Cervical Esophagostomy

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CHAPTER 6 Cervical Esophagostomy

Richard Ricketts

Step 1: Surgical Anatomy

♦ The approach is usually through the left side.
♦ Note the relationship of the trachea, esophagus, recurrent laryngeal nerve, and the thoracic duct (Fig. 6-1).
image

Figure 6-1

Step 2: Preoperative Considerations

♦ Use the left side of the neck for future esophageal replacement because this procedure will be done through the left chest, the mediastinum, or in the substernal position.
♦ Use the right side of the neck for the Kimura esophageal lengthening procedure (Kimura and Soper, 1994).
♦ Preoperative prophylactic antibiotics should be given.

Step 3: Operative Steps

Anesthetic Induction

♦ Endotracheal intubation and relaxation are used.
♦ The anesthesiologist should pass a blunt tipped bougie down the esophagus; this will aid in identifying the esophagus.

Positioning

♦ Place the patient supine with a roll under the shoulders to extend the neck.
♦ Turn the head slightly to the contralateral (usually right) side.

Incision

♦ A 2-cm incision is made 1 cm above the clavicle, extending from near the midline to the medial border of the clavicular head of the sternocleidomastoid muscle.
♦ Divide the clavicular head of the sternocleidomastoid muscle.
♦ Use rongeurs to remove a portion of the manubrium for better exposure.

Identify the Esophagus

♦ Retract the common carotid artery, internal jugular vein, and vagus nerve laterally.
♦ Locate the esophagus by palpating the bougie within it. Do not confuse this with the endotracheal tube!
♦ Dissect the soft tissues away from the esophageal wall using blunt and sharp dissection. Limit the use of electrocautery, which could damage the vagus or recurrent laryngeal nerves.
♦ Encircle the esophagus with a vessel loop; beware of the contralateral nerves.
♦ Continue the dissection distally, staying right on the esophageal wall, until the end of the esophagus is found.
♦ Place a 3-0 silk traction suture on the end of the esophagus and dissect the esophagus proximally up to the pharynx using blunt and sharp dissection.

Create the Stoma

♦ Bring the esophagus out through the lateral end of the incision.
♦ Attach the wall of the esophagus to the platysma muscle circumferentially with 5-0 silk or Vicryl sutures. Use muscular bites only, and do not enter the esophageal lumen. Make the stoma as wide as possible.
♦ Close the remaining wound (if any) in layers; a drain is not necessary. Apply Dermabond over the skin closure unless the stoma takes up the entire wound.
♦ Mature the stoma with full-thickness bites of the esophageal wall to the skin with fine absorbable sutures (Figs. 6-2 and 6-3).
♦ Calibrate the stoma with a Hegar dilator. It should be at least a #10 Hegar dilator size.
♦ Dress with ample dry gauze, or apply a stoma appliance to collect the saliva.
image

Figure 6-2

image

Figure 6-3

Step 4: Postoperative Care

♦ Dilate (“calibrate”) the stoma twice daily with Hegar dilators because these stomas tend to contract and close.
♦ “Sham” oral feedings may commence on the second or third postoperative day (assuming that the wound, if any, has healed).

Step 5: Pearls and Pitfalls

♦ Take special care when dissecting the esophagus away from the posterior (membranous) wall of the trachea.
♦ Stay directly on the esophagus to avoid nerve damage.
♦ Dissect more length than you think you need.
♦ Make the ostomy as wide as possible; they tend to shrink.
♦ Avoid full-thickness bites of the esophagus (except for maturing the stoma), or you will get side-hole fistulas.
♦ Teach the parents how to dilate (calibrate) the stoma; they should do this once or twice per day for several months.

Bibliography

Coran AG, Behrendt DM, Weintraub WH, et al. Esophageal atresia. In: Coran AG, et al, editors. Surgery of the neonate. Boston: Little, Brown and Company; 1978:45-57.

Kimura K, Soper RT. Multistage extrathoracic esophageal elongation for long gap esophageal atresia. J Pediatr Surg. 1994;29:566-568.

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