Cervical Esophagostomy

Overview

Many diseases are characterized by an inability to eat and a lack of appetite. Malnutrition, which is known to impair immune function and wound healing, can quickly result from these disorders. Treatment for sick people who are unable to consume enough food to meet their nutritional needs typically includes nutritional support. 

Nutritional support can save lives, or at least, it can accelerate the process of healing, getting out of the hospital, and getting back to normal activity. Nutritional supplementation may also benefit the patient's wellbeing if appetite is present but oral eating is not possible by merely lessening the unpleasant feeling of hunger. Patients can get parenteral feeding, but this requires the use of pricey, sterile admixtures containing only pure nutrients, and problems are not uncommon. 

To lower morbidity, mortality, and costs, it is currently advised in human medicine to avoid parenteral nourishment whenever the patient can be fed by the enteral route. It is even more appealing to use the enteral method in the case of big patients because of some unique features, like their big body size, complex gastrointestinal environment, and gastrointestinal tract that is adapted to frequent large meals. It is possible to deliver a small amount of widely used human feed with a significant amount of fiber for a few days using a large-bore nasogastric tube. 

A small-bore nasogastric tube can be used for extended periods without risking lesions in the upper airways. However, if used for a longer period, the tube would do so. It is challenging to provide any diet other than commercial liquid goods, which are more costly than homemade food and do not contain fiber, due to their small diameter. An esophageal stoma is a different method of delivering enteral nourishment. Through this treatment, meals can be administered for a prolonged period directly into the cervical esophagus using a large-bore tube without disturbing the upper airways. 

Esophagostomy is rarely used in patients’ cases, but it has been demonstrated experimentally that many patients can be fed via this method for up to 30 days. However, there have been reports of consequences such as severe periesophageal infection, laryngeal hemiplegia, and colic.

 

Enteral Feeding Types

Patients who are unable or unwilling to eat have a variety of feeding choices. Simple force-feeding can be distressing to both the doctor and the patient, whether done by hand or by syringe. Additionally, many patients flat-out object to being force-fed. A great alternative for those patients is tube feeding. Esophagostomy tubes, nasoesophageal tubes, pharyngostomy tubes, and percutaneous endoscopic gastrostomy (PEG) tubes are a few choices. Esophagostomy tubes are typically inserted in many facilities.

 

Esophagostomy Tubes

Patients who require medium-term nutritional support should get esophagostomy tubes. Esophagostomy tubes are typically well tolerated and are simply implanted with only light anesthesia. The risk of infection at the tube's entry site is the only significant related problem, and maintaining the tube requires attentive care of the surgical wound. Patients with mandibular, maxillary, nasal, or nasopharyngeal disease as well as those who are unable to prehend or masticate are indications. Three techniques exist for inserting an esophagostomy tube:

• Utilizing a percutaneous needle method.
• Using surgical cutdown.
• By the use of a percutaneous feeding tube applicator.

 

Cervical Esophagostomy Advantages

Esophagostomy tubes are simple to insert, highly tolerated, affordable, manageable for patients at home, and big enough to allow for the simple administration of blended canned food. Esophagostomy tubes can be withdrawn at any time after implantation (there is no need for a stoma to mature) and do not require expensive equipment or substantial training, nor do they require general anesthesia for removal. They are inserted into the mid-cervical esophagus and left there or in the stomach, avoiding the nose and pharynx in the meantime. As a result, oral feeding can be restarted while the tube is still in. Esophagostomy tubes could be used for a few weeks, many months, or even longer.

 

Cervical Esophagostomy Disadvantages

The need for general anesthesia, the fact that most esophageal diseases (such as megaesophagus, stricture, and gastroesophageal reflux) cannot be treated with esophagostomy tubes, the possibility of gastroesophageal reflux if the tube passes through the lower esophageal sphincter, and the fact that some patients find them uncomfortable (rare) are some drawbacks.

 

Cervical Esophagostomy Preparation

You will need to complete imaging examinations and other diagnostic tests to determine whether esophagostomy surgery is your best course of treatment. These tests enable the doctor to determine your tumor's size and location.

GERD-related tumors typically develop lower in the esophagus, towards the junction of the esophagus and stomach. In the esophagus, tumors induced by smoking and alcohol consumption are more common. Both kinds of cancers might be amenable to esophagostomy, however, the number of incisions required might differ depending on where the tumor is located.

Esophageal cancer is treated by doctors using a variety of techniques. Before esophagostomy, you might receive radiation or chemo to reduce the tumor size. After surgery, you might also need chemotherapy or radiation. They will carefully collaborate with you to develop the most effective treatment strategy for your disease at the esophageal surgery center.

Details on how to be ready for your surgery will be given to you by your surgical team. Your doctor will provide you with a list of medications to discontinue taking and a diet to follow to help you in getting ready.

You will start eating just liquids three days before the procedure. This entails limiting one's diet to smoothies, milkshakes, and cream soups. The diet switches to a clear liquid one the day before surgery. You must perform a gentle bowel prep the evening before surgery and refrain from eating or drinking after midnight.

 

Cervical Esophagostomy Procedure

Tube Selection

A suitable tube is an ideal length for the majority of people. Additionally, silicone tubes come in various lengths. Argyle tubes can be utilized and shortened to the right length for those with broader necks. Almost all patients (regardless of size) receive an appropriate French tube size (it is more challenging to administer blended food through smaller tubes).

 

Cervical Esophagostomy Technique

Preoperative insertion of a nasogastric catheter is beneficial. The anterior border of the sternocleidomastoid muscle is visible by a small incision two fingerbreadths above and parallel to the clavicle. Since the portion of the esophagus that needs to be opened should be retro-tracheal, it's crucial to avoid making an incision too high in the neck. The sternocleidomastoid muscle is pulled laterally by blunt dissection after the investing fascia is forcibly opened. When a finger is placed into the incision in a posteromedial orientation and touches the prominence of the 7th vertebral body, the areolar tissues have spread and the components of the carotid sheath have been pulled laterally. The trachea and thyrolaryngeal structures are anteromedial to the dissection area.

The nasogastric tube is inserted into the patient's esophagus before surgery, and the surgeon can readily feel it there. The esophagus is moved behind the upper trachea using delicate finger dissection. A 16-French Levin tube is introduced into the stomach after the esophageal wall is gripped or held with traction stitches and an adequate incision is produced. The nasogastric tube that was inserted before surgery is taken out. The Levin tube is not completely encircled by the esophageal incision. Only skin-level sutures are required, and they should be spaced apart to allow for free drainage. The tube itself serves as a wound drain, and a strong suture should be used to firmly anchor it to the surrounding skin. To prevent the tube from coming out before a well-established tract has formed, it is vital to carefully stitch or anchor the tube as it comes from the wound.

The inferior thyroid artery and recurrent laryngeal nerve are frequently visible during the blunt dissection for esophageal exposure; however, they can be easily overlooked. Bleeding is minimal throughout the process, which should take between 10 to 20 minutes to complete. In different doctors’ experience, endotracheal anesthesia or a general anesthetic given through a mask have been used when the operation is performed with another procedure involving the head or neck. The use of a local anesthetic is acceptable.

After the first week, the esophagostomy tube can be taken out and cleaned or replaced whenever necessary. The tract is then fully developed, making it simple to reintroduce the tube. However, there must be no wait as the tract soon narrows. After the initial adjustment, only a quick fixation with adhesive tape to the cervical skin is needed, and the tube can be easily hidden away under a blouse or shirt when it is not in use. After the tube is taken out, the fistula quickly closes.

 

Postoperative Tube Care

The tube needs to be kept comfortable, dry, and clean. Every stitch should be rather loose and checked regularly to make sure the skin has not been pulled through (it is much simpler to replace the stitch with the patient awake and then to replace the tube). For the first one to two weeks, the tube site should be cleansed every day with a diluted chlorhexidine solution. After the wound has healed, cleaning will only be required occasionally.

The tube needs to be flushed with 10 cc of water each time it is used to provide medication or for feeding. Warming the dish over a ten to fifteen-minute period is recommended. Although the food must be adequately mixed to ensure that there are no particles large enough to block the tube, using blended canned food is typically simple (particularly if a number 18 French tube is used). Food that contains big particles can be filtered before being fed via the tube if necessary. It is typical to use a dilute of one part water to two parts food.

 

Cervical Esophagostomy Outcomes

Nine cervical esophagostomies were performed at the Cleveland clinic hospital between 1963 and 1964. Squamous cell carcinoma of the tongue in three patients, recurrent squamous cell carcinoma of the buccal mucosa in two patients, malignant melanoma of the maxillary mucoperiosteum in two patients, squamous cell carcinoma of the mouth floor in one patient, and maxillary fibrosarcoma were the preoperative diagnoses one patient. One of the patients mentioned above, who had severely advanced metastatic carcinoma of the mouth floor, was successfully fed through a feeding cervical esophagostomy and will undoubtedly keep the opening for the remainder of his life. Another patient with tongue cancer is also feeding through a feeding cervical esophagostomy, and a patient with tongue squamous-cell carcinoma who underwent interstitial radiation treatment required a feeding cervical esophagostomy for several weeks due to their inability to handle their diet orally.

 

Cervical Esophagostomy Risks

The majority of monitoring for severely ill patients concentrates on preventing problems with nutritional support.

• Surgical complications. As uncommon placement complications, splenic laceration, gastric bleeding, pneumoperitoneum, displacement into the peritoneal cavity, and peritonitis have all been documented. It is an emergency when the patient removes the esophagostomy tube. Most of the time, a guide catheter can be used to insert a new tube through the current stoma site. After injecting an iodinated contrast agent, adequate replacement should be confirmed radiographically.
• Infection. Tube site infection is the most common consequence of esophagostomy tubes. In most cases, this can be avoided with careful cleaning. Based on culture and sensitivity testing, an appropriate antibiotic should be taken if an infection starts to spread.
• Obstruction of the tube. Tubes can occasionally become clogged with food. For easier obstruction removal, try massaging the surface of the tube while flushing and aspirating with water, injecting carbonated beverages (like cola soda), meat tenderizers, or pancreatic enzyme preparations for 15 to 20 minutes, or gently remove the obstruction using a polyurethane catheter. Tube replacement and removal are the last resort.
• Aspiration Pneumonia. If enteral feeding raises the patient's risk of vomiting or aspirating, or if the patient is laterally recumbent, sedated, or anesthetized, the opinion that enteral feeding increases the likelihood of aspiration pneumonia in the severely ill patient is most certainly justified. Nasoesophageal tubes that are not in the proper position will result in aspiration pneumonia if food is accidentally swallowed into the trachea rather than the esophagus.
• Overfeeding. In humans, enteral feeding frequently results in volume intolerance. Vomiting or just simple nausea may result.
• Refeeding syndrome. Studies on people have revealed that this syndrome may develop following enteral nutrition.

 

Conclusion

Esophagostomy is another method for feeding anorexic or dysphagic patients. Simple surgery is necessary, and low-cost diets can be used, although serious problems can happen. When a feeding tube is required for an extended period, esophagostomy is warranted. To avoid complications, the diet must be introduced gradually.