Minimally Invasive Technic for Construction of a Cervical Esophageal Conduit David G. Dibbell, MD, Madison, Wisconsin
From Trotter [I] in 1913 through Wookie [2] and Bakamjian [3] to Jurkiewicz [4], the technics employed for reconstruction of the cervical esophagus have been myriad for two reasons: (1) no particular technic is fully satisfactory and (2) it is rare for any two patients to present with the same technical problem. Hence, a variety of approaches have been conceived to deal with the vagaries of each patient’s needs. Most technics of esophageal reconstruction require a rather extensive surgical approach and/or multiple staged procedures with the definite risk of deep cervical or mediastinal infection. The present report describes a method that demands minimal surgical dissection and can be completed in a single stage. For these reasons this approach is applicable to some situations in which extensive surgical invasion in a metabolically unstable patient is deemed inadvisable.
to the parents. Accordingly, a 10 cm cervical conduit connecting the esophagostome with the stoma of the substernal portion of the colon was accomplished according to the technic to be described herein. She has now gone an entire year and a half using the new esophageal conduit, eating all sorts of food, maintaining weight, and going to school. The gastrostomy which had originally been left in place for security purposes, has been removed without difficulty. (Figure 1.) Method The operation is very simple in conception. First, it is necessary that the patient have adequately mobile skin in the cervical area between the stomata. Second, the apertures of the stomata must be of adequate size. Lax skin is then rolled upon itself without elevation to form a superficial tube. (Figure 2.) An elliptical incision is made through the epidermis only, connecting the two stomata. Another inci-
Case Report RL, a five year old white female, was born with a tracheoesophageal fistula. At age twelve months she underwent colonic interposition causing avascular necrosis at the cervicoesophageal junction. At age twenty months the colon was readvanced and reanastomosed to the cervical esophagus, but this too sloughed. From age twenty months to five years no reconstructive procedures were attempted and the patient was maintained on gastrostomy feedings with a cervical esophagostome. However, at age five years the patient weighed only 21 pounds and proper maintenance of her nutrition by gastrostomy feeding was becoming impossible. Additionally, the patient enjoyed eating continuously despite the fact that all food went out of the esophagostome. This led to considerable electrolyte and fluid deficits through loss of saliva, to say nothing of the fact that the continuous mess was a considerable burden
,’
*
From the Department of Surgery, University of Wisconsin Center for Health Sciences, Madison, Wisconsin. Reprint requests should be addressed to D. G. Dibbell. MD, University of Wisconsin Hospitals, Department of Surgery, 1300 University Avenue, Madison, Wisconsin 53706.
Volume 133, June 1977
:”
Figure 1. Patient one and a ha/f years after closure of conduit.
763
Dibbell
TUBE
EPITHEL .IAL STRIP
Figure 2. Demonstration of method of rolling up lax skin to form a superficial tube.
Figure 3. Deepithelialized ellipse closing over stomata.
-
--
--
Figure 4. Cross section of tube closure (2 /avers).
sion is made approximately 0.75 cm outside of the first (Figure 3) again through the epidermis only. The area between the incisions is deepithelialized, leaving a raw ellipse of dermis. The dermal strips are connected to each other in two layers, using. absorbable sutures inside and nonabsorbable sutures outside. (Figure 4.) Completion of the entire dermal closure forms a skin conduit between the stomata. At this juncture, the closure will be uncomfortably tight at its midportion. Accordingly, two lateral relaxing incisions should be made down through the
764
dermis only. The resulting lateral defects are closed with full thickness skin grafts from the groin. (Figure 5.) These grafts are placed under tie-over bolsters and the bolsters are removed after five days. In the present case, a #4 suction catheter was placed in the conduit through the closure in an effort to suction saliva away from the interior suture line, leaving an elective fistula. This was an unwise maneuver, as it took two later (though minor) procedures to close the small fistula. In retrospect, the entire conduit should have been closed primarily. Antibiotics should be administered and maintained for three to four weeks with gastrostomy feedings. Progression from oral feedings of liquids up through well masticated foods should be gradual. It is evident that this technic is applicable only to patients in whom a skin tube can be easily rolled up without actual elevation of the skin, However, such a procedure has the tremendous advantage of minimizing surgical trauma to the patient, with all incisions no deeper than the dermis. I do not believe that this is an end-stage reconstruction. In the patient described herein, the conduit was a lifesaving maneuver and a satisfactory tem-
The American Journal of Surgery
A Cervical Esophageal Conduit
porary solution to her social problems. It would be envisioned that, after the patient has achieved maturity, a more definitive esophageal reconstruction can be performed. Summary
Most technics of cervical esophageal reconstruction involve extensive surgical dissection with its attendant hazards. The present report describes a simplified technic that causes minimal trauma to the patient. A partially deepithelialized, superficial skin tube is created without elevation of flaps and joined to the existing stomata. The technic was successfully used in a frail, five year old patient who had had three previous unsuccessful attempts at colonic interposition for a trachea esophageal fistula. References
Figure 5. Conduit closed with lateral relaxing incisions covered with kril thk?kness skin gratts (sucHon catheter in place but unnecessary).
vokmlo 133. Jum 1977
1. Trotter W: The Hunterian lectures on the principles and techniques of the operative treatment of malignant disease of the mouth and pharynx. Lancer 1: 1075, 1913. 2. Wookey H: The surgical treatment of carcinoma of the pharynx and upper esophagus. Surg Gynecol Obstet 75: 499, 1942. 3. Bakamjian VY: A two stage method for primary pharyngoesophageal reconstruction with a primary pectoral skin flap. flast Reconstr Surg 36: 173, 1965. 4. Jurkiewicz MJ: Vascularized intestinal graft for reconstruction of the cervical esophagus and pharynx. Plast ffeconstr Surg 36: 509, 1965.
765
From Trotter [I] in 1913 through Wookie [2] and Bakamjian [3] to Jurkiewicz [4], the technics employed for reconstruction of the cervical esophagus have been myriad for two reasons: (1) no particular technic is fully satisfactory and (2) it is rare for any two patients to present with the same technical problem. Hence, a variety of approaches have been conceived to deal with the vagaries of each patient’s needs. Most technics of esophageal reconstruction require a rather extensive surgical approach and/or multiple staged procedures with the definite risk of deep cervical or mediastinal infection. The present report describes a method that demands minimal surgical dissection and can be completed in a single stage. For these reasons this approach is applicable to some situations in which extensive surgical invasion in a metabolically unstable patient is deemed inadvisable.
to the parents. Accordingly, a 10 cm cervical conduit connecting the esophagostome with the stoma of the substernal portion of the colon was accomplished according to the technic to be described herein. She has now gone an entire year and a half using the new esophageal conduit, eating all sorts of food, maintaining weight, and going to school. The gastrostomy which had originally been left in place for security purposes, has been removed without difficulty. (Figure 1.) Method The operation is very simple in conception. First, it is necessary that the patient have adequately mobile skin in the cervical area between the stomata. Second, the apertures of the stomata must be of adequate size. Lax skin is then rolled upon itself without elevation to form a superficial tube. (Figure 2.) An elliptical incision is made through the epidermis only, connecting the two stomata. Another inci-
Case Report RL, a five year old white female, was born with a tracheoesophageal fistula. At age twelve months she underwent colonic interposition causing avascular necrosis at the cervicoesophageal junction. At age twenty months the colon was readvanced and reanastomosed to the cervical esophagus, but this too sloughed. From age twenty months to five years no reconstructive procedures were attempted and the patient was maintained on gastrostomy feedings with a cervical esophagostome. However, at age five years the patient weighed only 21 pounds and proper maintenance of her nutrition by gastrostomy feeding was becoming impossible. Additionally, the patient enjoyed eating continuously despite the fact that all food went out of the esophagostome. This led to considerable electrolyte and fluid deficits through loss of saliva, to say nothing of the fact that the continuous mess was a considerable burden
,’
*
From the Department of Surgery, University of Wisconsin Center for Health Sciences, Madison, Wisconsin. Reprint requests should be addressed to D. G. Dibbell. MD, University of Wisconsin Hospitals, Department of Surgery, 1300 University Avenue, Madison, Wisconsin 53706.
Volume 133, June 1977
:”
Figure 1. Patient one and a ha/f years after closure of conduit.
763
Dibbell
TUBE
EPITHEL .IAL STRIP
Figure 2. Demonstration of method of rolling up lax skin to form a superficial tube.
Figure 3. Deepithelialized ellipse closing over stomata.
-
--
--
Figure 4. Cross section of tube closure (2 /avers).
sion is made approximately 0.75 cm outside of the first (Figure 3) again through the epidermis only. The area between the incisions is deepithelialized, leaving a raw ellipse of dermis. The dermal strips are connected to each other in two layers, using. absorbable sutures inside and nonabsorbable sutures outside. (Figure 4.) Completion of the entire dermal closure forms a skin conduit between the stomata. At this juncture, the closure will be uncomfortably tight at its midportion. Accordingly, two lateral relaxing incisions should be made down through the
764
dermis only. The resulting lateral defects are closed with full thickness skin grafts from the groin. (Figure 5.) These grafts are placed under tie-over bolsters and the bolsters are removed after five days. In the present case, a #4 suction catheter was placed in the conduit through the closure in an effort to suction saliva away from the interior suture line, leaving an elective fistula. This was an unwise maneuver, as it took two later (though minor) procedures to close the small fistula. In retrospect, the entire conduit should have been closed primarily. Antibiotics should be administered and maintained for three to four weeks with gastrostomy feedings. Progression from oral feedings of liquids up through well masticated foods should be gradual. It is evident that this technic is applicable only to patients in whom a skin tube can be easily rolled up without actual elevation of the skin, However, such a procedure has the tremendous advantage of minimizing surgical trauma to the patient, with all incisions no deeper than the dermis. I do not believe that this is an end-stage reconstruction. In the patient described herein, the conduit was a lifesaving maneuver and a satisfactory tem-
The American Journal of Surgery
A Cervical Esophageal Conduit
porary solution to her social problems. It would be envisioned that, after the patient has achieved maturity, a more definitive esophageal reconstruction can be performed. Summary
Most technics of cervical esophageal reconstruction involve extensive surgical dissection with its attendant hazards. The present report describes a simplified technic that causes minimal trauma to the patient. A partially deepithelialized, superficial skin tube is created without elevation of flaps and joined to the existing stomata. The technic was successfully used in a frail, five year old patient who had had three previous unsuccessful attempts at colonic interposition for a trachea esophageal fistula. References
Figure 5. Conduit closed with lateral relaxing incisions covered with kril thk?kness skin gratts (sucHon catheter in place but unnecessary).
vokmlo 133. Jum 1977
1. Trotter W: The Hunterian lectures on the principles and techniques of the operative treatment of malignant disease of the mouth and pharynx. Lancer 1: 1075, 1913. 2. Wookey H: The surgical treatment of carcinoma of the pharynx and upper esophagus. Surg Gynecol Obstet 75: 499, 1942. 3. Bakamjian VY: A two stage method for primary pharyngoesophageal reconstruction with a primary pectoral skin flap. flast Reconstr Surg 36: 173, 1965. 4. Jurkiewicz MJ: Vascularized intestinal graft for reconstruction of the cervical esophagus and pharynx. Plast ffeconstr Surg 36: 509, 1965.
765
