HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Young Mog Shim Kwhanmien Kim Yong Soo Choi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hoseok, I. Articles by Choi, Y. S. Search for Related Content PubMed PubMed Citation Articles by Hoseok, I. Articles by Choi, Y. S. Related Collections Esophagus - other

Ann Thorac Surg 2006;81:712-714
© 2006 The Society of Thoracic Surgeons

---

Case report

Pharyngo-Colostomy With Supraglottic Partial Laryngectomy in Caustic Oropharyngeal Stricture

^a Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
^b Department of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea

Accepted for publication December 17, 2004.

^_* Address correspondence to Dr Shim, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, 50 Irwon-Dong, Gangnam-gu, Seoul 135-710, South Korea (Email: youngmog.shim{at}samsung.com).

	Abstract

Top Abstract Introduction Case Reports Comment References

 
We present two cases of chronic caustic stricture from the oropharynx to the entire esophagus combined with laryngeal stricture in which the piriform sinuses were stenosed. The restoration of digestive continuity was accomplished by end-to-end pharyngo-colostomy at the level of the cricoid cartilage through the posterior mediastinal route. Supraglottic partial laryngectomy and pharyngoplasty were done simultaneously for the laryngeal and oropharyngeal stricture. The patients were able to swallow a soft blend diet to regular diet with negligible penetration.

	Introduction

Top Abstract Introduction Case Reports Comment References

 
Ingestion of a caustic agent can result in a range of injuries from a mild oral burn or sore throat to rapidly progressive life-threatening complication. After recovery from the initial injury, a wide variety of signs and symptoms are associated with caustic ingestion according to the affected lesions from the oropharynx to the stomach [1]. The concomitant development of severe hypopharyngeal stricture is infrequent, yet it is a critical complication [2, 3]. The oropharyngeal stricture combined with laryngeal stricture is another life-threatening complication. In these cases, major problems are that the upper anastomosis of the digestive graft used to bypass the stenotic area is located at the level of the laryngeal inlet, and fibrosis of the pharyngeal wall affects its capacity to propel the bolus through the anastomosis in the first voluntary stages of deglutition [4]. Thus restoration of the digestive continuity in this area interferes with the mechanisms of deglutition and respiration. In addition, recurrent contracture of oropharyngeal scar is troublesome.

We present two cases of severe chronic caustic stricture of oropharynx combined with laryngeal stricture treated with aggressive resection of scar tissues and physiological reconstruction of the upper digestive tract. They had been treated with conservative method at other centers before being referred to our institution for aggravated symptoms.

	Case Reports

Top Abstract Introduction Case Reports Comment References

 
Patient 1
A 42-year-old woman had ingested lye by accident and had undergone a tracheostomy and feeding jejunostomy for 4 months at another center. At the time of the referral she could not breathe without tracheostomy nor swallow anything. On laryngoscopic examination, the epiglottis was completely adhered to the posterior pharyngeal wall. An esophagography with barium showed only oropharynx with contracted and deformed piriform sinuses, but it did not show the esophagus at all. She underwent partial epiglottectomy with CO ₂ laser, release of posterior pharyngeal scar, and palatoplasty 139 days after caustic ingestion. One hundred and ninety-two days after the accident, reconstructive surgery was done.

Patient 2
A 42-year-old man had ingested lye by accident. The repeated bougienage and adhesiolysis with CO ₂ laser was done 8 times for a duration of 6 years and 8 months at another center. At the time of the referral he could swallow only fluids and showed aspiration, dyspnea on exertion, and inspiratory stridor. On laryngoscopic examination, the epiglottis was scar contracted and mostly adhered to the posterior pharyngeal wall, and the larynx could not be examined because of severe fibrosis and stricture of laryngeal aditus. In addition, the hypopharyngeal inlet could not be found. On esophagography with barium, contracted and deformed piriform sinuses could be seen on the left side, and the esophagus could be seen only a little. Also a large amount of barium was aspirated. He underwent tracheostomy with laryngomicroscopic evaluation 6 years and 9 months after the accident, which showed diffuse fibrosis and swelling of both false vocal cords and stricture of the hypopharynx and cervical esophagus. One week later reconstructive surgery was done.

The reconstructive surgery (Fig 1) included: (1) supraglottic partial laryngectomy (SPL), (2) transhiatal esophagectomy, (3) end-to-end pharyngo-colostomy in the midline at the level of the crico-arytenoid junction with descending and transverse colon through the posterior mediastinal route, (4) cologastrostomy at the anterior surface of the stomach, (5) colocolostomy, (6) pyloromyotomy, and (7) feeding jejunostomy. Deformed epiglottis, aryepiglottic folds, pharyngoepiglottic folds, and part of the posterior pharyngeal wall were resected, and a part of the false vocal folds were saved during SPL.

View larger version (32K): [in this window] [in a new window]   Fig 1. Schematic representation of supraglottic partial laryngectomy and end-to-end pharyngo-colostomy showing the imaginary median plane. The dotted line indicates the plane of transection for supraglottic partial laryngectomy. (A = arytenoid muscle; C = elevated colon graft; CC = cricoid cartilage; E = epiglottis; H = hyoid bone; PPW = posterior pharyngeal wall; T = thyroid cartilage; TH = thyrohyoid membrane; VC = vocal cord.)

Because of adhesion between the soft palate and oropharynx, revision palatoplasty and pharyngoplasty were done in patient 1 through the intraoral approach on postoperative day 80 after reconstruction.

Thereafter, additional surgical or conservative treatments such as adhesiolysis or bougienage have been unnecessary. On the last follow-up they could swallow a soft blend diet to regular diet well with minimal penetration and showed neither dyspnea nor hoarseness 8 months and 4 months, respectively, after reconstructive surgery.

	Comment

Top Abstract Introduction Case Reports Comment References

 
The main surgical problem raised by the combined caustic stricture from the oropharynx to the entire esophagus is that restoration of digestive continuity interferes with the process of deglutition and respiration.

When the piriform sinus remains open, a variety of reconstructions can be made according to the surgeon's experience and preference. The stomach, the right or transverse colon, right ileocolon [5], or free jejunal graft can be used. The pharynx may be entered anteriorly (by a transepiglottic or supraepiglottic approach), laterally, or posteriorly. The proximal anastomosis to the patent piriform sinus can be made with the side-to-side or end-to-side method.

However, when the stricture begins from the oropharynx, and the piriform sinus is stenosed so that the piriform sinus is not available for anastomosis, the surgical team should take several factors into consideration: (1) The contracture tendency of caustic injuries persists indefinitely, decreasing with time but never achieving complete stability. So a conservative management such as adhesiolysis or bougienage beyond the active inflammatory period can be repeated because of recurrent stricture. After the active phase, if possible, complete removal of contracted tissue should be made in order to avoid recurrent stricture. (2) Anastomosis should be made at the level of the laryngeal inlet because piriform sinuses are stenosed. Therefore a surgical approach may be anatomically difficult. (3) More physiologic anastomosis may be needed.

We conducted SPL with release of scar tissue on the posterior pharyngeal wall for complete removal of contracted tissue. An SPL allowed precise assessment of the lesions and proximal anastomosis under direct visual control, restoration of the oropharyngeal cavity by mucosal relining of the deep face of the infrahyoid muscles, and excision of the supraglottic stricture, thus preventing, or at least limiting the recurrence of the adhesion between the epiglottis and the posterior wall of the pharynx [6]. As closure progresses, the larynx gets reattached to the base of the tongue, restoring its anatomic relationship of suspension from the tongue for satisfactory physiological function during the act of swallowing [7]. During the act of swallowing, the base of the tongue overhanging the glottis moves posteriorly as the larynx is elevated, exaggerating the shelf effect to protect the glottis and thus prevent aspiration. An SPL allows satisfactory restoration of the anatomic continuity of the upper aerodigestive tract combined with restoration of the physiologic aspects of the pharyngeal phase of deglutition. The proximal anastomosis we used, with the end-to-end method in the midline after total esophagectomy may be anatomically more physiologic than the anastomosis to the piriform sinus or posterior pharyngeal wall.

Psychological profile is another important factor for successful recovery. Because the active participation of the patient is needed during the long and difficult postoperative period, precise psychological evaluation is indispensable. In our cases, they swallowed lye by accident and not for suicide, and they had no psychological abnormality.

Considering several criteria for SPL, such as the true vocal cord must be mobile, tongue mobility should be normal and pulmonary function may be reserved [7] in selected patients with chronic caustic stricture from the oropharynx to the entire esophagus in which piriform sinuses are stenosed. We can obtain satisfactory results with end-to-end pharyngo-colostomy combined with SPL.

	References

Top Abstract Introduction Case Reports Comment References

 

1. Joseph RS, Robert TS. Caustic injuries of the esophagusIn: Donald OC, Joel 3rd ER, editors. The esophagus. Philadelphia: Lippincott Williams & Wilkins; 1999. pp. 557-564.
2. Cardona JC, Daly JF. Current management of corrosive esophagitis Ann Otol Rhinol Laryngol 1971;80:521-527.[Medline]
3. Schild JA. Caustic ingestion in adult patients Laryngoscope 1985;95:1199-1201.[Medline]
4. Gupta S. Total obliteration of esophagus and hypopharynx due to corrosivesa new technique of reconstruction. J Thorac Cardiovasc Surg 1970;60:264-268.[Medline]
5. Park JK, Sim SB, Lee SH, Jeon HM, Kwack MS. Pharyngo-enteral anastomosis for esophageal reconstruction in diffuse corrosive esophageal stricture Ann Thorac Surg 2001;72:1141-1143.[Abstract/Free Full Text]
6. Tran Ba Huy P, Celerier M. Management of severe caustic stenosis of the hypopharynx and esophagus by ileocolic transposition via suprahyoid or transepiglottic approachanalysis of 18 cases. Ann Surg 1988;207(4):439-445.[Medline]
7. Jatin PS. Larynx and tracheaIn: Jatin 3rd PS, editor. Head and neck surgery and oncology. China: Mosby; 2003. pp. 267-352.

This article has been cited by other articles:

				M. Tettey, F. Edwin, E. Aniteye, M. Tamatey, K. Entsua-Mensah, E. Ofosu-Appiah, and K. Frimpong-Boateng Colopharyngoplasty for intractable caustic pharyngoesophageal strictures in an indigenous African community - adverse impact of concomitant tracheostomy on outcome Interact CardioVasc Thorac Surg, February 1, 2011; 12(2): 213 - 217. [Abstract] [Full Text] [PDF]

				J. A. Odel Another Option for Severe Caustic Oropharyngeal Stricture? Ann. Thorac. Surg., April 1, 2007; 83(4): 1579 - 1579. [Full Text] [PDF]

				H. I and Y. M. Shim Reply Ann. Thorac. Surg., April 1, 2007; 83(4): 1579 - 1579. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Young Mog Shim Kwhanmien Kim Yong Soo Choi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hoseok, I. Articles by Choi, Y. S. Search for Related Content PubMed PubMed Citation Articles by Hoseok, I. Articles by Choi, Y. S. Related Collections Esophagus - other