Ann Otol 84: 1975
SURGICAL MANAGEMENT OF SEVERE LYE BURNS OF THE ESOPHAGUS BY COLON INTERPOSITION WALLACE CHARLES GERSHON
L.
J.
P.
BERKOWITZ, M.D.
ROPER, M.D.
DONALD G. SESSIONS, M.D.
SPECTOR, M.D.
ST.
JOSEPH
H.
OGURA, M.D.
LOUIS, MISSOURI
SUMMARY - Thirty-seven patients with severe esophageal and hypopharyngeal burns from lye ingestion are reviewed. Preliminary surgical procedures consisting of gastrostomy, esophagostomy, esophagectomy, and tracheotomy were often performed prior to definitive esophageal bypass with colon interposition. The technical aspects of the two-team approach to colon interposition are described with particular emphasis placed on the cervical anastomosis. Common postoperative complications included aspiration, delayed tracheal decannulation, and restenosis in the anastomotic area. Functional restoration of deglutition and phonation was successful in most cases. Attention is focused on management of early and late complications. Results of colon transposition are discussed with references made to other surgical procedures. Functional evaluation of patients followed over a long period is described.
The techniques used in reconstruction of the lye-damaged upper alimentary tract are numerous.l" While no specific approach to hypopharyngeal and cervical esophageal stenosis appears to have a decided advantage, colon interposition has been a satisfactory method." This study analyzes the management of patients with severe hypopharyngeal and cervical esophageal lye-induced strictures. The initial, definitive, and revisional surgery that was required, along with early and late postoperative complications are reviewed. The technique of Ogura for hypopharyngeal and cervical esophageal anastomosis with colon transposition is described," Long term assessment of deglutition and phonation is presented. CLINICAL MATERIAL
All patients who underwent colon interposition for severe esophageal and
hypopharyngeal stricture from lye ingestion at Washington University Medical Center from 1959 to 1972 were included in the study. Analysis was made of the initial treatment, definitive surgical management, and the early and late results of this management. Patients who were longer than two years postcolon interposition and not under therapy were felt to be eligible for longterm assessment of deglutition and phonatory function. Deglutition was considered good if the patient led a normal life without special consideration, tolerated a regular diet, and maintained weight and nutrition. Deglutition was adequate if swallowing function interfered with normal living. Barium x-ray studies confirmed the subjective impression in all cases. Phonation was considered good if the patient had a normal sounding voice, fair if voice was hoarse, and poor if voice was breathy.
From the Departments of Otolaryngology and Surgery, Division of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri. Supported in part by NIH Training Grant 5TOI NSO 519015 from NINDS. Presented at the meeting of the American Broncho-Esophagological Association, Atlanta, Georgia, April 7-8, 1975. 576
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SURGICAL MANAGEMENT OF LYE BURNS PRINCIPLES AND TECHNIQUE OF COLON INTERPOSITION
Principles. Anatomical restoration of the upper alimentary tract may be a one or more stage procedure. Possible mediastinal contamination from an infection complicating a tracheotomy is the prime consideration for a staged procedure. Tracheotomy is necessary when pharyngeal reconstruction is required. Unless it is needed for. the initial management of the patient, tracheotomy and pharyngeal repair is best delayed until the second stage. Extensive supraglottic resection may be performed without imp~irin~ ~e glutition or phonatory function significandy. Accommodation of the swallowing mechanism occurs early in the postoperative period.
Technique. The first team opens the abdomen through a midline incision and mobilizes the right and transverse colon. The middle colic artery is isolated and along with the colon segment is passed posterior to the stomach a~d delivered through the gastro-hepatic omentum. A median sternotomy allows anterior mediastinal placement of the colon segment. The transverse colon is divided and an end-to-end ileo-transverse colostomy is performed. The proximal free end of the .transverse colon is then anastomosed high on the anterior aspect of the fundus of the stomach. A pyloroplasty completes the abdominal part of the procedure unless a gastrostomy has not been performed earlier.
577
current laryngeal nerve. The esoph~gus is mobilized and transected. The distal end is closed by interrupted 3-0 silk sutures, and the proximal end is anastomosed to the cecum in two layers. The sternal head of the clavicle and part of the manubrium are often removed to provide room for the colon. To prepare for the pharyngeal anastomosis, the skin incision is made on the side opposite the most severe scarring. The skin and subcutaneous tissues are elevated over the larynx, and dissection is carried toward the posterolateral border of the thyroid cartilage. The sternohyoid, thyrohyoid and omohyoid muscles are divided transverse~y at the superior border ~f the th>:rOld cartilage, and the medial constnctor muscles are divided along the thyroid cartilage edge. The perichondrium is elevated inferiorly and the cartilage is incised obliquely from the thyroid notch to a point just superior to the inferior cornu. The internal perichondrium and the hypopharyngeal area are exposed after the cartilage is resected. The pyriform sinus is identified. The hypopharynx is opened vertically, and the arytenoid eminence is identified. The incision is extended superiorly to the level of the epiglottis. The cecum is opened along one tenia for approximately 3 em for an end-to-side anastomosis with the hypopharynx. The esophagus distal to the anastomosis is closed. Drains are placed into the neck and upper mediastinum prior to wound closure.
If a pharyngeal repair is required, it A second team works simultaneously is performed two weeks after colon to prepare the cervical area for cecal interposition. A paramedian tracheanastomosis. Either an end-to-end high otomy using local anesthesia is followed cervical esophago-cecal or an end-to- by administration of general anesthesia. side pharyngo-cecal anastomosis is per- A transverse incision is made at the formed depending upon the extent and level of the hyoid bone. The supralocation of pharyngeal scarring. This hyoid muscles are partially separated scarring is determined by prior endo- and the hyoid bone is split in the midscopic evaluation. The skin is incised along the anterior border of the sterno- line. The pharynx is entered at the cleidomastoid muscle from the supra- vallecula. The midline incision may be sternal notch to the angle of the mandi- extended down to the thyroid notch ble. The dissection is carried down to for additional exposure. All epiglottic the esophagus carefully avoiding the re- and glossoepiglottic folds are cut on
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.57R
BERKOWITZ ET AL.
TABLE I COLON INTERPOSITION FOR ESOPHAGEAL AND HYPOPHARYNGEAL STRICTURE (N = 37)
Colon interposition (staged) Colon interposition (unstaged ) (a) End-to-end anastomosis ( cecum to esophagus) (b) End-to-side anastomosis ( cecum to hypopharynx)
No. Occurrences
% Occurrences
16 21
57%
12
33%
9
24%
43%
each side taking great care to avoid accidental incision into the colon. The arytenoid cartilage should not be traumatized since vocal cord fixation may result. Dissection may be carried into the endolarynx to below the false cords and into the ventricles. The epiglottis together with the remaining scarred supraglottic tissues are excised, taking care to preserve the pyriform mucosa, and a cuff of mucosa at the cecalpharyngeal anastomosis. Split thickness skin grafts are used to cover the raw supraglottic area. A Negus stent is used to secure the skin graft in position. The distal end of the stent is placed into the colon stoma. The neck wound is then closed after the hyoid bone is reapproximated.
year (4), children one to ten years ( 13), and young adults 10 to 18 years (6). Initial evaluation in all patients included a barium swallow roentgenographic contrast study and endoscopy. Initial management with corticosteroids, antibiotics, and endoscopic dilatation did not prevent eventual esophageal stricture in these patients.v"
The stent is removed in two to three weeks. Deglutition is attempted after the pharynx is healed and the laryngeal airway has been reestablished. If the tracheotomy tube is patent, a cork stopper must be used to allow the expired air column to assist clearing the larynx. The tracheotomy tube is removed when aspiration is no longer a significant problem.
The severity of the stricture determined whether reconstruction of the upper airway and alimentary tract was performed in one or two stages. Table I illustrates the definitive surgical management of these patients. In the 16 patients requiring two-stage reconstruction, the colon interposition was done initially with repair of the hypopharyngeal stenosis done secondarily. All of these patients had significant hypopharyngeal stenosis, as well as esophageal stricture. A single-stage procedure was possible in 21 patients who had esophageal stricture with minimal hypopharyngeal involvement.
RESULTS
Thirty-seven patients with severe lye burns of the esophagus and hypopharynx underwent colon interposition between 1959 and 1972. There were 26 males and 11 females. Age at the time of ingestion varied. The peak incidence occurred with adults over 18 ( 14). Children and young adults (23) were subdivided into infants less than one
Gastrostomy an d esophagostomy were performed to maintain nutrition in 29 and 7 patients, respectively. Esophagectomy was required subsequent to esophageal perforation and mediastinal infection in seven patients." Laryngeal edema with airway obstruction necessitated tracheotomy in six cases.
An end-to-end (cecum to esophagus) anastomosis was performed in 12 cases while an end-to-side (cecum to hypopharynx) anastomosis was accomplished in nine patients. Stenosis was distal to
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SURGICAL MANAGEMENT OF LYE BURNS
TABLE II EARLY POSTOPERATIVE COMPLICATIONS AND SURGICAL MANAGEMENT (N = 37) No. Occurrences
% Occurrences
Airway: significant aspiration prolonged tracheal cannulation tracheal stenosis
9 5 2
24% 13% 5%
Alimentary : cervical restenosis cervical anastomotic leak colon necrosis
7 2 2
19% 5% 5%
4 anastomotic dilatation 3 anastomotic revision 2 abdominal exploration
General: wound infection operative mortality
5 1
13% 2%
5 incision and drainage
Complication
the cricopharyngeus muscle in the former and involved the muscle in the latter nine cases. Table II indicates the incidence and treatment of early postoperative complications. Aspiration of food and saliva was noted in nine patients. Late spontaneous improvement in symptoms occurred in all but two. Extensive cervical scar resection and slow development of a swallowing technique were factors observed in patients with significant aspiration. Tracheal stenosis was noted in two patients. Early stenosis of the cervical colon anastomosis occurred in seven patients.
Surgical Management
Endoscopic dilatation was successful in four while revision of the anastomosis was required in three patients with severe lumen narrowing. Two patients had a small dehiscence at the pharyngeal anastomosis stricture. Both cases underwent surgical revision and are included with those cases requiring early revision of the cervical anastomosis. Abdominal exploration for intestinal obstruction was performed on two occasions. Necrosis of the transposed colon segment was observed in both cases. One patient died during surgery. In the second case, necrotic colon was excised and the stomach anastomosis was closed. The patient later underwent
TABLE III LATE-OCCURRING COMPLICATIONS AND SURGICAL PROCEDURES PERFORMED Late Complications Airway: persistent aspiration supraglottic stenosis persistent tracheal stenosis Alimentary: cervical anastomotic restenosis
No. Occurrences
% Occurrences
3 3 2
8% 8%
5%
5
13%
No. Occurrences
Surgical Procedures Airway: resection of tracheal stenosis resection of recurrent pharyngeal stenosis Alimentary: cervical anastomotic dilatation cervical anastomotic revision resection of esophageal diverticulum left colon interposition
2
3 5 3 1 1
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BERKOWITZ ET AL.
TABLE IV LONG-TERM RESULTS OF THERAPY
Evaluation Completed (27) Deglutition Function Good 25 Adequate 2 Phonation Function Good 21 Fair 4 Poor 2
successful left colon bypass. Five patients with superficial wound abscesses were treated by incision and drainage procedures with healing occurring secondarily. Table III summarizes the incidence of late-occurring complications and the surgical procedures performed during this period. Five patients continued to require tracheal cannulation for pulmonary toilet as a result of aspiration. Tracheal stenosis recurred after excision and end-to-end anastomosis. Restenosis of the colon anastomosis occurred with five patients and initially all were dilated successfully. Eventually three underwent surgical revision because repeated dilatation gave only transient relief of dysphagia. Three patients developed stenosis within the supraglottic area during the late postoperative period. Surgical revision was initially successful in all, but repeated scar formation occurred in two necessitating a second revision and skin graft. Symptoms of dysphagia in one patient were related to a diverticulum at the colon-esophageal anastomosis. Surgical resection of the pouch relieved his symptoms. Throughout the postoperative period, recurrent scarring was the predominant factor in most complications seen. There were no complications related to gastric acid reflux into the transposed colon segment.' Anastomosis of the colon to the fundus of the stomach seemed to be significant in this regard. In some reports, esophageal bypass involving transposition of a gastric tube or seg-
(N = 37)
Evaluation Not Completed (l0) Surgery less than 2 yrs Therapy continuing Therapy terminated Operative death
4 3 2 1
ment of jejunum was complicated by frequent distal stenosis with occasional necrosis resulting from acid reflux. Split thickness skin grafting for hypopharyngeal restoration has a high incidence of restenosis.P-" Graft failure occurs more frequently when skin is secured about a stent rather than sutured directly to the denuded pharynx before positioning of the stent to maintain lumen size. Even slight movements of a stent may prevent or disrupt skin adherence. Table IV summarizes the long term results of therapy. Twenty-seven of the 37 patients had completed therapy. There was one operative death. In four patients colon interposition was performed within the past two years. Two patients terminated therapy prematurely. Three patients were undergoing further management for restenosis. Deglutition was considered good in 25 patients (Fig. 1) and adequate in two patients. One of these two experienced intermittent symptoms of dysphagia with no evidence of stricture noted on barium-swallow roentgen examination. The second patient had good objective evidence of colon patency but continued to depend on gastrostomy feeding as he had done during repeated revisions for an anastomosis stricture. Phonatory function was good in 21 patients, fair in four, and poor in two. The four patients with a fair voice had required surgical revision for supraglottic and hypopharyngeal restenosis. The two patients with poor phonation had tracheal stenosis and a permanent tracheostomy.
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SURGICAL MANAGEMENT OF LYE BURNS
581
quiring immediate tracheotomy also s u g g est extensive hypopharyngeal burns.
Fig. 1. Good deglutition colon interposition.
following
DISCUSSION
Proper treatment of esophageal lye burns requires knowledge of the extent of damage.6 ,7 Esophagoscopy and barium-swallow x-rays should be performed as soon as possible. Extensive burns may be noted on t~e lips. and within the oral cavity. Indirect rmrror examination of the oro- and hypopharynx, along with direct endoscopic assessment dictate the course of therapy to be' implemented. With severe burns of the esophagus and hypopharynx, corticosteroids and early endoscopic dilatation are of no value and may be detrimental when esophageal perforation is imminent. Tracheotomy and other immediate life-support measures are often required in these patients before endoscopic evaluation can be performed. Tertiary burn of the hypopharynx and cricopharyngeal area is seen in cases that eventually require esophageal bypass and is the main factor for considering early therapy. The average time lapse from ingestion to definitive surgery was four months in this series. Esophagoscopy must be terminated at the first sign of a third degree burn to avoid esophageal perforation. Onc~ the severity of the burn has been venfied, appropriate therapy can be started. Laryngeal and supraglottic edema re-
Repeated dilatation of esophageal stricture by bougienage has been a successful method restoring deglutition when the phal.)'nx .and proxi",lal ~ervi cal esophagus IS unmvolv~d WIth.SIgnficant scarring. An extensive review of esophageal dilatation has recently been published.?? Relatively little has been published on long-t~rm follo.w-up a~d retrospective analysis of patients WIth hypopharyngeal and proximal cervical esophageal strictures. Techniques of hypopharyngeal reconstruction with free skin grafts," skin flaps from neck and chest,11 laryngotracheal a utografts 12 and modified Z-plasty procedures la.14 have been described as successfully restoring anatomical integrity necessary for deglutition in selected cases. The technique of pharyngeal reconstruction and esophageal replacement described by Ogura et aP was employed in the cases reviewed. Successful restoration of deglutition by objective roentgenographic appraisal occurred in ~ll patients. Barium swallow x-ray studies confirmed the subjective appraisal of deglutition. On subjective appraisal, two patients felt their swallowing efforts were labored, and their general activities were not entirely normal. Phonatory function was likewise subjectively assessed. Good results were achieved in over three-fourths of the patients. Long-term success using the technique described appears to be excellent. Wound dehiscence, poor skin graft take, residual unexcised scar, a narrow lumen, and foreign body irritation were some of the factors in stricture formation. On the other hand, successful long-term management seemed to rely on meticulous attention to technique for anatomical restoration. The relatively low complication rate with colon interposition accounts for its wide acceptance. Aspiration occurred in all patients requiring hypopharyngeal and supra-
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BERKOWITZ ET AL.
glottic reconstruction. Once swallowing was successful, aspiration subsided. Prolonged aspiration occurred in those patients finding swallowing difficult to relearn. Most cases resolved spontaneously once a technique of swallowing was mastered. Hospitalization in these instances was prolonged by a few days. In a few patients, pulmonary therapy was required for retained secretions. Tracheal decannulation was delayed as a result. Neck and chest Haps5 ,ll ,15 have been used for hypopharyngeal repair. A three-stage procedure for complete reconstruction is often required, but the incidence of restricture is low. The stomach and jejunum have been acceptable alternatives to colon interposition in patients with minimal hypopharyngeal involvement.s-! The incidence of jejunum necrosis following vascular compromise is high. The
jejunal segment is often limited by its length and blood supply to esophageal replacement. SUMMARY
Management of severe cervical esophageal and hypopharyngeal lye-induced strictures has been reviewed in this study. The indications, technique, and complications resulting from colon interposition as the procedure used to reestablish upper alimentary tract continuity are presented and analyzed. Postoperative complications and management are separated into early and late manifestations. Long-term results of deglutition and phonatory function are emphasized. Return to full function and original life style is the goal for every patient. Colon interposition with cervical esophageal and hypopharyngeal reconstruction seems to be a successful approach to attain this goal.
Request for reprints should be sent to Wallace P. Berkowitz, M.D., Dept. of Otolaryngology, Wash. Univ. School of Medicine, 517 S. Euclid, St. Louis, Mo. 63110. REFERENCES 1. Wookev H: The surgical treatment of carcinoma of the hypopharynx and the oesophagus. Br J Surg 36:249, 1947-48 2. Ogura JH, Roper CL, Burford TH: Functional restoration of the food passages in extensive stenosing caustic burns of the pharynx and esophagus. Laryngoscope 71: 885-902, 1961 3. Rienhoff WF: Intrathoracic esophagojejunostomy for lesions of the upper third of the esophagus. South Med J 39:928, 1945 4. Heimlich HJ: Esophagoplasty with reversed gastric tube. Review of fifty-three cases. Am J Surg 123:80-92, 1972 5. Leonard JR, Holt GD: Reconstruction of the hypopharynx and cervical esophagus. Otolaryngol Clin North Am 5:(3)435-446, 1972 6. Middlekamp IN, Cone AJ, Ogura JH, et a1: Endoscopic diagnosis and steroid and antibiotic therapy of acute lye bums of the esophagus. Laryngoscope 71: 1354-1362, 1961 7. Viscomi GJ, Beekhuis GJ, Whitten CF: An evaluation of early esophagoscopy and corticosteroid therapy in the management of corrosive injury of the esophagus. J Pediatr 59:356-360, 1961
8. Ritter FN, Cago 0, Kirsh MM, et a1: The rationale of emergency esophagogastectomy in the treatment of liquid caustic burns of the esophagus and stomach. Ann Otol Rhinol Laryngol 80:513-520, 1971 9. Rabuzzi DD, Camp HL: Repair of hypopharyngeal stenosis. Arch Otolaryngol 97: 256-258, 1973 10. Tucker JA, Turtz ML, Silberman HD, et al, Retrograde esophageal dilatation 19241974 - a historical review. Ann Otol Rhinol LaryngoI83:1-35 (Suppl, 16), 1974 11. Bakamjian VY: A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin Hap. Plast Reconstr Surg 36:173, 1965 12. Som ML: Laryngoesophagectomy. Arch OtolaryngoI63:474, 1956 13. Gross CW, Harris AS: Relief of stricture in the cervical esophagus by Z-plasty technique. Laryngoscope 81 :658-662, 1971 14. Bernstein L: Z-plasty in head and neck surgery. Arch Otolaryngol 89:574-584, 1969 15. Edgerton MT: One-stage reconstruction of the cervical esophagus or trachea. Surgery 31 :239, 1952
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SURGICAL MANAGEMENT OF SEVERE LYE BURNS OF THE ESOPHAGUS BY COLON INTERPOSITION WALLACE CHARLES GERSHON
L.
J.
P.
BERKOWITZ, M.D.
ROPER, M.D.
DONALD G. SESSIONS, M.D.
SPECTOR, M.D.
ST.
JOSEPH
H.
OGURA, M.D.
LOUIS, MISSOURI
SUMMARY - Thirty-seven patients with severe esophageal and hypopharyngeal burns from lye ingestion are reviewed. Preliminary surgical procedures consisting of gastrostomy, esophagostomy, esophagectomy, and tracheotomy were often performed prior to definitive esophageal bypass with colon interposition. The technical aspects of the two-team approach to colon interposition are described with particular emphasis placed on the cervical anastomosis. Common postoperative complications included aspiration, delayed tracheal decannulation, and restenosis in the anastomotic area. Functional restoration of deglutition and phonation was successful in most cases. Attention is focused on management of early and late complications. Results of colon transposition are discussed with references made to other surgical procedures. Functional evaluation of patients followed over a long period is described.
The techniques used in reconstruction of the lye-damaged upper alimentary tract are numerous.l" While no specific approach to hypopharyngeal and cervical esophageal stenosis appears to have a decided advantage, colon interposition has been a satisfactory method." This study analyzes the management of patients with severe hypopharyngeal and cervical esophageal lye-induced strictures. The initial, definitive, and revisional surgery that was required, along with early and late postoperative complications are reviewed. The technique of Ogura for hypopharyngeal and cervical esophageal anastomosis with colon transposition is described," Long term assessment of deglutition and phonation is presented. CLINICAL MATERIAL
All patients who underwent colon interposition for severe esophageal and
hypopharyngeal stricture from lye ingestion at Washington University Medical Center from 1959 to 1972 were included in the study. Analysis was made of the initial treatment, definitive surgical management, and the early and late results of this management. Patients who were longer than two years postcolon interposition and not under therapy were felt to be eligible for longterm assessment of deglutition and phonatory function. Deglutition was considered good if the patient led a normal life without special consideration, tolerated a regular diet, and maintained weight and nutrition. Deglutition was adequate if swallowing function interfered with normal living. Barium x-ray studies confirmed the subjective impression in all cases. Phonation was considered good if the patient had a normal sounding voice, fair if voice was hoarse, and poor if voice was breathy.
From the Departments of Otolaryngology and Surgery, Division of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri. Supported in part by NIH Training Grant 5TOI NSO 519015 from NINDS. Presented at the meeting of the American Broncho-Esophagological Association, Atlanta, Georgia, April 7-8, 1975. 576
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SURGICAL MANAGEMENT OF LYE BURNS PRINCIPLES AND TECHNIQUE OF COLON INTERPOSITION
Principles. Anatomical restoration of the upper alimentary tract may be a one or more stage procedure. Possible mediastinal contamination from an infection complicating a tracheotomy is the prime consideration for a staged procedure. Tracheotomy is necessary when pharyngeal reconstruction is required. Unless it is needed for. the initial management of the patient, tracheotomy and pharyngeal repair is best delayed until the second stage. Extensive supraglottic resection may be performed without imp~irin~ ~e glutition or phonatory function significandy. Accommodation of the swallowing mechanism occurs early in the postoperative period.
Technique. The first team opens the abdomen through a midline incision and mobilizes the right and transverse colon. The middle colic artery is isolated and along with the colon segment is passed posterior to the stomach a~d delivered through the gastro-hepatic omentum. A median sternotomy allows anterior mediastinal placement of the colon segment. The transverse colon is divided and an end-to-end ileo-transverse colostomy is performed. The proximal free end of the .transverse colon is then anastomosed high on the anterior aspect of the fundus of the stomach. A pyloroplasty completes the abdominal part of the procedure unless a gastrostomy has not been performed earlier.
577
current laryngeal nerve. The esoph~gus is mobilized and transected. The distal end is closed by interrupted 3-0 silk sutures, and the proximal end is anastomosed to the cecum in two layers. The sternal head of the clavicle and part of the manubrium are often removed to provide room for the colon. To prepare for the pharyngeal anastomosis, the skin incision is made on the side opposite the most severe scarring. The skin and subcutaneous tissues are elevated over the larynx, and dissection is carried toward the posterolateral border of the thyroid cartilage. The sternohyoid, thyrohyoid and omohyoid muscles are divided transverse~y at the superior border ~f the th>:rOld cartilage, and the medial constnctor muscles are divided along the thyroid cartilage edge. The perichondrium is elevated inferiorly and the cartilage is incised obliquely from the thyroid notch to a point just superior to the inferior cornu. The internal perichondrium and the hypopharyngeal area are exposed after the cartilage is resected. The pyriform sinus is identified. The hypopharynx is opened vertically, and the arytenoid eminence is identified. The incision is extended superiorly to the level of the epiglottis. The cecum is opened along one tenia for approximately 3 em for an end-to-side anastomosis with the hypopharynx. The esophagus distal to the anastomosis is closed. Drains are placed into the neck and upper mediastinum prior to wound closure.
If a pharyngeal repair is required, it A second team works simultaneously is performed two weeks after colon to prepare the cervical area for cecal interposition. A paramedian tracheanastomosis. Either an end-to-end high otomy using local anesthesia is followed cervical esophago-cecal or an end-to- by administration of general anesthesia. side pharyngo-cecal anastomosis is per- A transverse incision is made at the formed depending upon the extent and level of the hyoid bone. The supralocation of pharyngeal scarring. This hyoid muscles are partially separated scarring is determined by prior endo- and the hyoid bone is split in the midscopic evaluation. The skin is incised along the anterior border of the sterno- line. The pharynx is entered at the cleidomastoid muscle from the supra- vallecula. The midline incision may be sternal notch to the angle of the mandi- extended down to the thyroid notch ble. The dissection is carried down to for additional exposure. All epiglottic the esophagus carefully avoiding the re- and glossoepiglottic folds are cut on
Downloaded from aor.sagepub.com at Harvard Libraries on July 4, 2015
.57R
BERKOWITZ ET AL.
TABLE I COLON INTERPOSITION FOR ESOPHAGEAL AND HYPOPHARYNGEAL STRICTURE (N = 37)
Colon interposition (staged) Colon interposition (unstaged ) (a) End-to-end anastomosis ( cecum to esophagus) (b) End-to-side anastomosis ( cecum to hypopharynx)
No. Occurrences
% Occurrences
16 21
57%
12
33%
9
24%
43%
each side taking great care to avoid accidental incision into the colon. The arytenoid cartilage should not be traumatized since vocal cord fixation may result. Dissection may be carried into the endolarynx to below the false cords and into the ventricles. The epiglottis together with the remaining scarred supraglottic tissues are excised, taking care to preserve the pyriform mucosa, and a cuff of mucosa at the cecalpharyngeal anastomosis. Split thickness skin grafts are used to cover the raw supraglottic area. A Negus stent is used to secure the skin graft in position. The distal end of the stent is placed into the colon stoma. The neck wound is then closed after the hyoid bone is reapproximated.
year (4), children one to ten years ( 13), and young adults 10 to 18 years (6). Initial evaluation in all patients included a barium swallow roentgenographic contrast study and endoscopy. Initial management with corticosteroids, antibiotics, and endoscopic dilatation did not prevent eventual esophageal stricture in these patients.v"
The stent is removed in two to three weeks. Deglutition is attempted after the pharynx is healed and the laryngeal airway has been reestablished. If the tracheotomy tube is patent, a cork stopper must be used to allow the expired air column to assist clearing the larynx. The tracheotomy tube is removed when aspiration is no longer a significant problem.
The severity of the stricture determined whether reconstruction of the upper airway and alimentary tract was performed in one or two stages. Table I illustrates the definitive surgical management of these patients. In the 16 patients requiring two-stage reconstruction, the colon interposition was done initially with repair of the hypopharyngeal stenosis done secondarily. All of these patients had significant hypopharyngeal stenosis, as well as esophageal stricture. A single-stage procedure was possible in 21 patients who had esophageal stricture with minimal hypopharyngeal involvement.
RESULTS
Thirty-seven patients with severe lye burns of the esophagus and hypopharynx underwent colon interposition between 1959 and 1972. There were 26 males and 11 females. Age at the time of ingestion varied. The peak incidence occurred with adults over 18 ( 14). Children and young adults (23) were subdivided into infants less than one
Gastrostomy an d esophagostomy were performed to maintain nutrition in 29 and 7 patients, respectively. Esophagectomy was required subsequent to esophageal perforation and mediastinal infection in seven patients." Laryngeal edema with airway obstruction necessitated tracheotomy in six cases.
An end-to-end (cecum to esophagus) anastomosis was performed in 12 cases while an end-to-side (cecum to hypopharynx) anastomosis was accomplished in nine patients. Stenosis was distal to
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SURGICAL MANAGEMENT OF LYE BURNS
TABLE II EARLY POSTOPERATIVE COMPLICATIONS AND SURGICAL MANAGEMENT (N = 37) No. Occurrences
% Occurrences
Airway: significant aspiration prolonged tracheal cannulation tracheal stenosis
9 5 2
24% 13% 5%
Alimentary : cervical restenosis cervical anastomotic leak colon necrosis
7 2 2
19% 5% 5%
4 anastomotic dilatation 3 anastomotic revision 2 abdominal exploration
General: wound infection operative mortality
5 1
13% 2%
5 incision and drainage
Complication
the cricopharyngeus muscle in the former and involved the muscle in the latter nine cases. Table II indicates the incidence and treatment of early postoperative complications. Aspiration of food and saliva was noted in nine patients. Late spontaneous improvement in symptoms occurred in all but two. Extensive cervical scar resection and slow development of a swallowing technique were factors observed in patients with significant aspiration. Tracheal stenosis was noted in two patients. Early stenosis of the cervical colon anastomosis occurred in seven patients.
Surgical Management
Endoscopic dilatation was successful in four while revision of the anastomosis was required in three patients with severe lumen narrowing. Two patients had a small dehiscence at the pharyngeal anastomosis stricture. Both cases underwent surgical revision and are included with those cases requiring early revision of the cervical anastomosis. Abdominal exploration for intestinal obstruction was performed on two occasions. Necrosis of the transposed colon segment was observed in both cases. One patient died during surgery. In the second case, necrotic colon was excised and the stomach anastomosis was closed. The patient later underwent
TABLE III LATE-OCCURRING COMPLICATIONS AND SURGICAL PROCEDURES PERFORMED Late Complications Airway: persistent aspiration supraglottic stenosis persistent tracheal stenosis Alimentary: cervical anastomotic restenosis
No. Occurrences
% Occurrences
3 3 2
8% 8%
5%
5
13%
No. Occurrences
Surgical Procedures Airway: resection of tracheal stenosis resection of recurrent pharyngeal stenosis Alimentary: cervical anastomotic dilatation cervical anastomotic revision resection of esophageal diverticulum left colon interposition
2
3 5 3 1 1
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TABLE IV LONG-TERM RESULTS OF THERAPY
Evaluation Completed (27) Deglutition Function Good 25 Adequate 2 Phonation Function Good 21 Fair 4 Poor 2
successful left colon bypass. Five patients with superficial wound abscesses were treated by incision and drainage procedures with healing occurring secondarily. Table III summarizes the incidence of late-occurring complications and the surgical procedures performed during this period. Five patients continued to require tracheal cannulation for pulmonary toilet as a result of aspiration. Tracheal stenosis recurred after excision and end-to-end anastomosis. Restenosis of the colon anastomosis occurred with five patients and initially all were dilated successfully. Eventually three underwent surgical revision because repeated dilatation gave only transient relief of dysphagia. Three patients developed stenosis within the supraglottic area during the late postoperative period. Surgical revision was initially successful in all, but repeated scar formation occurred in two necessitating a second revision and skin graft. Symptoms of dysphagia in one patient were related to a diverticulum at the colon-esophageal anastomosis. Surgical resection of the pouch relieved his symptoms. Throughout the postoperative period, recurrent scarring was the predominant factor in most complications seen. There were no complications related to gastric acid reflux into the transposed colon segment.' Anastomosis of the colon to the fundus of the stomach seemed to be significant in this regard. In some reports, esophageal bypass involving transposition of a gastric tube or seg-
(N = 37)
Evaluation Not Completed (l0) Surgery less than 2 yrs Therapy continuing Therapy terminated Operative death
4 3 2 1
ment of jejunum was complicated by frequent distal stenosis with occasional necrosis resulting from acid reflux. Split thickness skin grafting for hypopharyngeal restoration has a high incidence of restenosis.P-" Graft failure occurs more frequently when skin is secured about a stent rather than sutured directly to the denuded pharynx before positioning of the stent to maintain lumen size. Even slight movements of a stent may prevent or disrupt skin adherence. Table IV summarizes the long term results of therapy. Twenty-seven of the 37 patients had completed therapy. There was one operative death. In four patients colon interposition was performed within the past two years. Two patients terminated therapy prematurely. Three patients were undergoing further management for restenosis. Deglutition was considered good in 25 patients (Fig. 1) and adequate in two patients. One of these two experienced intermittent symptoms of dysphagia with no evidence of stricture noted on barium-swallow roentgen examination. The second patient had good objective evidence of colon patency but continued to depend on gastrostomy feeding as he had done during repeated revisions for an anastomosis stricture. Phonatory function was good in 21 patients, fair in four, and poor in two. The four patients with a fair voice had required surgical revision for supraglottic and hypopharyngeal restenosis. The two patients with poor phonation had tracheal stenosis and a permanent tracheostomy.
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SURGICAL MANAGEMENT OF LYE BURNS
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quiring immediate tracheotomy also s u g g est extensive hypopharyngeal burns.
Fig. 1. Good deglutition colon interposition.
following
DISCUSSION
Proper treatment of esophageal lye burns requires knowledge of the extent of damage.6 ,7 Esophagoscopy and barium-swallow x-rays should be performed as soon as possible. Extensive burns may be noted on t~e lips. and within the oral cavity. Indirect rmrror examination of the oro- and hypopharynx, along with direct endoscopic assessment dictate the course of therapy to be' implemented. With severe burns of the esophagus and hypopharynx, corticosteroids and early endoscopic dilatation are of no value and may be detrimental when esophageal perforation is imminent. Tracheotomy and other immediate life-support measures are often required in these patients before endoscopic evaluation can be performed. Tertiary burn of the hypopharynx and cricopharyngeal area is seen in cases that eventually require esophageal bypass and is the main factor for considering early therapy. The average time lapse from ingestion to definitive surgery was four months in this series. Esophagoscopy must be terminated at the first sign of a third degree burn to avoid esophageal perforation. Onc~ the severity of the burn has been venfied, appropriate therapy can be started. Laryngeal and supraglottic edema re-
Repeated dilatation of esophageal stricture by bougienage has been a successful method restoring deglutition when the phal.)'nx .and proxi",lal ~ervi cal esophagus IS unmvolv~d WIth.SIgnficant scarring. An extensive review of esophageal dilatation has recently been published.?? Relatively little has been published on long-t~rm follo.w-up a~d retrospective analysis of patients WIth hypopharyngeal and proximal cervical esophageal strictures. Techniques of hypopharyngeal reconstruction with free skin grafts," skin flaps from neck and chest,11 laryngotracheal a utografts 12 and modified Z-plasty procedures la.14 have been described as successfully restoring anatomical integrity necessary for deglutition in selected cases. The technique of pharyngeal reconstruction and esophageal replacement described by Ogura et aP was employed in the cases reviewed. Successful restoration of deglutition by objective roentgenographic appraisal occurred in ~ll patients. Barium swallow x-ray studies confirmed the subjective appraisal of deglutition. On subjective appraisal, two patients felt their swallowing efforts were labored, and their general activities were not entirely normal. Phonatory function was likewise subjectively assessed. Good results were achieved in over three-fourths of the patients. Long-term success using the technique described appears to be excellent. Wound dehiscence, poor skin graft take, residual unexcised scar, a narrow lumen, and foreign body irritation were some of the factors in stricture formation. On the other hand, successful long-term management seemed to rely on meticulous attention to technique for anatomical restoration. The relatively low complication rate with colon interposition accounts for its wide acceptance. Aspiration occurred in all patients requiring hypopharyngeal and supra-
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glottic reconstruction. Once swallowing was successful, aspiration subsided. Prolonged aspiration occurred in those patients finding swallowing difficult to relearn. Most cases resolved spontaneously once a technique of swallowing was mastered. Hospitalization in these instances was prolonged by a few days. In a few patients, pulmonary therapy was required for retained secretions. Tracheal decannulation was delayed as a result. Neck and chest Haps5 ,ll ,15 have been used for hypopharyngeal repair. A three-stage procedure for complete reconstruction is often required, but the incidence of restricture is low. The stomach and jejunum have been acceptable alternatives to colon interposition in patients with minimal hypopharyngeal involvement.s-! The incidence of jejunum necrosis following vascular compromise is high. The
jejunal segment is often limited by its length and blood supply to esophageal replacement. SUMMARY
Management of severe cervical esophageal and hypopharyngeal lye-induced strictures has been reviewed in this study. The indications, technique, and complications resulting from colon interposition as the procedure used to reestablish upper alimentary tract continuity are presented and analyzed. Postoperative complications and management are separated into early and late manifestations. Long-term results of deglutition and phonatory function are emphasized. Return to full function and original life style is the goal for every patient. Colon interposition with cervical esophageal and hypopharyngeal reconstruction seems to be a successful approach to attain this goal.
Request for reprints should be sent to Wallace P. Berkowitz, M.D., Dept. of Otolaryngology, Wash. Univ. School of Medicine, 517 S. Euclid, St. Louis, Mo. 63110. REFERENCES 1. Wookev H: The surgical treatment of carcinoma of the hypopharynx and the oesophagus. Br J Surg 36:249, 1947-48 2. Ogura JH, Roper CL, Burford TH: Functional restoration of the food passages in extensive stenosing caustic burns of the pharynx and esophagus. Laryngoscope 71: 885-902, 1961 3. Rienhoff WF: Intrathoracic esophagojejunostomy for lesions of the upper third of the esophagus. South Med J 39:928, 1945 4. Heimlich HJ: Esophagoplasty with reversed gastric tube. Review of fifty-three cases. Am J Surg 123:80-92, 1972 5. Leonard JR, Holt GD: Reconstruction of the hypopharynx and cervical esophagus. Otolaryngol Clin North Am 5:(3)435-446, 1972 6. Middlekamp IN, Cone AJ, Ogura JH, et a1: Endoscopic diagnosis and steroid and antibiotic therapy of acute lye bums of the esophagus. Laryngoscope 71: 1354-1362, 1961 7. Viscomi GJ, Beekhuis GJ, Whitten CF: An evaluation of early esophagoscopy and corticosteroid therapy in the management of corrosive injury of the esophagus. J Pediatr 59:356-360, 1961
8. Ritter FN, Cago 0, Kirsh MM, et a1: The rationale of emergency esophagogastectomy in the treatment of liquid caustic burns of the esophagus and stomach. Ann Otol Rhinol Laryngol 80:513-520, 1971 9. Rabuzzi DD, Camp HL: Repair of hypopharyngeal stenosis. Arch Otolaryngol 97: 256-258, 1973 10. Tucker JA, Turtz ML, Silberman HD, et al, Retrograde esophageal dilatation 19241974 - a historical review. Ann Otol Rhinol LaryngoI83:1-35 (Suppl, 16), 1974 11. Bakamjian VY: A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin Hap. Plast Reconstr Surg 36:173, 1965 12. Som ML: Laryngoesophagectomy. Arch OtolaryngoI63:474, 1956 13. Gross CW, Harris AS: Relief of stricture in the cervical esophagus by Z-plasty technique. Laryngoscope 81 :658-662, 1971 14. Bernstein L: Z-plasty in head and neck surgery. Arch Otolaryngol 89:574-584, 1969 15. Edgerton MT: One-stage reconstruction of the cervical esophagus or trachea. Surgery 31 :239, 1952
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