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Eur J Cardiothorac Surg 2001;19:400-405
© 2001 Elsevier Science NL

Esophageal reconstruction for hypopharyngoesophageal strictures after corrosive injury

Division of Thoracic Surgery, Department of Surgery, National Cheng-Kung University Hospital, Tainan, Taiwan, Republic of China

Received 2 August 2000; received in revised form 28 October 2000; accepted 21 January 2001.

Corresponding author. Tel.: +886-6-2766120; fax: +886-6-2359562
e-mail: m2201{at}mail.ncku.edu.tw

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Comments References

 
Objective: To evaluate the surgical outcome of patients with caustic stricture of the hypopharyngoesophagus. Materials and methods: During a 25-year period, we performed esophageal reconstruction in 152 patients with diffuse or multiple caustic esophageal stricture. Of them, esophageal substitute was pulled up and anastomosed to the hypopharynx in 50 (33%) patients, and anastomosed to the cervical esophagus in the other 102 (67%) patients. Patients whose esophageal substitute anastomosed to the hypopharynx were enrolled to the present study. Among these 50 study patients, 13 underwent ablation of damaged organs and feeding jejunostomy in acute stage of corrosive injury, and the remaining 37 patients were initially organ preserved with or without feeding gastrostomy or jejunostomy. Six patients had respiratory distress caused by laryngotracheal stricture. The ileocolon (28/50) was commonly used as an esophageal substitute in reconstruction and most substitutes (43/50) went through the substernal route. Results: There was one operative death. Eight (16%) patients had major early postoperative complications. Six patients underwent revision for late stenosis of hypopharyngeal anastomosis, and one redoing reconstruction using the jejunum because of failure of the transplanted ileocolon. Postoperatively, swallow function and maintaining body weight were considered good in 42 patients (84%) after an average of 8 months follow-up. Five of six patients who underwent concomitant tracheostomy or laryngosurgery for laryngotracheal stricture got unsatisfactory result. The surgical outcome of the study patients was worse than that in patients with esophageal substitute anastomosed to a healthy cervical esophagus. In the later group of patients, 95/102 (93%) had good swallow function and only 7/102 (6.8%) had major early complications. Conclusion: Caustic stricture of the hypopharyngoesophagus is a challenging reconstructive problem. A successful reconstruction requires a correct hypopharyngeal opening and anastomosis, a good esophageal substitute, and a patent esophageal route and airway.

Key Words: Corrosive injury • Hypopharyngeal stricture • Esophageal reconstruction

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Comments References

 
In Taiwan, the ingestion of hydrochloride acid, which is used for toilet cleansing, is not rare and usually occurs among adults as an intentional suicide attempt. Multiple strictures involving high-level of the esophagus or hypopharynx are particularly difficult to manage because of requiring a long-segment esophageal substitute and some laryngotracheal strictures usually deteriorating the treatment outcome [1–8]. Hence, surgical results of these sequelae were not satisfied [3], and progressive scaring of hypopharyngeal anastomosis was not rare [9]. In our practice, most patients with multiple or diffuse caustic strictures usually underwent the anastomosis of esophageal substitute to the cervical esophagus or hypopharynx. Patients who had hypopharyngeal anastomosis of esophageal substitute were interested because of having peculiarities of treatment strategy. To understand the treatment outcome we debated our experience of esophageal reconstruction for the high-level caustic stricture during the past 25 years. The clinical data, the technical considerations, and the long-term results are discussed.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Comments References

 
From September 1976 to April 2000, we performed esophageal reconstruction in 152 patients with caustic esophageal stricture. All esophageal substitutes were anastomosed above to the cervical esophagus for diffuse or multiple strictures of the esophagus. Patients whose caustic strictures limited in the cervical or lower thoracic esophagus and only underwent limited interposition or intrathoracic anastomosis were not included in the category of standard esophageal reconstruction. Of these 152 patients, 50 (33%) had anastomosis at the hypopharynx, and 102 (67%) anastomosis at the cervical esophagus. The later group also included cervical anastomosis combined with segmental resection of the pharyngoesophageal junction. Patients whose esophageal substitute anastomosed to the hypopharynx were enrolled to the present study. Among these 50 study patients, 12 underwent esophagogastrectomy and feeding jejunostomy, one esophagogastroduodenectomy, partial jejunectomy and feeding jejunostomy in the acute stage of corrosive injury, and 37 were not initially operated on the esophagus. The medical records, initial management, operative data, postoperative course, and follow-up data of these 50 patients with stricture involving the hypopharyngoesophagus were reviewed. There were 14 male and 36 female patients ranging in age from 6 to 69 years (average age, 38 years). Hydrochloric acid was the most frequently ingested agent (n=42 patients, 84%), and followed by alkaline substances (n=8, 16%). The intent to commit suicide was the motivation for all the adult patients (n=49); in one child, the ingestion was accidental. The interval between ingestion of the caustic agent and reconstruction ranged from 40 days to 40 years. Thirty-seven patients were operated on within 6 months after injury and the others, after longer intervals: five patients after 6 months to 1 year; three patients after 1 year to 3 years; and five patients after 3 to 40 years. Of these patients, 5 had undergone weekly wire-guided bougienage of the esophagus for varying periods, but these esophagi had became undilatable due to progressive scaring. The remaining 45 patients had not undergone dilation before reconstruction because of status of esophagectomy, patients intolerability, or surgeons’ unwillingness to do the high-failure-rate procedure.

2.1. Management of the patients prior to reconstruction
The initial treatment of acute cases included nasogastric decompression, correction of the acid-base imbalance, antibiotics, and ventilatory assistance. Panendoscopy was performed within 48 h and the injury of alimentary tract was graded as follows: grade 0, normal examination; grade 1, edema and hyperemia of the mucosa; grade 2a, superficial localized ulceration, friability and blisters; grade 2b, grade 2a plus circumferential ulceration; grade 3 multiple and deep ulceration and areas of extensive necrosis. Patients who had peritoneal signs, continuos gastrointestinal bleeding, and endoscopic finding of severe burns of the esophagus and stomach were subject to undergo ablation of damaged organs and feeding jejunostomy. Those patients were nourished using jejunostomy feeding prior to reconstruction. Upper gastro-intestinal series (UGI series) and panendoscopy were performed when patients had symptoms of dysphagia, postprandial vomiting, or bleeding. These examinations were usually done 4–5 weeks after corrosive injury. Patients who had findings of isolated gastric complication and non-potential delayed esophageal stricture were subject to solitary gastric resection. If injury severity of the esophagus worse than grade 2b, it almost always tended to develop esophageal stricture. Even progressive scaring of the esophagus, patients were allowed to ingest if tolerable. Thus, gastrostomy or jejunostomy was reserved for nutrition maintenance until intolerable to liquid diet. These 50 patients were nourished by jejunostomy (n=25) or gastrostomy (n=15) feeding, or initially ingestion of liquid and finally supplemented parenteral nutrition (n=10) until reconstruction. The candidates for reconstruction included patients who underwent ablation of damaged esophagus in acute stage of corrosive injury and patients whose stricture of esophagus intolerable to liquid diet. All patients with ingestion of corrosive agent were consulted the psychiatrist after stabilization of physical condition. Psychiatric problem was evaluated and controlled by psychiatrist prior to reconstruction.

2.2. Level and severity of caustic stricture
Level and severity of the stricture were evaluated by esophagography and panendoscopy. The problematic airway was checked using bronchoscope before reconstruction. Moderate to severe stricture of pharynx and larynx usually presented with obliteration of the piriform sinus and adhesion of the epiglottis. In the severe cases, the narrowed laryngopharynx was reluctant to pass a panendoscope. Among these 50 patients, seven of 13 patients who underwent esophagectomy in acute stage of injury had stricture of the esophageal stump and moderate to severe involvement of the pharynx. In the remaining 37 patients without organ ablation, the esophagus presented diffuse stricture in 24 and multiple strictures in 13. Of the above 37 patients, four had moderate to severe pharyngeal involvement. Of the above 11 patients with moderate to severe involvement of the pharynx, six had severe laryngotracheal stricture and presented with respiratory distress.

2.3. Operative procedures
All esophageal substitutes were anastomosed to the hypopharynx. Bypass was performed in 31 patients, replacement of the esophagus through the substernal route in 13, replacement of the esophagus through posterior mediastinum in five, and replacement of the esophagus through the subcutaneous route in 1 (Table 1). All except one esophageal substitutes were isoperistaltic. Six patients with severe laryngotracheal stricture required concomitant tracheostomy (n=3), scar release of larynx using laser surgery (n=2), or laryngectomy (n=1).

2.4.2. Selection and preparation of esophageal substitute
The ileocolon was mobilized from the cecum extending to the ascending colon, transverse colon and left colon. The esophageal substitute was chosen according to condition of the marginal artery, size and length of colon or ileocolon. Vascular network of the transplant was carefully preserved during surgical dissection. Distance between the hypopharynx and vascular pedicle of the transplant was measured before transecting the transplant. Viability of the esophageal substitute was assured by temporary clamping of the vessels except the depending ones before they were divided.

2.4.3. Exploration of hypopharyngoesophagus
The cervical esophagus and hypopharynx were explored through an oblique cervical incision. The incision was made along the anterior border of the left sternocleidomastoid muscle and it was extended upward to anterior portion of the neck to open the pharynx. Because of complete obstruction of the esophageal orifice, a Baker's dilator was used from the oropharynx to direct and the hypopharynx was cut a reversed ‘T’ opening. The created opening was wider than 2.5 cm in diameter at the caudal part of the posterior pharyngeal wall, which usually allowed an surgeon's finger upward to touch the tongue base.

2.4.4. Choice of esophageal route
We chose the posterior mediastinum as an esophageal route when native esophagus was resected in same instance. However, in patients whose esophagus was resected in acute stage or in patients for by-pass surgery, substernal route was the alternate.

2.4.5. Creation of substernal route
The prevertebral space of the neck was dissected free from adhesions, and left paratracheal space was also created to permit passage of the transplant. The thoracic inlet was opened widely by blunt and sharp dissection of the ligaments and fasciae deep to the thymic surface. This produced a space large enough for passage of the esophageal substitute and its subsequent food contents. Partial resection of the manubrium and clavicle head was reserved for patients with a narrow thoracic inlet. The substernal tunnel was created by blunt dissection aided by a light provided retractor.

2.4.6. Pull-up and positioning of the esophageal substitute
The esophageal substitute was encased in a plastic bag so that when it was pulled up, the bag could prevent disruption of the vessels. Pull-up of the transplant was achieved in one action. The esophageal substitute was positioned carefully to preserve the vascular competence of the transplant.

2.4.7. Hypopharyngoenterostomy
After careful evaluation of the proximal esophagus and the hypopharynx, the anastomosis was performed above the level of the abnormal hypopharyngeal mucosa. When the hypopharynx was opened wide, a hypopharyngoenterostomy was performed. It was done with one-layer or two-layer interrupted sutures.

2.4.8. Placement of the nasogastric tube
Before completion of the hypopharyngeal anatomosis, a nasogastric tube was inserted via a nostril to pass the esophageal substitute for temporary feeding from 4th to 10th postoperative days. The tube was removed after confirmation of anastomotic competency. Patient who had a feeding jejunostomy, the nasogastric tube was removed early.

2.4.9. Closure of the wounds of neck and abdomen
The cervical incision was carefully closed to assure patency of the esophageal substitute, and not to bulk the neck during swallowing lately. When closing the linea alba and peritoneum, an opening was maintained for passage of the esophageal substitute from the substernum into the peritoneal cavity. Non-compression or non-twisting of the whole alimentary tract was assured. In some instance, intraoperative endoscopy was used to confirm the patency of the reconstructed alimentary tract. The abdominal procedures for associated gastric strictures were illustrated in our previous report [1], which included cologastroduodenostomy, gastroduodenostomy and cologastrostomy, gastrojejunostomy and cologastrostomy, cologastrotomy and colojejunostomy, and gastrectomy and colojejunostomy. Of these 50 patients, 18 patients with total gastrectomy in acute injury stage (n=15) or during reconstruction (n=3), the colojejunostomy was the only way to restore the alimentary continuity. In the remaining patients, the gastric stricture could be corrected by suitable one of above procedures. Retention sutures were usually placed in the abdominal wound to prevent wound disruption.

2.5. Follow-up
The length of follow-up ranged from 2 months to 15 years with an average of 8 months. The follow-up studies included barium meal study, clinical evaluation and radionuclide scintigraphy.

2.5.1. Barium meal study
Two weeks after reconstruction, barium meal studies were routinely carried out to evaluate the patency of conduit and the condition of anastomoses.

2.5.2. Clinical evaluation
Patients were monitored in the Out-Patient-Department. Data were obtained through clinical visits and questionnaires after discharge from the hospital. Ability to swallow regular diet without dysphagia or only semiliquid or liquid diet, body weight, activity, aspiration, and timing and frequency of regurgitation were recorded. Complications developing immediately after operation or during long-term follow-up were considered operative morbidity. Deaths within one month after operation were defined as operative deaths.

2.5.3. Esophageal transit scintigraphy (dynamic radionuclide imaging)
Nine patients with caustic stricture of hypopharyngoesophagus had been enrolled to evaluate the function of esophageal substitutes in our previous report [10]. All of them were able to swallow full diet without dysphagia after reconstruction. The functional study aimed to measure the transit time, swallowing time and to detect regurgitation, which was performed at least 4 months after reconstruction. The colleagues who volunteered were normal as control group.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Comments References

 
In these 50 study patients, one died of adult respiratory distress syndrome on the 11th postoperative day. Eight (16%) had major early postoperative complications, including leakage of anastomosis, intestinal obstruction, obstruction of the esophageal substitute, graft failure and pneumonia (Table 2). Three cervical anastomotic leaks resulted in subsequent stenosis. Subsequently six underwent revision of hypopharyngeal anastomosis, and one redoing reconstruction using the jejunum because of failure of the transplanted ileocolon. Obstruction of the intestine, obstruction of the esophageal substitute, leakage of abdominal anastomosis, and late complication of gastric mucocele were surgically corrected through a laparotomy. Functional results of 42 patients (84%) were categorized as ‘Good’ according to ability to swallow full diet without any dysphagia, and gaining weight accordingly. Four patients (8%), including three with laryngotracheal stricture and another one who underwent esophageal reconstruction 40 years after corrosive injury, were categorized as fair results according to a limited ability to swallow semiliquid diet or frequent regurgitation at night time, underweight, and showing a decrease in daily activities. Two patients (4%) with laryngeal stricture had poor results with presentations of serious dysphagia, saliva aspiration at night time and underweight. They were nourished completely depending on gastrostomy or jejunostomy feeding. In other words, five of six patients who underwent concomitant tracheostomy or laryngosurgery for associated laryngotracheal stricture got unsatisfactory result. In the long-term follow-up, one patient died of multiple organs failure 2 years after first esophageal reconstruction because of re-ingestion of corrosive agent. Her initial esophageal substitute and intra-abdominal organs appeared severely necrotic in laparotomy. Another patient died of suffocation 2 years after esophageal reconstruction because of ingestion of a large amount of wasted food in the psychiatric ward. The surgical outcome of the study is that patients were worse than that in patients with esophageal substitute anastomosed to a healthy cervical esophagus. In the later group of patients, 95/102 (93%) had good swallow function and only 7/102 (6.8%) had major early complications (Tables 1 and 2). Nine patients who underwent study of esophageal transit scintigraphy presented a decreased clearance ability of esophageal substitutes compared to the control subjects. The transit time of radiotracer return to 30% and to 40% were 319 s versus control of 2.1 s and 173 s versus control of 1.4 s, respectively, and the swallowing time was also significantly prolonged, 1.5 s versus control of 0.22 s. Of the above nine patients, seven were demonstrated to have radiotracer reflux by scintigraphy after abdominal binding.

	4. Comments

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Comments References

A free jejunal graft or forearm flap can be used for replacement of the cervical esophagus [11,12]. Five of our six patients whose stricture only involving cervical esophagus underwent segmental resection with primary anastomosis, and the remaining one underwent replacement of cervical esophagus with a free jejunal graft. The above six patients were not included in the series of 152 patients with esophageal reconstruction. Four of our patients whose stricture involving hypopharyngoesophageal junction and thoracic esophagus, the esophageal substitute was anastomosed to the remaining cervical esophagus, and concomitant hypopharyngoesophagoplasty was performed. These four patients were included in the series of 152 patients with esophageal reconstruction, but not included in the study series of 50 patients in which the esophageal substitute was anastomosed to the hypopharynx.

The positioned routes of esophageal substitute are subcutaneous, pleural, substernal and posterior mediastinum. Subcutaneous route is the last choice because it is longest. Pleural route usually causes distention of esophageal substitute and respiratory distress. The posterior mediastinum is the shortest route and a good passage way. Hence we resected the native esophagus to create the route in recent 10 years. However, its use is not always possible because of severe fibrosis in severe injury or after esophageal resection for caustic ingestion. The substernal route is thus commonly used as an alternate in this series.

In the study series, 28/50 (56%) patients underwent reconstruction using the right ileocolon as an esophageal substitute. We realize that left colon is a favorable substitute because of its suitable size and vessels. Furthermore, the right ileocolon is a good substitute because of the ileocecal valve's ability to prevent regurgitation. In most cases, the stomach is not a suitable candidate for esophageal substitution because it is usually moderately or severely injured by acid. Based on our long-term observation, we firstly choose right ileocolon as an esophageal substitute. To get a lumen calibre adequacy for hypopharyngoileostomy, the end of the ileum is obliquely cut to fit the opening of the hypopharynx.

Among these 152 patients with esophageal reconstruction, 29 underwent concomitant esophagectomy during reconstruction. The resected esophagi presented as severe fibrosis without malignant change. However, in our other series of esophageal cancer, three patients had history of corrosive injury. They were aged 37, 37 and 50 years, interval between corrosive injury and cancer operation were 34, 17, and 20 years, and agent ingested were alkaline, acid and acid, respectively.

Swallowing difficulty after reconstruction could be related to stenosis of the hypopharyngeal anastomosis. Revision of hypopharyngeal anastomosis is mandatory after careful examinations of barium meal study and endoscopy. In the study series, five of six patients got a good result after revisional surgery. In our previous report [9], we suggested that a failed surgical revision can be attributed to (1) poor preoperative evaluation, (2) inadequate releasing of the esophageal substitute, (3) shortness of the esophageal substitute, (4) no interposition of the long segmental defect, (5) unresolved stricture of the laryngopharynx. Although surgical revisions could increase risk of anastomotic fistula and vocal cord paralysis, in our practice the complication rate of surgical revision is still low.

Poor result of esophageal reconstruction is not only attributed to anastomotic stenosis or obstruction of esophageal substitute, but also to dysfunction of the larynx. Goodwin et al. [5] reported that two of four patients, who sustained laryngeal damage at the time of initial injury, required total laryngectomy because of persistent aspiration. Total laryngectomy should be reserved for those patients who cannot be rehabilitated following optimal reconstruction. In our present series, five of six patients who underwent concomitant tracheostomy or laryngosurgery for larngotracheal stricture got unsatisfactory result of swallowing function. We did not convince these patients to perform laryngectomy for the problem of aspiration. However, one of them underwent concomitant total laryngectomy and thyroidectomy for laryngeal stenosis and thyroid cancer. He can swallow regular diet postoperatively.

In our previous study [10], we found the function of clearance ability, transit time and possibility of regurgitation are worse in any kind of esophageal substitute than that of the normal esophagus. Hence, the acme of reconstruction we do only offers the patients the ability of swallowing full diet without any dysphagia, less regurgitation, and gaining weight accordingly.

Caustic stricture of the hypopharyngoesophagus is a challenging reconstructive problem. A successful reconstruction requires a correct hypopharyngeal opening and anastomosis, a good esophageal substitute, and a patent esophageal route and airway. A good esophageal substitute necessitates adequate blood supply, suitable size and enough length, minimal amount of surrounding fatty tissue, non-redundancy of length, and isoperistalsis.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Comments References

 

1. Wu M.H., Lai W.W. Reconstruction of esophagus for esophageal stricture or resection after corrosive injury. Ann Thorac Surg 1992;53:798-802.[Abstract]
2. Popovici Z. Results of the surgical treatment of severe caustic pharyngo-esophageal stenosis. The value of complete reconstruction of the pharynx by transposition of the ileum and colon. Chirurgie. 1998;123:552-559.[Medline]
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4. Thomas A.N., Dedo H.H., Lim R.C., Jr, Steele M. Pharyngoesophageal caustic stricture. Am J Surg 1976;132:195-203.[Medline]
5. Goodwin W.J., Jr, Lundy D.S., Livingstone A.S. Reconstruction of the stenotic hypopharynx and cervical esophagus without total laryngectomy. Laryngoscope 1984;94:1153-1157.[Medline]
6. Berkowitz W.P., Roper C.L., Sessions D.G., Spector G.J., Ogura J.H. Surgical management of severe lye burns of the esophagus by colon interposition. Ann Otol 1975(84):576-582.
7. Meredith J.W., Kon N.D., Thompson J.N. Management of injuries from liquid lye ingestion. J Trauma 1988(28):1973-1980.
8. Doolin E.J. Composite reconstruction of the esophagus and hypopharynx after severe caustic injury. Ann Otol, Rhino & Laryngo. 1994;103:36-40.
9. Wu M.H., Lai W.W., Lin M.Y., Cho N.S. Prevention and management of strictures after hypopharyngocolostomy or esophagocolostomy. Ann Thorac Surg 1994;58:108-111.[Abstract]
10. Wu M.H., Chiu N.T., Lin M.Y., Tseng Y.L. Functional evaluation of esophageal substitutes. Chinese Med ROC. 1996;58:223-229.
11. McLear P.W., Hayden R.E., Muntz H.R., Fredrickson J.M. Free flap reconstruction of recalcitrant hypopharyngeal stricture. Amer J Otolaryngo 1991;12:76-82.
12. Chen H.C., Tang Y.B., Noordhoff M.S. Patch esophagoplasty with free forearm flap for focal stricture of the pharyngoesophageal junction and the cervical esophagus. Plast & Reconstruc Surg 1992;90:45-52.

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