Sternocleidomastoid muscle myocutaneous flap for corrosive pharyngoesophageal strictures

Corrosive Ingestion

Corrosive ingestion remains a common problem in developing countries, such as India due to the lack of strict laws that regulate the sale of caustics. While appropriate treatment of the acute phase can mitigate tissue damage improper management of the acute corrosive injury is widely prevalent due to the limited experience of the individual physicians in managing this condition. The aim of this review is to summarize the epidemiology and pathophysiology of corrosive ingestion, principles in the management of acute phase injury, long-term effects of caustic ingestion, and prevention of corrosive ingestion.

HOW TO CITE THIS ARTICLE

Kalayarasan R, Ananthakrishnan N, Kate V. Corrosive Ingestion. Indian J Crit Care Med 2019;23(Suppl 4):S282-S286.

Tight near-total corrosive strictures of the proximal esophagus with concomitant involvement of the hypopharynx: Flexible endoscopic management using a novel technique

AIM

To investigate the role of a novel minimally invasive endoscopic technique in the management of tight near-total corrosive strictures of the proximal esophagus involving the hypopharynx.

METHODS

Two patients with near-total corrosive strictures of the proximal esophagus involving the hypopharynx were managed with the novel endoscopic technique. The technique involved passing a 0.025-inch flexible guide-wire across the stricture, and stricture dilatation, using 10F coaxial diathermy and balloon dilators, followed by electro-incision of the proximal aspect of the residual eccentric stricture by means of a novel approach using a wire-guided sphincterotome.

RESULTS

Both patients were successfully managed on an outpatient department basis with the complete relief of symptoms and resolution of strictures on endoscopy and an esophagogram. No adverse events were seen during or after the procedure. There was no recurrence of symptoms at a follow-up of over a year in both cases. There was a significant improvement in the body mass index of both patients after the procedure.

CONCLUSION

We report a novel flexible endoscopic technique for the management of complex hypopharyngo-esophageal strictures. In experienced hands, the procedure is relatively simple, safe and effective with a durable response.

Caustic ingestion

Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for stratification of patients to emergency resection or observation. Oesophageal stricture is a common consequence of ingestion and newer stents show some promise; however, the place of endoscopic stenting for corrosive strictures is yet to be defined. We summarise the evidence to provide a plan for managing these potentially life-threatening injuries and discuss the areas where further research is required to improve outcomes.

Step-Down Approach for Pharyngoesophageal Corrosive Stricture: Outcome and Analysis

BACKGROUND

Pharyngoesophageal stricture (PES) is an Achilles' heel in the management of corrosive injury. Advances in endoscopic techniques were utilized in its management. We classified the stricture as per its dilatability and then planned their treatment.

METHODS

PES was sub-categorized based on endoscopic dilatation and availability of cervical oesophagus: group-1 stricture with available cervical oesophagus; group-2 stricture with some part of upper oesophagus made available after endoscopic dilatation and anastomosis in cervico-pharyngeal area; group-3 stricture not amenable for dilatation, anastomosis done at the pharynx. Endoscopic dilatation was performed using through-the-scope pyloric balloon. Number and duration of dilatation sessions before surgery, incidence of tracheostomy, time and incidence for re-stricture and present status of swallowing were evaluated.

RESULTS

Of 226 patients managed, 46 underwent oesophageal replacement for PES. Group 1, 2 and 3 had 12, 14 and 20 patients, respectively. An average 3 (2-4) preoperative balloon dilatation sessions were performed over 6-8 weeks. Tracheostomy was required in 1, 0, 8 patients (p = 0.010), and median hospital stay was 10, 9 and 13 days (p = 0.09) in group 1, 2, 3, respectively. Re-stricture developed in 4/12, 4/14, 9/20 patients with average sessions of dilatation required in post-operative period was 4, 3.5 and 8 in group 1, 2, 3, respectively. >90% of patients are taking normal diet in each group.

CONCLUSION

We attempted to avoid the high anastomosis by dilating the PES and step down the level of anastomosis in two-third patients. We thereby avoided tracheostomy, aspiration and swallowing problems related to high strictures.

Use of a sternocleidomastoid myocutaneous flap based on the sternocleidomastoid branch of the superior thyroid artery to reconstruct extensive cheek defects

INTRODUCTION

Reconstruction of head and neck defects has always been challenging due to functional and cosmetic concerns. Although sternocleidomastoid (SCM) flaps have been used for many head and neck defects, use of an SCM flap to reconstruct a cheek defect based only on the superior thyroid artery has not been reported previously.

CASE REPORT

The case of a 40-year-old farmer with a large full-thickness cheek squamous cell carcinoma is reported. An SCM myocutaneous flap based on the SCM branch of the superior thyroid artery was used.

CONCLUSION

An SCM myocutaneous flap is a valuable option for head and neck reconstructions with reasonable aesthetic results. For properly selected cases, this flap obviates the need to use the pectoralis major or other more distant flaps.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recurrent cervical esophageal stenosis after colon conduit failure: Use of myocutaneous flap

A 53-year-old male developed cervical esophageal stenosis after esophageal bypass surgery using a right colon conduit. The esophageal bypass surgery was performed to treat multiple esophageal strictures resulting from corrosive ingestion three years prior to presentation. Although the patient underwent several endoscopic stricture dilatations after surgery, he continued to suffer from recurrent esophageal stenosis. We planned cervical patch esophagoplasty with a pedicled skin flap of sternocleidomastoid (SCM) muscle. Postoperative recovery was successful, and the patient could eat a solid meal without difficulty and has been well for 18 mo. SCM flap esophagoplasty is an easier and safer method of managing complicated and recurrent cervical esophageal strictures than other operations.

A case of corrosive injury-induced pharyngeal stricture treated by endoscopic adhesiolysis using an electrosurgical knife

Here, we report a case of corrosive injury-induced pharyngeal stricture in a 69-year-old female, which was successfully treated with endoscopic adhesiolysis using an electrosurgical knife. The patient had ingested sodium hydroxide in an attempted suicide, and immediate endoscopy revealed corrosive injuries of the pharynx, esophagus, and stomach. When a liquid diet was permitted, she complained of nasal regurgitation of food. Follow-up endoscopy revealed several adhesive bands and a web-like scar that did not allow passage of the endoscope into the hypopharyngeal area. For treatment of the hypopharyngeal stricture, the otolaryngologist attempted to perform an excision of the fibrous bands around the esophageal inlet using microscissors passed through an esophagoscope, but this procedure was not effective. We then dissected the mucosal adhesion and incised the adhesive bands using an electrosurgical knife. After this procedure, nasal regurgitation of food no longer occurred. To our knowledge, this case is the first report of endoscopic adhesiolysis with an electrosurgical knife in a patient with a corrosive injury-induced pharyngeal stricture.

Outcome following surgical management of corrosive strictures of the esophagus

OBJECTIVE

To analyze the short- and long-term outcomes following surgical treatment for corrosive stricture of the esophagus.

BACKGROUND

Surgery is a well-established treatment for corrosive strictures of the esophagus and involves either resection or bypass of the damaged esophagus and replacement by a conduit. The need for resection and the choice of the ideal conduit for esophageal replacement in these patients continues to be debated and there are only a few studies reporting on the long-term outcome following the surgical treatment.

METHODS

This was a retrospective analysis of patients with corrosive stricture of the esophagus who were managed surgically between 1983 and 2009. The type of surgery performed (resection or bypass), the conduit used, the short- and long-term outcomes were assessed.

RESULTS

One hundred seventy-six corrosive strictures of the esophagus were managed surgically (resection: 64, bypass: 112). A transhiatal resection could be accomplished in 59 of 62 patients in whom it was attempted. Stomach conduits were used in 107 patients and colonic conduits in 69. The mean operating time was 4.3 ± 1.5 hours and the mean estimated blood loss 592 ± 386 mL. Cervical anastomotic leak occurred in 22 patients (12.5%). Follow up of more than 10 years was available for 78 patients (44.3%) and more than 15 years for 54 patients (30.7%). Recurrent dysphagia developed in 33 patients (18.7%). There were no differences in the short- or long-term outcomes in patients who underwent resection or bypass. The mean duration of surgery, intraoperative blood loss, incidence of conduit necrosis, and in-hospital mortality was significantly lower in patients with stomach conduits as compared with colonic conduits. There was a higher incidence of recurrent laryngeal nerve palsy, recurrent dysphagia, and aspiration after surgery in patients with strictures involving the upper end of the esophagus at or near the hypopharynx.

CONCLUSIONS

Satisfactory outcomes are achieved after surgery for corrosive strictures of the esophagus. Resection of scarred esophagus may be done without a substantial increase in the morbidity and mortality; however, the outcomes are not significantly different from bypass. Stomach is a good conduit and the colon should be reserved for cases where the stomach is not available. Long-term outcomes in patients with hypopharyngeal strictures, however, continue to be poor.

The sternocleidomastoid myocutaneous "patch esophagoplasty" for cervical esophageal stricture

Esophageal strictures may be caused by many etiologies. Patients suffer from dysphagia and many are tube-feed dependent. Cervical esophageal reconstruction is challenging for the plastic surgeon, and although there are reports utilizing chest wall flaps or even free flaps, the use of a sternocleidomastoid (SCM) myocutaneous flap provides an ideal reconstruction in select patients who require noncircumferential "patch" cervical esophagoplasty. We present two cases of esophageal reconstruction in which we demonstrate our technique for harvesting and insetting the SCM flap, with particular emphasis on design of the skin paddle and elucidation of the vascular anatomy. We believe that the SCM flap is simple, reliable, convenient, and technically easy to perform. There is minimal donor site morbidity with no functional loss. The SCM myocutaneous flap is a viable option for reconstructing partial esophageal defects and obviates the need to perform staged procedures or more extensive operations such as free tissue transfer.

Therapeutic options for management of pharyngoesophageal corrosive strictures

INTRODUCTION

Pharyngoesophageal strictures due to corrosive injury raise difficult therapeutic problems due to the site of stricture, the possible association with laryngeal injury and the presence of downstream esophageal strictures. We present here our approach to management of 51 consecutive patients with pharyngoesophageal strictures seen over a 30-year period.

METHODS

Patients (51) with PES were managed by one of several options depending on the individual case, viz. dilatation alone, dilatation followed by esophagocoloplasty, dilatation after cervical esophagostomy with or without an esophagocoloplasty, pectoralis major or sternocleidomastoid myocutaneous flap inlays with or without esophagocoloplasty, pharyngocoloplasty with tracheostomy, and neck exploration followed by esophagocoloplasty if a lumen was found in the cervical esophagus.

RESULTS

The overall results were excellent with satisfactory swallowing restored in 45 out 51 patients (88.2%). There was one death and three incidences of complications, two patients with temporary cervical salivary fistula, and one patient in whom swallowing could not be restored because of lack of suitable conduit. The mean dysphagia score was improved from a pre-operative value of 3.6 to 1.5 post-operatively.

CONCLUSION

In conclusion, pharyngoesophageal strictures require considerable expertise in management, and one should be aware of various options for this purpose. The choice of procedure depends on site of stricture, time of presentation after the corrosive injury, relationship of the stricture to the laryngeal inlet, status of the larynx and the airway, length of the stricture, presence or absence of a lumen distal to the stricture in the cervical esophagus, and presence or absence of strictures further downstream. With proper treatment, mortality is negligible and morbidity minimal and is usually restricted to temporary salivary fistula.

Locations of the motor endplate band and motoneurons innervating the sternomastoid muscle in the rat

Sternocleidomastoid (SCM) is a long muscle with two bellies, sternomastoid (SM) and cleidomastoid (CM) in the lateral side of the neck. It has been widely used as muscle and myocutaneous flap for reconstruction of oral cavity and facial defects and as a candidate for reinnervation studies. Therefore, exact neuroanatomy of the SCM is critical for guiding reinnervation procedures. In this study, SM in rats were investigated to document banding pattern of motor endplates (MEPs) using whole-mount acetylcholinesterase (AChE) staining and to determine locations of the motoneurons innervating the muscle using retrograde horseradish peroxidase (HRP) tracing technique. The results showed that the MEPs in the SM and CM were organized into a single band which was located in the middle portion of the muscle. After HRP injections into the MEP band of the SM, ipsilaterally labeled motoneurons were identified in the caudal medulla oblongata (MO), C1, and C2. The SM motoneurons were found to form a single column in lower MO and dorsomedial (DM) nucleus in C1. In contrast, the labeled SM motoneurons in C2 formed either one (DM nucleus), two [DM and ventrolateral (VL) nuclei], or three [DM, VL, and ventromedial (VM)] columns. These findings are important not only for understanding the neural control of the muscle but also for evaluating the success rate of a given reinnervation procedure when the SM is chosen as a target muscle.

Strengthening the understandings on corrosive esophageal burn and prevention and management of corrosive esophageal stricture

Caustic esophageal injuries are corrosive burns of esophagus mostly caused by ingestion of chemical caustic substances such as strong acid or alkali. There is often "saddle" dysphagia following three pathologic phases after injury. In addition to early emergency treatment, it is very important to prevent corrosive esophageal stricture by medication, dilation, stenting and so on. Different surgical operations can be selected for those with cicatrix stricture of esophagus. In this paper, we comment on the causes, pathology, diagnosis of caustic esophageal injury and prevention and management of corrosive esophageal stricture.