Esophageal Disasters and their Management: Lessons Learned

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Esophageal Disasters and their Management
Lessons Learned

• Scott B. Johnson, MD
• Associate Professor
• Cardiothoracic Surgery
• UTHSCSA
• Baptist CME Grand Rounds
• February 13, 2007

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Examples

• Caustic ingestion
• Esophageal perforations with and without
  fistulization
• Longterm graft failure
• Failure s/p previous multiple esophageal
  surgeries for benign disease

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Important Considerations

• Urgency of the situation/degree of acute
  illness
• Phases of swallowing/patient expectations
• Available reconstructive conduits and their
  intended route
• What is the bail-out plan?
• Life-expectancy/operative risk

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Case Report 1

• 24 y/o HF brought to ED with abdominal pain, s/p
  MVA 2wks prior, continued to deteriorate w/pH
  7.12.
• Explored and found to have perforated, necrotic
  stomach and nonviable spleen.
• Esophagus necrotic to pharynx

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Surgery

• THE, total gastrectomy, spit fistula, FCJ,
  tracheostomy
• Conversion of spit fistula to tube pharyngostomy

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Preoperative Studies

• Endoscopy
• Visceral angiogram

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Case Report 1 (cont.)

• Endoscopy 4 months later revealed severely
  scarred epiglottis and hypopharynx
  cricopharyngeous obliterated

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Pharyngeal phase of swallowing Physiology

• 1. CNs V, VII, IX, X, XII
• 2. Motor neurons C1 - C3
• 3. Swallowing center (Medulla)

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PHYSIOLOGY

• Tongue pharynx (pharyngeal phase)
• 1. Soft palate/larynx elevates
• 2. Tongue moves posteriorly
• 3. Epiglottis tilts backward
• 4. Posterior pharyngeal constrictors
  contract
• 5. Cricopharyngeus relaxes
• 6. Food bolus propelled into the esophagus

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Special considerations

• Loss of stomach as a conduit
• Proximal scarring
• Reconstruction to pharynx necessary
• Alteration of pharyngeal phase of swallowing was
  inevitable
• Unclear extent of injury to colon pedicle if any

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Surgery Performed

• Substernal colon interposition with creation of a
  colopharyngostomy, Roux-en-Y colojejunostomy,
  revision of FCJ

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Available Conduits

• Colon
• Good size match
• Durable blood supply
• Three anastomoses

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Johnson SB. DeMeester TR. Esophagectomy for
benign disease use of the colon. Advances in
Surgery. 27317-34, 1994.
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Johnson SB. DeMeester TR. Esophagectomy for
benign disease use of the colon. Advances in
Surgery. 27317-34, 1994.
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Johnson SB. DeMeester TR. Esophagectomy for
benign disease use of the colon. Advances in
Surgery. 27317-34, 1994.
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Principles of Management

• Important to personally perform endoscopy
• Determine extent of proximal injury/scarring
• Map out proximal anastomotic site in cases of
  complete esophageal and pharyngeal involvement
• Counsel the patient w/r/t phases of swallowing
  and postoperative expectations
• Know conduit to be used and route

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Principles of Management (cont.)

• Steroids controversial
• Antibiotics controversial
• Dilutions - controversial

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Speech Therapy

• Therapeutic approaches to the management of
  pharyngeal dysphagia involve
• postural changes
• modification of respiration
• swallowing techniques
• food consistency
• thermal stimulation.

Volume 106(2) Supplement 78, February 1996, pp
1-12
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Speech Therapy (cont.)

• Application of these techniques alters the way in
  which gravity maneuvers the bolus through the
  pharynx by accomplishing the following
• preventing the bolus from entering the airway
• strengthening base of tongue and the pharyngeal
  wall approximation
• increasing the strength and duration of vocal
  cord closure before and during the swallow by the
  application of extrinsic pressure

Volume 106(2) Supplement 78, February 1996, pp
1-12
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Other Available Conduits

• Stomach
• Least number of anastomoses
• Small bowel
• Pedicled graft may only reach to the pulmonary
  hilum
• Free flap to the cervical esophagus/pharynx
• Supercharged grafts

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Case report 2

• 53 y/o WF transferred in from OH for TE fistula
  resulting from a traumatic percutaneous
  tracheostomy
• PSH significant for several ex laps for
  malrotation/SBO, biliary leak, SB resections
• Lives with her parents, IQ lt 80.

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grand rounds.mpg
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Operation

• Right thoracotomy, division of TE fistula with
  primary repair of trachea and esophagus LD
  interpositional rotational flap

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Principles of Management

• Variety of surgical options available to repair a
  TEF
• direct closure of the tracheal and esophageal
  defects with or without pedicled muscle flaps
• tracheal closure with an esophageal patch
• segmental tracheal resection, and anastomosis
  with esophageal closure
• esophageal diversion

The Journal of Thoracic Cardiovascular Surgery
Volume 119(2), February 2000, pp 268-276
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Principles of Management (cont.)

• Esophageal injuries may be primarily reparable
  regardless of timeline
• Even though you may want to run the other way,
  sometimes the most dreaded cases turn out to be
  the most gratifying

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Volume 27(8), August 1999, pp 1617-1625
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Case Report 3

• 41 y/o RN s/p accidental lye ingestion as a
  toddler, s/p substernal colonic interposition,
  now with right sided chest discomfort and
  dysphagia associated with eating

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Additional Work Up

• Endoscopy
• Mesenteric Arteriography

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Surgery Performed

• Median sternotomy
• Identification of colonic pedicle
• Resection of redundant colon
• Primary anastomosis

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gt10cm
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Principles of Management

• Isoperistaltic interpositions preferred due to
  possible development of complications later in
  life
• Swallowing in these patients will never be
  normal
• Revision of existing conduits is possible, so
  long as one has adequate knowledge and provides
  protection of blood supply
• Video esophagography provides useful information
  regarding both anatomy and function
• Literature lacking w/r/t revision of existing
  conduits

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Case Report 4

• 49 y/o WM transferred from San Angelo for
  suspected esophageal perforation.
• One day PTA noted episode of food becoming
  lodged in esophagus with subsequent hematemesis
  followed immediately with bilateral parasternal
  chest pain radiating to bilateral shoulders and
  back between the scapulae
• Patient noted approximately one year history of
  difficult swallowing both solids and liquids.

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Operation Performed

• Esophagoscopy left thoracotomy with
  decortication esophagectomy with creation of end
  cervical esophagostomy Stamm gastrostomy and
  feeding jejunostomy

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Postoperative course

• Patient did well, was eventually discharged home
  on tube feeds. Returned three months later
  desiring reconstruction
• At that time, esophageal reconstruction was
  performed using substernal stomach

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Principles of Management

• Causes of esophageal perforation
• intraluminal instrumentation (68)
• spontaneous rupture (13)
• foreign bodies (11)
• trauma (7)
• Diagnosis requires high index of suspicion
• Missed injury carries high mortality
• Non-operative management can be done in selected
  cases

Michel L, Grillo HC, Malt RA. Operative and
nonoperative management of esophageal
perforations. Ann Surg. 19811945763
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Principles of Management

• Esophageal resection with delayed reconstruction
  a good option when significant sepsis present
  and primary repair not possible
• Previous G-tube does NOT negate the use of
  stomach as a conduit
• Timing of reconstruction should be individualized

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Case Report 5

• 72 y/o WF referred from private surgeon with
  history of 3 prior laparoscopic Nissen procedures
  for hiatal hernia repair since 1995, last one
  2002 with mesh, who was symptom free for 3-4
  years until she developed dysphagia, odynophagia,
  esophageal spasm, epigastric pain, nausea, and
  bloating.
• She has to sleep on 2-3 pillows to prevent
  regurgitation at night.

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Stationary manometry
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Operation Performed

• Left thoracotomy with takedown and reduction of
  previous Nissen, takedown of left hemidiaphragm
  with lysis of adhesions, reconstruction of
  esophageal hiatus with redo transthoracic Nissen
  Fundoplication EGD

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Hunter Ann Surg, Volume 223(6).June 1996.673-687
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Reoperative fundoplications are effective
treatment for dysphagia and recurrent
gastroesophageal reflux

• Seventy-nine per cent of patients with reflux
  prior to reoperation, 100 per cent with
  dysphagia, and 74 per cent with both noted
  excellent or good outcomes after reoperation
• Failure leading to reoperation was due to hiatal
  failure in 28 per cent, wrap failure in 19 per
  cent, both in 33 per cent, and slipped Nissen
  fundoplication in 20 per cent.

Rosemurgy et al, American Surgeon.
70(12)1061-7, 2004 Dec.
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Principles of Management

• Successful reoperative esophageal surgery
  performed for benign disease may require
  maximally invasive techniques
• Entrance into the abdomen can be achieved
  through take-down of the diaphragm radially
• Esophageal conservation preferred whenever
  possible

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In Summary

• A proper and thorough preoperative evaluation
  should be performed before any major esophageal
  surgery is contemplated
• Video esophagography
• Endoscopy
• Stationary manometry
• CT scanning

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