A histopathological study of esophageal atresia and tracheoesophageal fistula

BACKGROUND/PURPOSE: Histopathologic examination of the esophagus has not been reported often in esophageal atresia (EA) and tracheoesophageal fistula (TEF). Abnormal esophageal motility has been reported after successful repair of EA and TEF, although the exact etiology of this motility disorder remains unclear. Histological evaluation of the fistulous portion of the esophagus has been performed to document any abnormality that may be responsible for the abnormal motility. METHODS: Histopathological study of fistulous segment of esophageal atresia and distal TEF was conducted on 65 patients, which included autopsy material from 3 patients in whom the entire esophagus was examined by serial section. Special stains were administered to each specimen to look for tracheobronchial remnants and the arrangement of muscle fibers. Clinical evaluation was performed in 27 patients who were available for review 6 months to 9 years after successful surgical treatment. These patients were categorized into 3 groups according to their clinical status. RESULTS: These findings showed that the majority of these patients have tracheobronchial remnants in the esophagus in the form of abnormal mucous glands and ducts, abnormal mucin secretion, presence of cartilage, and a disorganized muscle coat. CONCLUSIONS: The presence of abnormal mucous glands and abnormal mucin secretion has not been highlighted before. Although tracheobronchial remnants and a disorganized muscle coat are common findings in the fistulous portion of the esophagus, these may not reflect the structure of the remaining esophagus.     

Laparoscopic treatment of esophageal stenosis due to tracheobronchial remnant in a child

Esophageal stenosis due to the presence of abnormal tracheal cartilage in the wall of the esophagus is an uncommon disease, which presents with vomiting or a failure to thrive. Surgical excision of the cartilaginous segment is the preferred treatment. This is a report of a new technique for the treatment of esophageal stenosis in children. We performed a laparoscopic lower esophageal stricturoplasty with anterior fundoplication for esophageal stenosis caused by a tracheobronchial remnant in the wall of the lower esophagus.     

Usefulness of endoscopic ultrasonography in the diagnosis of congenital esophageal stenosis

Background/Purpose: Endoscopic ultrasonography (EUS) is considered a potentially useful tool to investigate structural abnormalities of the esophagus in pediatric patients, as in adults. The aim of this study was to evaluate the usefulness of EUS for the diagnosis of congenital esophageal stenosis. Methods: High-frequency catheter probe EUS was performed under general anesthesia in 2 patients who had congenital esophageal stenosis. Results: A 4-year-old boy with anorectal anomaly showed tapered narrowing in the distal esophagus, which was not ameliorated with balloon dilatation. High-frequency catheter probe EUS showed hypertrophy of the muscular layer in the esophageal wall at the narrowed portion, but no images suggested the presence of tracheobronchial remnants. The histologic diagnosis of fibromuscular hypertrophy was confirmed at esophagoplasty. A 5-month-old boy with Gross C-type esophageal atresia and symptomatic gastroesophageal reflux showed tapered narrowing in the middle esophagus on esophagography. The symptoms of stenosis were not ameliorated by balloon dilatation performed 4 times. High-frequency catheter probe EUS showed hyperechoic lesions suggesting cartilage at the esophageal narrowing. The diagnosis of tracheobronchial remnants was confirmed by the finding of 2 pieces of cartilage in the specimen obtained at the time of esophageal resection. Conclusion: EUS can be applied to show structural abnormalities of the esophageal wall even in pediatric patients with congenital esophageal stenosis and is useful for planning the therapeutic strategy.     

Diagnosis and treatment of 34 cases of congenital tracheobronchial cartilage remnants of esophagus

Purpose

To describe the diagnosis and treatment of 34 cases of congenital tracheobronchial cartilage remnants of esophagus.

Double stenting for esophageal and tracheobronchial stenoses

Background. We examined the complications and outcomes of placing stents for both esophageal and tracheobronchial stenoses.

Methods. We placed stents for both esophageal and tracheobronchial stenoses in 8 patients (7 with esophageal cancer and 1 with lung cancer). Covered or noncovered metallic stents were used for the esophageal stenoses, except in 1 patient treated with a silicone stent. Silicone stents were used for the tracheobronchial stenoses. The grades of esophageal and tracheobronchial stenoses were scored.

Results. All patients experienced improvement of grades of both dysphagia and respiratory symptoms after stent therapy. The complications were: (1) 2 patients suffered respiratory distress after placement of the esophageal stent because of compression of the trachea by the stent; and (2) 3 patients developed new esophagotracheobronchial fistulae, and 2 patients had recurring fistula symptoms because of growth of preexisting fistulae after the stent placement, which were caused by pressure from the 2 stents. Despite the fistulae, the 5 patients treated with covered metallic stents did not complain of fistula symptoms, but 2 patients treated with noncovered metallic or silicone stents did complain.

Conclusions. For patients with both esophageal and tracheobronchial stenoses, a stent should be introduced into the tracheobronchus first. Because placement of stents in both the esophagus and tracheobronchus has a high risk of enlargement of the fistula, a covered metallic stent is preferable for esophageal cancer involving the tracheobronchus.     

Distal congenital esophageal stenosis associated with esophageal atresia

A series of six patients with congenital esophageal stenosis associated with esophageal atresia (EA) and distal tracheoesophageal fistula is presented. Three patients required only repeated dilatations, and have had good results. Two patients required limited resections of the distal esophagus, with excellent results. One patient died following a Heller myotomy. Tracheobronchial rests were present in the distal esophagus in the latter three patients. Diagnosis of congenital distal esophageal stenosis following repair of EA requires a high index of suspicion and a careful review of previous esophagrams. It is important to exclude anastomotic stricture and stenosis associated with gastroesophageal reflux. This requires barium esophagram, esophagoscopy with biopsy, and esophageal pH monitoring. Once a congenital basis for distal esophageal stenosis is suspected, management consists of dilatation by bouginage followed by balloon dilatation. Resection is reserved for persistent stenoses from tracheobronchial rests, which usually do not respond to dilatations.     

Bronchoscopic staging of squamous cell carcinoma of the upper thoracic esophagus

OBJECTIVE: To identify bronchoscopic findings that predict resectability of squamous cell carcinoma of the upper thoracic esophagus. DESIGN: Tracheobronchoscopy was performed in patients with squamous cell carcinoma of the thoracic esophagus to assess the infiltration of the tracheobronchial tree by the tumor and predict the resectability. Bronchoscopic records were matched with clinical outcome and intraoperative findings. SETTING: University hospital, tertiary care referral center. PATIENTS: A total of 113 patients with supracarinal esophageal carcinoma underwent bronchoscopy as part of the preoperative staging. In 47 patients the bronchoscopy was repeated after a regimen of neoadjuvant chemotherapy. INTERVENTION: A total of 160 bronchoscopies performed by the same operator. MAIN OUTCOME MEASURES: Bronchoscopic records matched with clinical outcome and intraoperative findings. RESULTS: Including patients before and after neoadjuvant chemotherapy, 27 of the 46 with no bronchoscopic abnormalities were operated on: in 24 (89%) of them radical surgical resection was possible. Among the 22 patients with a slight compression on the tracheobronchial tree admitted to surgery, a radical surgical resection was possible in 20 cases (91%). In none of the 5 patients with compression/deviation associated with fixation of the tracheobronchial tree but no mucosal infiltration who underwent surgery was a radical surgical resection possible because of tracheobronchial infiltration. CONCLUSIONS: Compression of the tracheobronchial tree does not necessarily mean infiltration by esophageal carcinoma. If the compression is slight and the mobility of the tracheobronchial tree is normal, a radical esophagectomy is possible in 91% of patients.     

Spontaneous emphysema of the mediastinum

Cases of 104 patients with the spontaneous emphysema of the mediastinum were thoroughly analyzed. The disease affects young men, aged less the 30 years, with asthma or chronic bronchitis. Differentiation should be made between iatrogenic esophageal or tracheobronchial rupture and spontaneous rupture of esophagus. Surgical treatment is indicated to less then 4% of patients with spontaneous mediastinal emphysema.     

Evaluation of noninvasive tests for the preoperative staging of carcinoma of the esophagus: a prospective study

A prospective study was undertaken to define the usefulness of conventional full-lung linear tomography, radionuclide liver plus spleen and bone scans, and thoracic and abdominal computed tomography for the preoperative staging of carcinoma of the esophagus. Thirty-three patients with carcinoma of the esophagus were studied. The computed tomographic (CT) scan of the thorax and upper abdomen was the single most accurate noninvasive study. With computed tomography, the relationship of the tumor to the tracheobronchial tree was the feature most useful in predicting local resectability. In all patients with the finding of tracheobronchial compression by the tumor, the tumor could not be resected completely. The predictive value of this CT finding in patients with locally unresectable tumor was high (0.83), indicating its usefulness in assessing unresectability. The CT finding of visible separation between tumor mass and tracheobronchial tree was present in 10 of 14 patients with locally resectable tumor (predictive value, 0.63). However, tumor abutting the tracheobronchial tree without compression was a poor predictor of unresectability (predictive value, 0.36). The radionuclide bone scan was the only other noninvasive study to demonstrate a metastasis not evident by CT scan. The combination of chest and abdominal CT scan, bone scan, and bronchoscopy before operation will accurately stage the majority of patients with esophageal cancer but no noninvasive test is of sufficient reliability to exclude patients from operative resection if otherwise indicated.     

Indication of the use of pedicled omentum in chest surgery

The omentum has been known to have a remarkable power of repair through neovascularization and scavenger function. Nine patients have been treated with the pedicled omentum. In 4 patients the omentum was used to obtain healing in the presence of infection. Bronchial fistulas were successfully closed in 3 patients with lung cancer and bronchial anastomotic leakage was repaired in one patient who received carinal reconstruction. In 5 patients, all of them had simultaneous resection of thoracic esophagus, the preventive use of omentum made a good result in two tracheoplasties, one pneumonectomy and one terminal tracheostomy. But one patient with esophago-tracheofistula after irradiation to esophageal cancer developed tracheal necrosis postoperatively. The omentum is useful in the case of postoperative empyema with bronchial fistula especially in patient with lung cancer. In the case of tracheobronchial resection after radiation therapy or with resection of thoracic esophagus, the suture line should be wrapped by omentum to prevent anastomotic leakage.     

Thoracoscopic approach for congenital esophageal stenosis

Congenital esophageal stenosis (CES) is an infrequent entity; however, many cases have been reported during the last years. Its incidence falls between 1 per 25,000 and 1 per 50,000 live births and is associated with other congenital malformations in 17% to 33% of cases (mainly esophageal atresia). Congenital esophageal stenosis is defined as an intrinsic alteration of the esophageal wall given by the presence of ectopic tracheobronchial tissue, membranous diaphragm, muscular hypertrophy, or diffuse fibrosis of the submucosa, among other causes. The therapeutic options include endoscopic dilation and resection plus anastomosis (by either laparotomy or thoracotomy, depending on the level of the stenosis).We present the case of a 1-month-old baby boy with a CES located in the distal esophagus that is associated with anophthalmia and micropenis. We treated the lesion by means of a thoracoscopic resection of the affected segment and an esophageal end-to-end anastomosis. The patient's long-term outcome was uneventful.As far as we know, this is the first report on thoracoscopic resolution of a CES.     

The Use of Diaphragmatic Pedicle Grafts for Reconstructive Procedures in the Esophagus and Tracheobronchial Tree

The use of well vascularized, denervated grafts of diaphragmatic muscle for repair of injury to the esophagus and tracheobronchial tree is described. The techniques for mobilization of the grafts to different areas of the chest and neck are outlined and illustrated by reference to patients with spontaneous esophageal perforation, bronchopleural fistula, and injury to the posterior tracheal membrane at the thoracic inlet. Diaphragmatic muscle is strong, elastic, well vascularized, and resistant to necrosis, with good regenerative capacity. These attributes make it the ideal material for reconstructive work in the chest and neck.     

Circular myectomy for the treatment of congenital esophageal stenosis owing to tracheobronchial remnant

The management of the congenital esophageal stenosis is not well established. The authors present an infant with critical esophageal stenosis owing to tracheobronchial remnant. This lesion was managed successfully by circular myectomy of the esophageal wall without resection. An 1-year-old girl was referred for recurrent vomiting and dysphagia. An esophagogram showed an abrupt stenosis, and endoscopic ultrasonography showed cartilaginous tracheobronchial remnants within the esophageal wall. The extirpation of muscular layer, which contained cartilage, was attempted. Circular muscular layer was resected in 1 cm width leaving mucosal layer intact. Muscular layer was closed horizontally with absorbable sutures. The patient is free from the symptoms and eats normally 1 year after surgery. In case of short segmental stenosis owing to tracheobronchial remnant, this may be the preferred approach.     

Anesthetic management for thoracoscopic repair of type I esophageal atresia with continuous-flow single-lung ventilation

We describe a continuous flow mode of ventilation for repair of type I esophageal atresia in an infant. This type of atresia is defined by distal stenosis of the esophagus with a proximal blind pouch and no connection to the tracheobronchial tree. In traditional repair procedures the surgical approach is by thoracotomy, but newer videoassisted thoracoscopic techniques have introduced novel challenges to ventilatory mechanics in these low-weight infants. The literature contains little discussion of the anesthetic management or respiratory mechanics of these patients. Trying to maintain adequate tidal volume and oxygenation while thoracoscopic maneuvers take place increases the risk of barotrauma. Single-lung ventilation with a continuous flow respirator was effective in the case we report.     

Application of the self-inflating bulb to a hollow intubating introducer

BACKGROUND: The aspiration test, performed by a self-inflating bulb (SIB), is a simple and reliable method to detect an accidental esophageal intubation. The aim of the study, in case of employment of a hollow intubating introducer (HII), was to verify the possibility to directly perform the test with the introducer and its efficacy in allowing the detection of its position. METHODS: Experimental design: prospective, randomized study. Environment: operating theater in a university hospital. Patients: adult patients, without evidence of gastro-esophageal or tracheobronchial pathologies, scheduled for elective surgery. Interventions: patients were randomized in two groups T (HII was placed in trachea) and E (HII was positioned in the esophagus). Under general anesthesia, a HII was placed in either the trachea or the esophagus. A blinded anesthesiologist connected the SIB to the HII and performed the test twice. Measurements: the anesthesiologist inferred the position of the device, based on the re-inflation observed. RESULTS: One hundred subjects were studied. In group E patients, a prompt and complete re-inflation of the bulb was never observed and the anesthesiologist correctly inferred the position of the HII. Occasionally (3.5% of cases), in group T patients, a prevented or incomplete re-inflation of the bulb occurred, leading to an incorrect judgment of the HII position. CONCLUSIONS: The aspiration test with the SIB allows the proper detection of the introducer in esophagus. When used in combination with a HII, both time and local trauma associated with an erroneous, introducer-guided esophageal intubation in case of difficult laryngoscopy may be reduced.     

Treatment policy for children with gastroesophageal reflux complicated by Barrett esophagus

Barret's esophagus (BE) is a rare disease in children. It is caused by gastroesophageal reflux (GER). From 1996 to 1999 seventy-eighth children with GER were treated. Twenty-four-hour pH-metry and manometry of the esophagus, scintigraphy and contrast roentgenoscopy of the esophagus were used for diagnosis of GER. All the children underwent biopsy of mucosa membrane of distal esophagus. Morphologic examinations revealed BE in 16 (20.5%) children. Metaplasia of esophageal epithelium by intestinal type (IT) in combination with one by gastric type (GT) were revealed in 8 children, metaplasia by gastric type alone (epithelium of gastric and fundal parts of the stomach)--in 8 children. Six children with IT metaplasia of the esophagus with long strictures underwent extirpation of the esophagus with one-stage esophagoplasty. It esophageal stenosis is not long or is absent, fundoplication by Nissen (4 children) and drug therapy (6 children) are performed. It is concluded that in IT metaplasia of the esophagus with long peptic esophageal strictures resistant to bouginage extirpation of the esophagus with one-stage coloesophagoplasty is desirable. Other methods of treatment do not exclude probability of esophageal adenocarcinoma. These children should be followed up with esophageal biopsy each 6-12 months.     

Perforation of Barrett's ulcer: a challenge in esophageal surgery

Background. Barrett’s ulcer, which develops within Barrett’s esophagus, is frequently responsible for bleeding. Perforation is a rare complication constituting a great challenge for diagnosis and management.

Methods. Three personal cases and 31 published reports of perforated Barrett’s ulcer were reviewed retrospectively. The site of perforation, clinical presentation, management, and outcome were assessed.

Results. The clinical presentation proved to be heterogeneous and was determined by the site of perforation: this was the pleural cavity (20% of cases), mediastinum (20%), left atrium (16.6%), tracheobronchial tract (13.3%), aorta (13.3%), pericardium (10%), or pulmonary vein (6.6%). Early esophagectomy and esophageal diversion-exclusion were the most frequent procedures, and overall mortality was 45%.

Conclusions. The poor prognosis of perforated Barrett’s ulcer should be improved by earlier diagnosis and adequate emergent operation. Although early esophagectomy constitutes the recommended procedure, esophageal diversion-exclusion, which allows control of both sepsis and bleeding, is also of interest.     

Effect of Slip Time in Forming Neo‐Esophageal Stenosis After Replacement of a Thoracic Esophagus With Nitinol Artificial Esophagus

Attempts have been made to investigate the effect of slip time of nitinol artificial esophagus for forming neo‐esophageal stenosis after replacement of a thoracic esophagus with nitinol artificial esophagus in 20 experimental pigs. The pigs whose slip time was less than 90 days postoperatively had severe dysphagia (Bown's III) immediately after they were fed, and the dysphagia aggravated gradually later on (Bown's III–IV). The pigs whose slip time was more than 90 days postoperatively had mild/moderate dysphagia (Bown's I–II) immediately after they were fed, and the dysphagia relieved gradually later on (Bown's II‐I‐0). The ratios between the diameter of neo‐esophagus in different slip time and normal esophagus were 25% (at 2 months postoperatively), 58% (at 4 months postoperatively), and 93% (at 6 months postoperatively), respectively. The relationship between nitinol artificial esophagus slip time and neo‐esophageal stenosis showed a positive correlation. After replacement of a thoracic esophagus with nitinol artificial esophagus, the artificial esophageal slip time not only affected the original diameter of the neo‐esophagus immediately, but also affected the neo‐esophageal scar stricture forming process later on. The narrowing of neo‐esophagus is caused by overgrowth of scar tissue. But there is the positive correlation between artificial esophagus slip time and neo‐esophageal stenosis, so this can be a way of overcoming neo‐esophageal stenosis by delaying slip time of artificial esophagus.     

Correlations between esophageal diseases and manometric length: A study of 617 patients

The purpose of this study was to measure the length of the esophagus and assess its relationship to sex, weight, age, height, and various esophageal disorders. A retrospective analysis was undertaken of 617 esophageal manometric studies, which included 51 normal control subjects (27 males and 24 females) and 566 patients (297 males and 269 females) with esophageal disorders (50 with achalasia, 6 with diffuse esophageal spasm, 64 with strictures, 38 with nutcracker esophagus, 398 with gastroesophageal reflux disease [GERD] with positive 24-hour pH monitoring, and 66 with possible GERD but negative 24-hour pH monitoring). Manometry was performed in all of them by the station pull-through technique. The length of the esophagus was defined as the distance between the proximal end of the upper esophageal sphincter and the distal end of the lower esophageal sphincter. In the control group the mean (± standard deviation) length of the esophagus was 28.3±2.41 cm. In patients with esophageal disorders the mean length of the esophagus was 28.0 ±2.87 cm. Length of the esophagus is related to height but not to weight, sex, age, diffuse esophageal spasm, or nutcracker esophagus. Achalasia is associated with a longer esophagus, and GERD is associated with a shorter esophagus. Stricture is associated with a shorter esophagus, but this is in part due to the association between stricture and GERD. Patients with possible GERD but negative 24-hour pH monitoring have an esophageal length similar to that of GERD patients with positive 24-hour pH monitoring. Patients with GERD and stricture formation showed esophageal shortening in shorter patients. Achalasia, GERD, and GERD with stricture formation influence esophageal length. GERD-related strictures shorten the esophagus more significantly in short patients.     

Total esophageal reconstruction after extraction of the esophagus.

During the period between 1971 and 1974, 25 cases of carcinoma of the hypopharynx and cervical esophagus underwent esophageal extraction and total esophageal reconstruction without operative mortality. The operative methods used for this series were blunt dissection, or everting stripping of the thoracic esophagus without thoractomy followed by pharyngogastro or -colostomy as a one stage procedure via a posterior mediastinal route created by esophageal extraction. The operative technique of esophageal extraction without thoracotomy is described. It is obvious that mediastinal tunnel is the shortest route through which to put the chosen organ for esophageal substitution. This operation is to be recommended for lesion of the hypopharynx and cervical esophagus as well as some esophageal stricture because of its operative simplicity, ease, safety and rare postoperative complications.