Pharyngotomy for a swallowed denture

The introduction of inhalation anaesthesia, first by the use of ether in 1845 and then of chloroform in the following year, saw an explosion in the range and extent of major surgical procedures as patients were spared the agonies of the surgeon's knife. A good example of this was the operation of pharyngotomy - opening the cervical oesophagus through a lateral incision of the neck - to remove an impacted foreign body. One cannot imagine a surgeon being able to do this without the benefit of an anaesthetic! Edward Cock, a surgeon at Guy's Hospital, performed this operation successfully on two occasions; the second was reported in detail in the Guy's Hospital Reports 1868, Volume 28.

Pharyngostomy

A retrospective analysis of a prospective observational study of a cohort of patients who required prolonged foregut/midgut decompression/intraluminal stenting and/or enteral nutritional support was conducted. Those patients were intolerant of protracted nasogastric intubation. They also manifested hostile peritoneal cavities and therefore were not candidates for a laparoendoscopic gastrostomy or jejunostomy. Accordingly, they underwent insertion of a pharyngogastric or pharyngojejunal tube. With patients properly positioned and anesthetized and with attention to the anatomy of the superior carotid cervical triangle, those pharyngostomies and cannulations were performed safely and efficiently. The tubes remained indefinitely or were changed/removed ad libitum. Morbidity was nil and no mortality attributable to the procedure was observed. Pharyngostomy should be part of the armamentarium of all general surgeons.

A novel surgical method of managing a high output pharyngostome

Pharyngocutaneous fistulas following large oncological surgical resection of the upper aerodigestive tract are common and typically heal over a number of weeks. A pharyngostome is a surgically created non-healing opening into the pharynx, which is far less common and often difficult to manage.

Die laterale Pharyngotomie – ein seltener Zugangsweg zur Fremdkörperentfernung im oberen Ösophagusdrittel

Esophageal foreign body impaction is a serious emergency. Diagnostic workup includes an exact history and physical examination as well as several imaging modalities. The extraction of an esophageal foreign body can be done using nonflexible or flexible esophagoscopy. We report on a 43-year-old patient with typical symptoms of esophageal foreign body impaction. The x-ray overview upon admission showed the adjustment wires of one component of a metal denture in the area of the upper esophagus. Extraction by nonflexible esophagoscopy was rendered impossible because parts of the denture had speared themselves into the esophageal wall. Safe and uncomplicated removal was then performed through a lateral pharyngotomy.

Tube pharyngostomy: a simple method for prolonged intubation of the foregut following oesophagogastric surgery

Tube pharyngostomy involves the percutaneous passage of a tube through the pharynx as an alternative to nasogastric intubation. We use this method for upper gastrointestinal decompression after oesophagectomies and total gastrectomies where prolonged intubation of the foregut is anticipated. It is simple to perform and very well tolerated as compared to a nasogastric tube. The pharyngostomy tube can also be used for enteral feeding. We present here the technique in detail and our experience with 67 procedures over the last 6 years where only few minor complications were encountered. We also review the literature for previous reports of pharyngostomy.

[Surgical access routes in enteral nutrition]

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last < or = 6 weeks, nasoenteral tubes are the best option. In NE > or = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 +/- 21.9 days, and 72 double lumen nasojejunal tubes.

Cervical pharyngostomy: an alternative approach to enteral feeding

Surgical patients may be unable or unwilling to feed normally, owing to mechanical obstruction to ingestion because of nausea or anorexia or secondary to neurologic abnormality. Such patients may be in a malnourished state that compromises their chances of successful recovery. The Nasogastric tube (NGT) has been the standard method of postoperative alimentation in head and neck cancer patients. However, prolonged use of an NGT has been associated with many problems. Percutaneous endoscopic gastrotomy (PEG) tubes are generally easier to manage and more esthetically pleasing than NGTs. However, they are associated with their own set of shortcomings. Problems and complications with traditional NGT led us to evaluate feeding tubes placed through a cervical pharyngostomy. We present our experience with this technique in 15 patients in whom it was used for postoperative feeding after oropharyngeal cancer resection and reconstruction. The cervical pharyngostomy technique has proven to be a safe, reliable, cost-effective and convenient method for postoperative feeding.

Percutaneous cervical pharyngostomy: a traditional technique revisited

Enteral tube feeding is widely used in intensive care units, high dependency units and general wards. In some patients, an adequate intake is not maintained because patients cannot tolerate the tube. Insertion of an enteral feeding tube via a pharyngostomy is simple and potentially more easily tolerated. We describe our experience with three critically ill patients, using disposable vascular access equipment and a dilational technique. All three patients received markedly increased nutrition, but one patient suffered haemorrhagic complications.

The sniff-like aspiration reflex evoked by electrical stimulation of the nasopharynx

Forced inspiratory efforts resembling the sniff-like aspiration reflex (AR) were evoked by single-shocks or trains of electrical impulses to the dorsal pharyngeal and nasal mucosal surfaces in 12 anaesthetized spontaneously breathing cats. The strongest ARs determined by diaphragmatic (DIA) EMG and peak-inspiratory flows were elicited from the dorsolateral nasopharyngeal wall close to the torus tubalis. Highly responsive sites were also detected in the posterolateral nasal cavity and in the rostrolateral oropharynx. Repetitive stimulation at threshold strength evoked ARs exclusively in the late inspiration and early expiration. Suprathreshold responses abolished and replaced the tidal respiration. ARs exhibited a two-phase response in DIA EMG: a short latency (25.2 +/- 2.4 msec, M +/- SD) powerful excitation (69.7 +/- 10.7 msec) followed by an voltage-dependent inhibition (63.9 +/- 11.3 msec). Irrespective of voltage repetitive ARs were attenuated at rates above 7-9 Hz. In conclusion, electrical stimulation within the large receptive area of the nasal-pharyngeal airway evokes sniff-like efforts with biphasic inspiratory pattern and marked phase-dependent properties.

Complications of pharyngostomy

An account is given of a fatal complication following the use of a pharyngostomy feeding tube. The literature on this topic is reviewed with regard to complications. Of the 671 patients that have been reported previously there have been no fatal or serious complications and minor complications were reported in only 42 patients. We regard the technique of pharyngostomy to be safe but recommendations are made to avoid the complication reported here.

The feeding pharyngostomy: an alternative approach to enteral feeding

We present a six-year retrospective review of feeding pharyngostomies as performed in this department. The indications, technique and complications of this procedure are discussed.

Pharyngostomy with double tube and anastomosis in the posterior wall of the stomach as a method of avoiding leakage after esophagectomy

The cervical esophagogastrostomy is a surgical method that has frequent fistula-like complications and it increases the morbidity and mortality rate in surgical treatment for carcinoma of the esophagus. One-hundred and thirty-eight instances of carcinoma of the esophagus were treated surgically from 15 October 1968 to 30 April 1986. In the last 15 instances (10.8 per cent), esophageal anastomosis with the posterior wall of the stomach was done. The decompression of anastomosis and enteral nutrition are done by a Kher drain and Levine catheter, respectively, that are exteriorized by a pharyngostomy. With this method, no fistulas occurred after cervical esophagogastrostomy.

Is the laryngoplasty a successful method after total laryngectomy?

Laryngoplasty as outlined by STAFFIERI (1973) is a new surgical technique for vocal rehabilitation after total laryngectomy. After the creation of the neoglottis however many complications such as aspiration and narrowing occur. Out of 36 patients who underwent total laryngectomy and vocal rehabilitation with the technique of Staffieri 13 achieved a good result. Twenty-three patients failed to develop voice production as a result of altered swallowing function.