Complete Esophageal Diversion: A Simplified, Easily Reversible Technique

SURGEON AT WORK

Complete Esophageal Diversion: A Simplified, Easily Reversible Technique Leonidas G Koniaris, MD, FACS, Seth A Spector, MD, Kevin F Staveley-O’Carroll, MD, PhD Intrathoracic esophageal perforation presents an extremely challenging clinical scenario. Morbidity and mortality for these patients may be extreme and further complicated by the need for numerous additional operations. Diagnosis of an intrathoracic esophageal perforation is often delayed; such patients commonly present with significant mediastinal soilage. In addition to primary repair and tube drainage, complete esophageal diversion can be extremely helpful in controlling ongoing thoracic contamination and sepsis.1,2 The role of controlling oral secretions is critical, because undiverted oral secretions have an extremely high concentration of mixed flora. Techniques of complete esophageal diversion may result in subsequent esophageal leak or late stricture when reconstruction is finally attempted.3 Ultimately, late stricture may result in the need for conduit replacement using stomach or colon. On the other hand, standard loop esophagostomies, although easy to reverse, do not provide complete diversion; this can perpetuate mediastinal soilage.4 We report a simplified technique for complete esophageal diversion that is subsequently easily reversible. We describe five patients who have undergone these procedures. With up to 4 years of followup, neither leak nor stricture has been observed as a subsequent complication to this diversion technique (Table 1).

and retracted laterally. The omohyoid muscle and the middle thyroid vein are transected. The carotid sheath is retracted laterally while the thyroid is retracted medially. The esophagus is identified, palpating the nasogastric tube anterior to the cervical vertebrae. The esophagus is encircled with a Penrose drain, generally at the level of the midcervical esophagus. Care is taken to encircle close to the esophagus to avoid inadvertent injury to the recurrent laryngeal nerve that runs in the tracheoesophageal groove. Of note, specific identification of the nerve is not undertaken. Next, the esophagus is generously mobilized, superiorly to the level of the carotid bifurcation and inferiorly to the level of the thoracic inlet. This mobilization allows the esophagus to be brought to the inferior apex of the skin incision without tension. A longitudinal or transverse incision is made in the esophagus. A #1 absorbable suture (Vicryl; Ethicon) is then placed around the esophagus just distal to this opening, essentially ligating the inferior third of the cervical esophagus. The side ostomy is then incorporated into the lower edge of the cervical incision closure (Fig. 2). Once the sepsis is resolved and the patient is determined to have made an adequate recovery, the ostomy is closed; this procedure is generally undertaken 6 weeks after the initial perforation. We have routinely performed this procedure under general anesthesia, although local anesthesia is an option. The incision is reopened and the esophagus freed from the skin and underlying tissues. A Hagar dilator is passed through the esophageal stoma distally through the ligature, reestablishing esophageal continuity (Fig. 3). In our experience, this is easily performed and immediately results in a widely patent distal esophagus. The freed esophagus is closed transversely to prevent stricturing as in a HeinekeMikulitz-type of closure (Fig. 4). The platysma is reapproximated and the skin is then closed. External neck drainage is optional. Diet is usually advanced by postoperative day 5 after a negative contrast study, and the patient is discharged shortly thereafter.

Operative technique

If the determination for complete esophageal diversion is made, we approach the neck through a left modified anterior sternocleidomastoid incision (Fig. 1A). The sternocleidomastoid muscle is looped in a Penrose drain No competing interests declared.

Received March 18, 2004; Revised July 16, 2004; Accepted July 21, 2004. From the DeWitt Daughtry Department of Surgery, University of Miami, Miami, FL (Koniaris, Spector); and the Department of Surgery, Penn State University College of Medicine, Hershey, PA (Staveley-O’Carroll). Correspondence address: Kevin F Staveley-O’Carroll, 500 University Dr, MC H149, Hershey, PA 17033.

© 2004 by the American College of Surgeons Published by Elsevier Inc.

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Table 1. Outcomes of Five Patients with Esophageal Perforations with Diversion Patient age (y)/gender

Problem

Treatment

56/M

Boorhaave’s

Thal patch, G and J-tube, diversion

90/F

Boorhaave’s

Chest drain, G and J-tube, diversion

24/F

Gastric bypass with leak and incarceration in chest Status postesophagogastrectomy with thoracic leak day 9 Perforated proximal gastric ulcer

Primary transthoracic repair, repair of hernia, G and J-tube, diversion Intercostal muscle flap, G and J-tube, diversion

82/M

63/F

Discussion

In patients with an intrathoracic esophageal perforation, primary repair and drainage are critical to control or prevent mediastinal sepsis. Grillo and Wilkins,5 in 1975, were the first to advocate primary repair of the esophagus whenever possible. General principles of treatment involve primary repair of the perforation with a tissuebuttress and closed suction drainage.3 Specific therapeutic options and technical approaches are well described in a number of texts and atlases.6,7 Care of the injured esophagus is dependent on the location of injury, underlying pathology, condition of the esophageal tissue, time to diagnosis, and status of the patient. Nonetheless, primary repair alone may be associated with an extremely high mortality rate.3,8,9 In a subset of patients, particularly where the risk or

Figure 1. Steps of esophageal diversion. (A) A lateral incision is made anterior to the sternocleidomastoid. (B, C) Esophagus is encircled with a Penrose drain with attention given to avoid inadvertent incorporation of the recurrent laryngeal nerve.

Gastrectomy, stapled esophagus in discontinuity, G and J-tube, diversion

Outcomes

48 mo, no stricture 6 wk, no stricture 42 mo, no stricture 23 mo, no stricture 19 mo, no stricture

ability to tolerate ongoing sepsis is impaired and there is significant injury or underlying disease, complete cervical diversion should be undertaken. We advocate such an approach in patients with extensive thoracic contamination, especially when time to treatment exceeds 12 hours. The classic cervical approach to esophageal perforation involves either partial diversion by lateral esophageal ostomy formation or complete diversion through stapling of the distal esophagus and the creation of a proximal end-ostomy.6 Both procedures are problematic. In the case of lateral ostomy formation, there is only partial diversion, so ongoing thoracic contamination may occur. In the case of esophageal transection with end-ostomy, reestablishment of esophageal conti-

Figure 2. (A) Ligation of the distal esophagus with formation of a longitudinal cervical esophagus incision. (B) Matured cervical esophagostomy. Esophageal ostomy is incorporated into the inferior edge of the cervical neck incision.

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Figure 4. Placement of a Hagar dilator into the mobilized esophagus, with reestablishment of esophageal continuity.

REFERENCES

Figure 3. Transverse closure of longitudinal esophageal incision.

nuity is a technical challenge. Such patients may require esophageal reconstruction with a gastric or colonic conduit or even a free flap using skin and muscle or jejunum.10,11 The technique described here affords complete esophageal diversion while allowing a relatively simple subsequent reconstruction. The diversion is immediately reversible with dilation and the esophagus is spared complete esophageal transection with subsequent reconstruction. To date, this approach has not resulted in esophageal stricturing or leak after reversal.

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