Thoracic Inlet Located Corrosive Oesophageal Strictures

Abstract

Background

Cicatricial corrosive oesophageal strictures are usually multiple and occasionally single but the thoracic inlet segment of the oesophagus being a rapid transit section is not a common site for isolated strictures. Thoracic inlet located strictures pose two major problems. First, in cases with total obstruction of the oesophagus radiological assessment even with luminal contrast fails to delineate the lower limits and real extent of the lesions. The purported single stricture in such cases becomes merely a sentinel to perhaps a coexisting rosary of strictures more distally. Secondly, the technical difficulty associated with their surgical approach is inherent in the location. The customary anterior low cervical approach is often inadequate thereby making necessary a complementary high left posterolateral thoracotomy, partial anterior mediastinotomy or hiatal approach particularly in situations where the excision of the damaged gullet is advisable.

Materials and Methods: In a series of cases treated for cicatricial corrosive stricture those with apparently isolated strictures in the thoracic inlet formed the cohort for this study. Only oesophagoscopy and contrast barium studies were available for the definition of the lesions. Treatment varied from simple resection with end to end anastomosis in seven (7) to more extended resections with gastric or colonic conduits as replacement in four (4) who had extensive cicatricial obliteration of the lumen with tubularization and rigidity of the gullet distal to the apparently solitary stricture. In some of these cases transgastric retrograde bouginage was an option for a reasonable evaluation of the luminal state of the oesophagus distal to the proximal lesion at the thoracic inlet. The reconstructive oesophageal anastomoses were all placed in the neck; none was intrathoracic.

Results: In a series of 316 cases treated for cicatricial corrosive oesophageal strictures, 11 had isolated strictures located in the region of the thoracic inlet. Free swallowing was restored in all cases and where anastomotic leakage occurred they healed spontaneously.

Conclusion: Isolated corrosive oesophageal strictures in the region of the thoracic inlet are uncommon and not necessarily single. There are finite diagnostic and operative challenges inherent in their location.

Introduction

The thoracic inlet is an uncommon site for isolated corrosive oesophageal strictures and curiously stenosing malignant growths originating in the region are also not frequently encountered, the latter preferring the area immediately below, that is, around the aortic arch or much above in the cricopharyngeal area.

The bony outline of the thoracic inlet comprises the body of the first thoracic vertebra posteriorly, the first ribs and their cartilage and the corresponding costocondral joints laterally and, the upper border of the manubrium sterni anteriorly. From the incisor teeth the oesophagoscopic 20 to 23cm of the gullet (that is, segment 5 to 8cm of the oesophagus) is found in the thoracic inlet and is closely related to major blood vessels at the root of the neck, the trachea, the pleura and apex of the lungs.

Physiologically it is a rapid transit segment a feature which may explain its reduced propensity to damage by intraluminal fluids and liquids including those with carcinogenic properties. Thoracic inlet located benign strictures are of interest not only from the view point of their aetiology but more importantly from the technical difficulties in their surgical approach which is inherent in their location. They are commonly cicatrixial outcomes of corrosive ingestion or luminal damage from instrumentation during the management of corrosive burns and their sequelae. Presented herewith is our experience with established corrosive oesophagel fibrous strictures located at the thoracic inlet. The options of surgical treatment are discussed and so is the rationale for resecting the affected section of the gullet.

Reports

Results: All together 316 patients had various forms of surgical treatment during the 32 year period for obstructive corrosive fibrosis ranging from segmental to multiple and total involvement of the gullet. On the average the patient were referred to the Unit when total dysphagia had become established at two to eighteen months from the initial incident. In 11 cases however the lesion was located in the segment associated with the thoracic inlet.(Figs 1,2,3) They were 7 males and 4 females aged between 3 and 25 years. The surgery carried out (Table I) varied from simple resection with end to end anastomosis to oesophageal replacement with whole stomach or segment of colon for complete non distensible stricture or definitive failure of bouginage and dilatation. Satisfactory swallowing was restored in all cases.

Materials

Materials and Methods: Consecutive cases of corrosive fibrous stricture who were treated at the Cardiothoracic Unit of the University of Benin Teaching Hospital for the period 1977 to 2009 were examined for the extent and location of the main obstructing lesions. The time of corrosive ingestion, the type of treatment received and the intervening period before referral to the unit were also noted. Investigations carried out in the Unit included chest radiograph (CXR), barium swallow and oesophagoscopy with possible visualization and assessment of the characteristics of the stenosed area. The treatment modalities used included temporary gastrostomy (or jejunostomy in a few) to optimize preoperative nutritional status, bouginage and dilatation and, varying degrees of resective surgery with segments of colon or whole stomach as replacement conduits.

Those patients who were treated only for obstructive fibrotic lesions limited to the gullet in the thoracic inlet formed the cohort for this study. The surgical approach was through an adequate oblique incision defined by the anterior border of the sternomastoid muscle. In cases associated with dense perioesophageal fibrosis a left upper posterolateral thoracotomy in addition became necessary to ensure adequate mobilization of the affected area and obviate damage to the trachea and major blood vessels. Such also enabled the placement of all anastomosis above the thoracic inlet without recourse to any intrathoracic anastomosis thereby restricting their implication in complications. Treatment was mainly by conservative resection of the affected segment with end to end anastomosis for reconstruction of the gullet coupled with not more than two semi-circular myotomy incisions to decrease tension at the site of anastomosis. Where the length of gullet excised was more than 3cm and the adjoining oesophageal remnant had evidence of significant fibrosis the extent of resection was necessarily extended to accommodate the transfer of whole stomach or segment of colon as replacement conduit.

Discussion

Discussion: The epicurean statement that life equates with pleasure in eating finds its practical expression perhaps in satisfactory and unimpeded deglutition. This is borne out by the fact that those deprived of swallowing as happens through gastrostomy and jejunostomy feeding feel miserable and await eagerly for the day of restoration to normality which in some cases is achieved through surgery some times with significant morbidity and mortality! Corrosive thoracic inlet strictures pose special operative problems in connection with resective surgery. Normally their location and mobilization lend readily to a cervical approach.

However in many cases as was our experience, densely penetrating all coat oesophageal fibrosis cause obliteration of natural tissue planes with calcification in some cases thereby making necessary an additional distal approach through a high left thoracotomy or partial anterior mediastinotomy. Some authors would opt for transhiatal approach.2,3 Also, when patients have not benefitted from early measures to prevent or limit stenosis and tubularization from fibrosis, extensive resection with colonic or gastric replacements becomes advisable. It is generally agreed that resections of the gullet beyond a continous segment of 3 centimenters, may not be safely reconstructed using end to end oesophago-oesophageal anastomosis due to concomitant disruptions and inadequacy of blood supply4,5. It becomes necessary to establish the lower limit of a stricture especially in cases of complete obstruction where fluid contrasts fail to outline radiologically the extent of the lesion beyond its upper limits. Such may require transgastric retrograde bouginage or more extensive thoracotomy for which the patient should be adequately prepared. In such cases the inlet stricture acts as a guide to a more serious situation distally. At present the application of ultrasound techniques in determining the extent of oesophageal cancer is yet to find firm application in the management of benign strictures hence recourse remains in the very much limited oesophagoscopy and barium sulphate contrast studies.6,7

Of particular note is the issue of resection of the affected gullet or bypassing it and leaving it in place in order to avoid the additional morbidity and mortality associated with oesophageal resections.1,8 It is our opinion and practice to resect the diseased oesophagus as necessary if the adjoining part is healthy. However, where extensive scarring with dense fibrosis with tubularization and fixation have occurred beyond the stenosed area, the affected portion should be excised totally, a situation which often involves most of the gullet. This is necessary since it is known that the scarred areas may be associated later with the development of carcinoma in a sizeable number of patients.8,9,10. Also leaving behind, by limited resection, a portion of inert aperistaltic gullet in order to achieve simple end-to-end oesophago-oesophageal anastomosis invariably results in poor satisfaction on the part of the patient; the stenosis and stricture may have been removed but free swallowing is not restored or guaranteed.4 It is concluded that corrosive thoracic inlet located stricture is a localized and definite entity with a definite operative treatment the aim being to conserve the native oesophagus as much as possible. It is however important to identify its lower limits and so ascertain the absence of a rosary of strictures more distally in order to address the situation effectively with some sense of finality.

Figure 1:

Barium swallow showing a short stricture in the thoracic inlet. This was treated by simple resection with end-to-end anastomosis.

Figure 2:

Barium swallow showing a long stricture with rigidity and tubularization of the gullet distal to the obstruction. Treated by wide resection and oesophagogastric anastomosis.

Figure 3:

Complete obstructive stricture with gross proximal dilatation below which the oesophageal lumen was non patent and densely fibrosed.