Ann Thorac Surg 2006;81:1519-1521
© 2006 The Society of Thoracic Surgeons
How to do it
Simple and Useful Endoscopic Technique in the Re-Establishment of Esophageal Patency for the Treatment of a Completely Obstructed Esophagus
Cliff K. Choong, FRACS,
Carlo Martinez, MD,
Bryan F. Meyers, MD
*
Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
Accepted for publication February 7, 2005.
* Address correspondence to Dr Meyers, Washington University School of Medicine, Division of Cardiothoracic Surgery, Department of Surgery, St. Louis, MO 63110 (Email: meyersb{at}msnotes.wustl.edu).
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Abstract
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Complete esophageal obstruction by benign or malignant diseases is an extremely morbid condition resulting in a very poor quality of life. Nutritional support through gastrostomy feeding or total parenteral nutrition is required to sustain life for such a patient. Re-establishment of esophageal patency allows for resumption of oral intake resulting in a marked improvement in the quality of life and avoids the complications associated with nutritional support through alternate routes. We describe a simple, safe, and effective endoscopic technique in the re-establishment of esophageal luminal patency.
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Introduction
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Esophageal and major airway obstructions are both debilitating conditions. We report a case of complete esophageal and left main bronchial airway obstructions successfully treated using an endoscopic technique.
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Technique
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A 90-year-old woman was self-referred for further management of complete dysphagia. She had a 2-year history of complete esophageal obstruction and used a feeding gastrostomy tube for nutritional support. She weighed 90 pounds, and her esophageal obstruction had been considered but was not proven to be due to malignancy. A barium esophagram confirmed a completely obstructed esophagus at the level of the carina (Fig 1A). A chest computed tomographic scan revealed a 3-cm mass in the mid-esophagus that involved and narrowed the left main bronchus with resultant atelectasis of her left lung (Fig 1B). Flexible bronchoscopy revealed a 90% obstruction of the left main bronchus caused by granulation tissues and a 4 cm2 plastic pill wrapper that had apparently eroded through the membranous wall of the bronchus from the esophagus (Figs 1C, 1D). The plastic and granulation tissues were removed, leaving a patent left bronchus. Antegrade and retrograde flexible esophagoscopy performed through the mouth and the gastrostomy confirmed a completely obstructed esophagus (Fig 2A). A small lumen was created by cauterizing through the obstructed tissues using the tip of a polypectomy snare (AcuSnare, Wilson-Cook Medical, Inc, Winston-Salem, NC). The snare was housed within a 7-French sheath and was passed through the working channel of the retrograde esophagoscope. The tunneling procedure was performed under fluoroscopy by aligning the two esophagoscopes in a straight line, with the alignment confirmed on two views that were 90° apart (Fig 2B). The correct positioning of the two esophagoscopes at the site of obstruction was further confirmed by transillumination through the tissues and also by bulging of the tissues when the tip of one esophagoscope pushed against it (Fig 2A). The small lumen created by the cautery snare tip allowed placement of a guidewire through the obstruction. The tunnel was then incrementally dilated to 18 mm using Savary-Gillard dilators (Wilson-Cook Medical, Inc, Winston-Salem, NC). A 25-mm wide by 90-mm long Polyflex-stent (Rusch Inc, Duluth, GA) was placed spanning the involved esophagus and suspected bronchoesophageal fistula (Fig 2C). Biopsies from the bronchus and esophagus revealed granulation tissues with no evidence of malignancy. The procedure findings suggested that she had previously swallowed the plastic pill wrapper that had become impacted in the esophagus, which subsequently eroded through the anterior wall of the esophagus into the posterior wall of the left main bronchus with incitement of marked inflammatory responses. She made a good recovery and was able to resume oral intake. Her chest roentgenogram 1 month later showed the esophageal stent in a good position and complete resolution of her left lung atelectasis (Fig 2D).
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Fig 1. (A) Barium esophagram demonstrating a complete obstruction of the esophagus at the level of the carina. (B) Chest computed tomographic scan showing a 3-cm soft tissue mass occupying the mid-esophagus with involvement and narrowing of the left main bronchus. (C) Bronchoscopic view of a near total obstruction of the left main bronchus. (D) Photograph of a 2 x 2 cm piece of plastic pill wrapper with sharp edges removed from the left main bronchus.
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Fig 2. (A) Endoscopic photograph showing a complete obstruction of the mid-esophagus. Transillumination from the retrograde esophagoscope is seen through the obstructing tissues. (B) Radiograph showing alignment of antegrade and retrograde flexible esophagoscopes. (C) Re-established esophageal lumen with Polyflex stent placed. (D) Roentgenogram showing position of the esophageal stent (three separate dotted circles) and clear lung fields.
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Comment
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Foreign body ingestion remains a common problem, with an annual incidence of 13 episodes per 100,000, making it the third most common non-biliary endoscopic emergency, resulting in approximately 1,500 deaths each year in the United States [1]. The esophagus is the narrowest tube of the gastrointestinal tract and is the most common site of foreign body impaction within the gastrointestinal tract [2]. The leading cause of foreign bodies in the esophagus is the purposeful ingestion of foreign bodies by children or psychiatric patients [3]. Inadvertent ingestion of a foreign body is the next leading cause, which occurs more frequently in the elderly, with chicken and fish bones being the most frequent foreign bodies [2, 3]. Impaired vision, incomplete food mastication due to poor dentition or ill-fitting dentures, and diminished mucosal sensitivity of the palate due to dental plates contribute to the ingestion of a foreign body in the elderly [4]. Foreign body impaction in the esophagus most frequently occurs in the cervical esophagus at the cricopharyngeal level [3]. The thoracic esophagus at the level of the left main bronchus is the second most common site due to indentation caused by the crossing of the left main bronchus and the aortic arch [2]. Patients with foreign bodies in the esophagus usually present early and the majority can be successfully treated endoscopically [1, 3]. Esophageal perforation by a foreign body is uncommon and usually occurs with sharp objects [4, 5]. This often leads to serious complications, carrying with it a grave prognosis [4, 5]. Mediastinal abscess and aortoenteric fistula are the most common causes of death in patients with esophageal perforation caused by a foreign body [2, 4, 5].
Complete esophageal obstruction by benign or malignant diseases is an extremely morbid condition resulting in a very poor quality of life. Nutritional support through gastrostomy feeding or total parenteral nutrition is required in order to sustain life for such a patient. Re-establishment of esophageal patency allows for resumption of oral intake resulting in a marked improvement in the quality of life and avoids the complications associated with nutritional support through alternate routes. The endoscopic technique described in this case is a simple, safe, and effective technique in the re-establishment of esophageal luminal patency, and it helps to avoid invasive open surgery.
In summary, we report a case of complete esophageal and left main bronchial airway obstruction caused by esophageal foreign body perforation. Both the obstructions were successfully treated and a useful endoscopic technique to re-establish esophageal patency is described.
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References
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- Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: epidemiology and therapy. A retrospective, observational study Gastrointest Endosc 2001;53:193-198.[Medline]
- Nandi P, Ong GB. Foreign body in the esophagusreview of 2394 cases. Br J Surg 1978;65:5-9.[Medline]
- Chaikhouni A, Kratz JM, Crawford FA. Foreign bodies of the esophagus Am Surg 1985;51:173-179.[Medline]
- Maleki M, Evans WE. Foreign-body perforation of the intestinal tract Arch Surg 1970;101:475-477.[Medline]
- Ctercteko G, Mok CK. Aorto-esophageal fistula induced by a foreign bodythe first recorded survival. J Thorac Cardiovasc Surg 1980;80:233-235.[Abstract]
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Abstract
Introduction
