THE ANNALS OF THORACIC SURGERY Vol22 No 2 August 1976

Permanent Extracorporeal Esophagogastric Tube for Esophageal Replacement David B. Skinner, M.D., and Tom R. DeMeester, M.D.

ABSTRACT Six patients are presented in whom an extracorporeal esophagogastric tube bypass was em- ployed in lieu of standard methods of esophageal reconstruction. These tubes, obtained from Japan, have functioned well in 4 of the 6 patients. This approach offers an alternative to gastrostomy feed- ings alone in a patient with advanced esophageal disease in whom no other method of surgical recon- struction can be offered.

Occasionally, patients having advanced esoph- ageal disease are unsuitable candidates for standard techniques of esophageal recon- struction. Permanent gastrostomy and cervical esophagostomy may be necessary. In 1969, Ikeda and Fukishima of Yokohama, Japan, in- formed us of the extracorporeal esophagogastric tubes developed by Akiyama. In Japan these tubes sometimes are used in lieu of reconstruc- tion following esophagectomy for carcinoma [l, 21. Such tubes, obtained from Japan, have been used in 6 patients. We have not found a descrip- tion of this method in an English language re- port.

The available set of tubes* includes a gastros- tomy tube, two esophagostomy tubes, a plastic connector, and a clamp (Fig 1). The tubes are made of silicone-coated rubber. The gastric tube has a 60-degree angle at the neck and ends in a large, mushroom-shaped flange. The esoph- ageal tubes have a 45-degree bend at the neck. One of them has a small mushroom- shaped flange and is used during the initial stages of application. The second esophageal tube has a larger mushroom, to be used after a

From the Department of Surgery, University of Chicago Hospitals and Clinics, and the University of Chicago Pritz- ker School of Medicine, Chicago, IL. Presented at the Twelfth Annual Meeting of The Society of Thoracic Surgeons, Washington, DC, Jan 2628, 1976.

Address reprint requests to Dr. Skinner, Department of Surgery, University of Chicago Hospitals and Clinics, 950 E 59th St, Chicago, IL 60637. ‘Masuda Medical Instruments Co, Urafune-chyo, Minami- ku, Yokohama-shi, Konagwa-ken, Japan.

subcutaneous pocket is developed in the esophageal stump. Sets of tubes come in three sizes, having internal diameters of 11,12.5, or 14 mm .

Technique of Insertion The gastrostomy tube is inserted permanently in a standard fashion. We use a double pursestring suture to invaginate a cuff of gastric wall around the neck of the tube. The tube is brought through the omentum and abdominal wall in the left or right upper quadrant, depending upon the side of the neck in which the esophagostomy stoma is placed. The stomach is anchored to the peritoneum with four sutures. The neck of the tube is attached to the skin with a heavy synthe- tic suture. The tube is positioned so that the stem points straight cephalad.

The cervical esophagostomy is generally per- formed in the left side of the neck but may be done on the right. The cervical esophagus is exposed through an incision passing anterior to the sternocleidomastoid muscle and between the thyroid gland and trachea medially and the carotid sheath laterally. The esophagus is mobilized from its prevertebral location, taking care not to injure the recurrent laryngeal nerves. At least a 4 cm segment of esophagus below the cricopharyngeus should be employed. After the esophagus is divided, the distal end is sutured closed. The stump is brought through the inci- sion to the level of the skin. The stoma may be placed either in the medial aspect of the skin incision or through a separate stab wound, de- pending on where it lies easily without tension or angulation. As the incision is closed, the muscular layers of the esophagus are anchored to the cervical fascia and to the subcutaneous tissue. The full thickness of the esophagus is anastomosed to the dermis with multiple inter- rupted sutures. The esophageal stoma is allowed to heal for several weeks. It is important that the stoma be dilated as necessary so that a finger can easily be passed through it. If this is not done,

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108 The Annals of Thoracic Surgery Vol 22 No 2 August 1976

Fig I. The tubeset includes, from top to bottom, a gastrostomy tube, two esophagostomy tubes, a connector with vent , and a clamp.

the stoma contracts and makes it impossible to insert the tube.

After healing is complete, the esophageal tube with the small mushroom flange is gently in- serted. The mushroom is folded on itself to re- duce its diameter until it lies in the esophagus beneath the skin; then the tube is allowed to snap open to fill the esophageal lumen. With the patient standing completely erect or lying supine, the esophageal tube is shortened so that it attaches by the plastic connector to the gastric tube with a slight bit of redundancy. This arc in the connected tubes keeps some pressure on the esophageal tube, which helps to maintain it in position (Fig 2).

Initially the patient is instructed to swal- low liquids, and eventually he advances to a solid' diet as confidence and experience are gained. Meals are eaten sitting upright to prevent free reflux and aspiration. Between meals the gastric tube is clamped and the esophageal tube is removed to prevent irritation of the skin. Patients quickly learn the technique of inserting the esophageal tube. A pediatric stoma1 appliance works well for collecting saliva and secretions from the cervical stoma between meals and during sleep. The esophageal tube should never be left in place overnight due to the dangers of skin breakdown and ulceration.

under the stem of the tube to hold it forward. The gastric tube deteriorates with time and needs to be changed at three- to six-month intervals. This is generally done without hos- pitalization of the patient or undue difficulty. Another common problem is leakage around the esophageal tube. As the pocket for the flange in the subcutaneous tissue enlarges, it is necessary to shift to the tube with the larger mushroom flange or to a larger caliber tube. Adjusting the

Fig2. ThetubesinplaceinPatient5.

Technical Problems The gastric tube functions without leaking if the mushroom flange is held against the abdominal wall. This may require placing a gauze pad

109 Skinner and DeMeester: Extracorporeal Esophagogastric Tube

angle of exit of this tube from the stoma is impor- tant in correcting leakage around the tube. Gauze pads strategically placed beneath the tube may assist in this. It is essential that the stoma be dilated daily and the tube inserted to prevent contraction. If contraction occurs, it may be necessary to perform a Z-plasty revision of the cervical stoma. If the esophageal stump is too short, peristaltic contraction will tend to pull the esophagus away from the skin and lead to for- mation of a cicatricial band. If the stump is mark- edly short, there may be insufficient length for the flange of the tube to ride below the cricopharyngeus, and the tube will not be toler- ated by the patient.

Illustrative Cases Patient 1 A 59-year-old white man was first seen in Oc- tober, 1969, because of an esophageal stricture. Biopsies demonstrated adenocarcinoma arising in an esophagus lined with columnar epithelium. Subtotal esophagectomy with radi- cal mediastinal node dissection and partial gas- trectomy was performed. Mediastinal lymph nodes contained metastases. A cervical esophagostomy and gastrostomy were placed temporarily while the patient was prepared for a colon bypass.

One week after a substernal left colon interpo- sition, it was apparent that the bowel segment had infarcted, and it was removed. Following recovery, the patient was fitted with the ex- tracorporeal esophagogastric tubes. These were well tolerated, and the patient refused a pro- posed right colon or gastric interposition. For the remaining eighteen months of his life he ate a regular diet at home or in public with the tubes, experienced a 10.4 kg weight gain, and resumed his work as a business executive. He required one revision of the cervical stoma be- cause of stenosis early in his recovery. Death was caused by extensive metastases.

Patient 2 A 64-year-old white woman underwent radical near-total esophagectomy in January, 1971, fol- lowing preoperative radiation therapy for squamous carcinoma of the upper third of the esophagus. A 1 cm cuff of esophageal stump was

left below the cricopharyngeus. Right colon bypass was attempted but failed because of ven- ous infarction. After she recovered from this, the cervical and gastric stomas were prepared for insertion of the extracorporeal tubes.

The cervical stump was too short for the pa- tient to tolerate the tube except for short periods. As a result, the palliation achieved with the tubes was poor. The patient subsisted on gas- trostomy tube feedings during the remaining year of her life before dying of metastatic dis- ease.

Patient 3 A 70-year-old white man was referred in April, 1971, when he developed a tracheoesophageal fistula during radiation therapy for squamous carcinoma of the middle third of the esophagus. The patient refused a bypass operation. Accord- ingly, the cardia was transected and closed, and the Japanese gastrostomy tube was inserted. The cervical esophagus was divided, the distal end was closed, and a stoma was created.

The patient received nutrition through the gastric tube initially and eventually through the esophagogastric tube connection. Because of depression due to his illness, the patient went for several days at a time without using the esophageal stoma or dilating it. This led to the need for one cervical Z-plasty revision to reopen the stenosed stoma. Because of the patient’s de- pression and intolerance of the tube, this result can only be judged fair. Nevertheless, when he used the tube, he could eat a regular diet. The patient died six months later of pneumonia.

Patient 4 A 62-year-old white woman was referred in April, 1973, after an esophagectomy followed by right colon interposition for a lye stricture had failed and a subsequent gastric tube bypass op- eration was unsuccessful. When first seen she had an inflamed midsternal gastrostomy open- ing, a jejunostomy, and a pharyngostomy. Be- cause there was insufficient colon to attempt another bypass and because the stomach had been utilized in the gastric tube operation, she was advised that the extracorporeal tubes repre- sented the only approach for long-term man- agement. The stump of the gastric tube was re-

110 The Annals of Thoracic Surgery Vol 22 No 2 August 1976

sected and the gastrostomy tube was inserted. A cervical stoma was created to accept the Japanese tube, and the pharyngostomy was closed.

This patient has tolerated the tubes well and has eaten a regular diet for three years since the tubes were inserted. She has gained 16.75 kg above her admission weight. Three re- visions of the cervical stoma have been neces- sary, partly because of neck scarring from the previous pharyngostomy and earlier neck explo- rations.

Patient 5 A 64-year-old white man was referred in January, 1974, after a Collis gastroplasty and re- section of a reflux stricture with left colon inter- position had failed. He was evaluated for a pos- sible further reconstructive procedure. Because of a previous colon resection in addition to the attempted colon interposition and because the stomach had been utilized for the gastroplasty, we advised him that the extracorporeal tubes were the only approach for long-term manage- ment. These were inserted through a revision of his esophagostomy and gastrostomy openings.

The palliation achieved has been excellent. With a regular diet his weight has increased nearly 16 kg, and he has resumed normal activity during a little more than two years since he began using the tubes.

Patient 6 A 71-year-old white man was referred in November, 1974, for treatment of squamous cell

carcinoma of the middle third of the esophagus. Because of involvement of the trachea, resection was not attempted. Radiation therapy was insti- tuted, but a tracheoesophageal fistula de- veloped. The patient refused the offered colon bypass operation and agreed to have the gastros- tomy and esophagostomy tubes inserted. At laparotomy the cardia was divided completely and closed. The gastrostomy tube was inserted. The cervical esophagus was transected and a stoma was created; this was in the field of radia- tion therapy, and healing was delayed. One cer- vical Z-plasty was required.

Eventually the patient developed an excellent result with the tubes. The course of radiation therapy was completed. He has maintained his weight and taken a regular diet for more than sixteen months since his tracheoesophageal fis- tula 'developed. At present the fistula measures approximately 6 cm, and the esophagus, closed at both ends, is like a diverticulum on the trachea.

Comment Complications of therapy for carcinoma were the primary indication for the external esophagogastric tube in 4 of the 6 patients; in the other 2 the tube was used following failure of several operations for benign stricture. A sum- mary of indications, results, and follow-up is presented in the Table. Because of the an- noyance to the patient and the need for continu- ing care of the stomas, this procedure is em- ployed only when other types of permanent

Indications for and Results with the Esophagogastric Tube

Patient No. Indication

Stoma Result Revision Follow-up

1 Infarcted L colon bypass,

2 Infarcted R colon bypass,

3 T-E fistula during

4 Failed R colon interposition,

5 Failed Collis gastroplasty,

6 T-E fistula during

esophagectomy & radiotherapy

esophagectomy & radiotherapy

radio therapy

failed gastric tube bypass

failed L colon interposition

radiotherapy

Excellent 1 Cervical Dead 15 mo;

Poor None Dead 12 mo;

Fair, 1 Cervical, Dead 6 mo;

Excellent 3 Cervical Well 34 mo;

Excellent None Well 25 mo;

Excellent 1 Cervical Well 16 mo;

10.4 kg weight gain

stump too short

when used 1 gastrostomy weight stable

16.75 kg weight gain

15.85 kg weight gain

weight stable

T-E = tracheoesophageal

111 Skinner and DeMeester: Extracorporeal Esophagogastric Tube

esophageal reconstruction are unavailable or are refused by the patient. The operation itself is relatively simple and of low risk compared with other types of esophageal replacement. Never- theless, the patient must make a great invest- ment in the care of the tubes and must have sufficient optimism and enthusiasm to make them work. Provided that the cervical stump is long enough, a successful outcome depends on the patient’s commitment to achieving a good result.

Another difficulty encountered with this ap- proach is availability of the tubes. Because the

market for these devices is small, we have been unable to date to interest an American manufac- turer in developing them. They are available from Japan, and delivery generally takes four months following submission of an order.

References 1. Akiyama H, Hatano S: Esophageal cancer: pallia-

tive treatment. Jap J Thorac Surg 21:391, 1968 2. Akiyama H, Okuyama T, Kogure T, et al: Palliative

surgery of broncho-esophageal fistula caused by malignant esophageal cancer, with special refer- ence to palliation of the esophagus and cardios- tomy. Shujutsu 23:418, 1969

Notice from The Society of Thoracic Surgeons Call for Abstracts-1977 Meeting (Deadline: September 15, 1976) Abstracts for papers to be presented at the 1977 Annual Meeting of The Society of Thoracic Sur- geons are now being accepted. The meeting is to be held at the San Francisco Hilton Hotel, San Francisco, California, January 24-26, 1977.

The deadline for receipt of abstracts is Sep- tember 15, 1976. An original and eight copies should be submitted to F. G . Pearson, M.D., Chairman, Program Committee (Abstracts), The Society of Thoracic Surgeons, 111 E Wacker Dr, Chicago, IL 60601. Abstracts must summarize an original contribution not presented or submit- ted elsewhere. Abstracts received after the dead- line will not be considered. It is requested that the covering letter indicate the author who is tc receive notice of acceptance or rejection and the author who will present the paper.

The Program Committee reserves the right to select papers for either regular or forum-type presentation. The author may also designate his preference for presentation in the forum. Es- sayists are reminded that the complete manu- script must be submitted in duplicate either to the Editor of The Annals of Thoracic Surgery be- fore the meeting or to the Secretary of the Society at the meeting, immediately prior to presenta- tion.

Call for Surgical Films (Deadline: September 15, 1976) The popular surgical movie program will again

be presented at the San Francisco meeting. The Program Committee hereby solicits the submis- sion of surgical films, which may portray a sur- gical procedure or simply a technical maneuver that the surgeon thinks will be of interest to the Society. The film may not exceed 10 minutes in length. Sound movies are acceptable but not necessary, and live narration by the principal surgeon is a requirement for participation in the movie night program. The movies may be on Super-8 or 16-mm film. The deadline for sub- mission of films is September 15, 1976. Films also should be sent to F. G . Pearson, M.D., Chairman, Program Committee, at the Society office, 111 E Wacker Dr, Chicago, IL 60601.

Application for Membership (Deadline: September 1, 1976) Requests for membership application forms should be addressed to Charles R. Hatcher, M.D., Chairman, Membership Committee, The Society of Thoracic Surgeons, 111 E Wacker Dr, Chicago, IL 60601.

The completed application forms and sup- porting letters must be in the hands of the Mem- bership Committee by September 1, 1976, for the applicant to be considered for election at the San Francisco meeting next January.

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