias, 1 esophageal atresia with proximal fistula, and 2 atresias with distal fistula). In a sixth case (atresia with distal fistula) a free jejunal graft was used. In one case initial surgery was confined to cervical esophagostomy and feeding gastrostomy, in the remaining 5 interposition was necessitated by failure of a primary repair. The age at surgery ranged from 8 to 16 months. The development of the technique and outcome in each patient is described. We conclude that a free jejunal graft is preferable to augmenting the native blood supply and intend to continue with this latter technique.

TOW CASES OF TUBE FEEDING CERVICAL ESOPHAGOSTOMY

Tow cases were constructed a tube feeding cervical esophagostomy by an esophageal dilation technique, and elemental diet was controlled well for a long term. Esophageal dilation technique is as follows; at first balloon tube was inserted into the esophagus via the nasal cavity, and esophagus was dilated by the balloon filling with the contrast medium, then esophagostomy was performed by the double lumen needle which was inserted into the cervical esophagus under the fluoroscopy. This techniques is easy, and less painful for patient, and valuable for a long-term enteral hyperalimentation.

One-stage operation for treatment after delayed diagnosis of thoracic esophageal perforation

Perforation of the thoracic esophagus can be fatal unless diagnosed promptly and treated effectively. The high mortality with delayed treatment is due principally to an inability to effectively close the perforation and prevent leakage. From 1982 to 1988, 7 consecutive patients (aged 16 to 73 years) were treated after a delayed diagnosis (26 hours to 25 days) of thoracic esophageal perforation. In all patients, the perforation was closed after debridement with total exclusion of the esophagus (T-tube cervical esophagostomy plus absorbable ligatures applied to the esophagogastric junction and the cervical esophagus distal to the esophagostomy). Radical decortication and wide mediastinal and pleural drainage were also done. Nutritional supply was given through a feeding gastrostomy. Antibiotics were administered according to the results of cultures. All patients survived. Continuity of the esophagus was established by removal of the T tube and spontaneous absorption of the ligatures. Endoscopy and esophagography performed 4 weeks after the initial operation showed a well-healed esophagus without stenosis or leakage in all patients. No secondary thoracotomy or esophageal reconstruction was necessary. No dysphagia was noted during follow-up (range, 12 to 50 months; mean follow-up, 23 months). We conclude that primary closure of the perforation and total esophageal exclusion with the use of absorbable ligatures and T-tube esophagostomy can provide a one-stage operation with good results for repair of thoracic esophageal perforation diagnosed late.

Successful salvage of an 8-month-old child with an aortoesophageal fistula

Aortoesophageal fistula (AEF) from an impacted esophageal foreign body was first described in 1818 and has been a uniformly fatal condition to this date. We report the salvage of an 8-month-old child with an AEF from ingesting a straight pin. She survived a massive gastrointestinal (GI) bleed and primary esophageal and aortic repairs performed in conjunction with aortic shunting, interposed pleural flap, and a diverting cervical esophagostomy. This represents the first successful outcome of an AEF from a foreign body, many of which have been described in infants and children. History of esophageal foreign body and signal upper GI hemorrhage should mandate aggressive diagnosis and surgical intervention.

New technique of esophageal exclusion for chronic esophageal perforation

A new technique of near-total esophageal exclusion was used successfully in the treatment of 2 patients with chronic thoracic esophageal perforation and continuing sepsis. The most striking point of this technique is the use of cervical T-tube esophagostomy with the lower arm of the T tube circumfixed by chromic catgut tie to prevent swallowing of saliva. Whereas most of the previously reported procedures of cervical esophageal diversion require subsequent esophageal reconstruction, this technique is simple and effective and does not require a second operation.

食道再建を目的とした非定型的遊離小腸移植術

An esophageal reconstruction using a free bowel graft following pharyngolaryngoesophagectomy for a carcinoma involving the pharynx or cervical esophagus can be termed“typical”free gut transfer, while other types of reconstruction using a free bowel graft can be termed“atypical. ”During the period from 1988 to 1989, we have experienced 23 cases of free gut transfer in our hospital. Twelve cases of these underwent typical operation. An atypical operation was performed in 11 cases involving 4 cases of a carcinoma of the hypopharynx or cervical esophagus, 3 cases of a recurrence following esophagectomy for a carcinoma in the thoracic esophagus, one case of a carcinoma in the esophagus at the cervicothoracic junction, one case with cervical esophagostomy following esophagectomy for a carcinoma in the thoracic esophagus, one case of recurrence following chemotherapy for a breast carcinoma, and one case of pharyngoesophageal corrosive stricture. From our experience of atypical free gut transfer, we conclude that the free gut transfer is useful for the reconstruction of various types of a pharyngoesophageal defect. Also we conclude that the cervical transverse artery and the external jugular vein as the recipient vessels in the neck are most convenient, and the thoracoacromial artery and the cephalic vein are most convenient in the anterior chest wall. Important postoperative complications involved aspiration pneumonia in cases preserving the larynx, dysphagia in cases with free graft of the long intestine, and graft failure due to a vascular obstruction. However, these complications could be avoided with improvement in the operative indications, the procedures and techniques employed.

Sloughing of the proximal colon segment in retrosternal colonic esophagoplasty and lengthening of the distal colonic stump

A case of esophageal atresia with tracheoesophageal fistula is described. When the female neonate was 5 days old a right thoracotomy with division of the fistula was performed and a stamm gastrostomy was established because of a long gap between the esophageal stumps. These procedures were followed by elongation of the upper esophageal stump by bougienage. Severe respiratory complications later necessitated a left cervical esophagostomy. Retrosternal, isoperistaltic interposition of the right colon was performed for esophagogastric reconstruction when the baby was 20 months old. The proximal segment of the retrosternal colonic conduit sloughed postoperatively at the level of the sternal angle. This complication was treated by re-exploration of the anterior mediastinum through a midline sternotomy. Dissection and elongation of the distal colonic stump were done. Elongation of the colonic stump became feasible by partially excising the proximal anterior taenia coli and creating relaxing, transected incisions of the seromuscular layers of the distal anterior taenia coli. This maneuver provided additional length and permitted stretching of the colonic segment. Thus, an easy, new retrosternal esophagogastric reconstruction was feasible when the child was 30 months old.