* Erom the Departments of Radiology and Pediatrics, University of Oklahoma M edical Center, Oklahoma City, Oklahoma.
VOL. 103, No. 2
277 DEM ONSTRATION OF THE DISTAL ESOPHAGEAL POUCH IN ESOPHAGEAL ATRESIA W ITHOUT FISTULA* By LEONARD E. SW ISCHUK, M .D. OKLAHOM A CITY, OKLAHOM A T HE selection of an appropriate surgical procedure for correction of esophageal atresia without fistula is dependent on the length ofthe proximal and distal esophageal pouches. If they are long and generous, an end-to-end esophageal anastomosis is pos- sible, whereas if they are short and far apart, a colon interposition is required. Preoperative assessment of the size of the esophageal pouches is therefore of consider- able significance and is accomplished pri_ m arily by roen tgenographic techniques. The proximal pouch is usually first identi- fied on the plain roentgenogram as an air filled blind sac; confirmation is then ob- tained with contrast studies. Visualization of the distal pouch has not received similar attention. It is the purpose of this paper to demonstrate the roentgenographic delinea- tion of this pouch. Utilizing the fact that many normal new- born infants reflux gastric content into the esophagus,25 a technique for regurgitation of barium into the distal esophageal pouch was evolved. The procedure, simple and innocuous, consists of introducing barium into the stomach after a gastrostomy has been performed. Thereafter, under fluoro- scopic control, barium is refluxed into the distal esophageal pouch with maximal fill- ing being obtained by turning the infant on his left side. At this point spot roentgeno- grams are obtained and assessed with the roentgenograms demonstrating the proxi- mal pouch. Utilizing these two studies an accurate estimation of the gap between the proximal and distal pouches is derived. Recently Altman et al. indicated success with a similar maneuver and suggested its use as a routine investigation procedure in esophageal atresia without fistula. In view of the fact that it is a simple and easily per- formed procedure, and because it provides immediate useful information to the sur- geon, the author believes that reiteration with the following 4 cases is justified. REPORT OF CASES CASE I. L. L., a 3 day old premature infant, weighing 5 lb. 2 oz., was admitted to the Childrens M emorial Hospital, Oklahoma City on June 3, 1963 with a typical history of respi- ratory distress and choking on feeding. A tube could not be passed into the stomach and roentgenography showed an air filled proximal esophageal pouch and an airless abdom en. Contrast medium studies of the upper pouch showed that it extended to the level of T3 (Fig. iA). On the following day a feeding gas- trostomy was performed and retrograde filling of the distal esophageal pouch was achieved. The small, short pouch was noted to extend to the level ofT9 (Fig. iB). Because of the extensive gap between the proximal and distal esophageal pouches, it was thought that direct anastomosis was impossible and plans were made for a colon interposition. Unfortunately, 2 days later tlue infant de- veloped a gastric perforation and peritonitis. A laparotomy was performed and the perfora- tion sealed but the infant did poorly and ex- pired the next day. At postmortem examina- tion, in addition to the esophageal atresia and gastric perforation, a complex cardiac anomaly was found in the form of an arteriovenous communis and a single ventricle. CASE II. D. L., a day old premature infant was admitted to the Childrens M emorial Hospital, Oklahoma City, on June 23, 1964, with a diagnosis of esophageal atresia without fistula. A history similar to that noted in Case i was elicited and roentgenography again re- vealed an airless abdomen and an air filled proximal pouch extending to the level of T3. This was confirmed with contrast medium D o w n l o a d e d
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278 Leonard E. Swischuk JUNE, 1968 4 1 r 0 0 d lit;. 2. Case ii. (4) The proximal pouch extends to approximately the inferior aspect of T3. (B) Ihe exceed- ingly long distal pouch extends to about the level of T3-4. A v;tgue outline of the proximal pouch is seen (arrows). The pouches, in this case, were exceptionally close together and an easy end-to-end ;tnastomosis was accomplished. lic. I. Case i. (A) There is a proximal pouch extending to the inferior aspect of T3. (B) A very small distal esophageal pouch extends to the inferior aspect of T9. The distance between the two pouches was long and colon interposition was the procedure of choice. studies (Fig. 2 /) and 3 days later a gastrostomy was performed. Approximately 3 weeks later a barium study of the distal esophageal pouch was carried out, and an extremely long distal pouch, extending to the level of 13-4 was demonstrated (Fig. 2B). Because of these findings a direct esophageal anastomosis was planned and per- formed 2 months later. The infant did well postoperatively and in subsequent follow-up. CASE III. C.M ., a c8 hour old infant was ad- mitted to tile Childrens M emorial Hospital, Oklahoma City, on October 31, 1966. The usual history of choking with feeding was elicited l!ld roentgenographv revealed a rather large air filled proximal esophageal pouch extending to the level of T (Fig. 3d). In addition, no air was seen in tile abdoinen and on tile basis of these findings it was thougilt that the patient D o w n l o a d e d
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0 * / p. 0 0 11G. 4. Case iv. (A) An air filled proximal pouch (arrows) extends to the level of I3. (B) The barium tlis- tended distal pouch extending to the superior aspect tOl) of T9 is shown. Because of the extensive gap between the two Pouches a colon interposition was planned. \OL. 103, No 2 Esophageal Atresia without Fistula 279 li;. . Case III. (1) There is an exceedingly generous and large proximal pouch distended with air (arrows). It extends down to tile level of 1 -6. Note the l)ariunl filled distal pouch at the bottom. Ibis is more clearly shown in (B), where the distal Pouch extends to the level of 18. In view of the rather generous pmoxim al pouch an end-to-end anastomosis was performed. had esOI)h ageal atresia wit ilou t fistu I a. A gas- trostomv was performed and 7 days later tile distal pouch was (lenulnstrated with barium. It eXteil(led to tile level (If IS (Fig. 38). I)espite tue llle(Iitinl length of tile distal esoph ageal pouch, a direct esopil ageal an asto- illosis W as planned in hopes (If utilizing the ex- trenlelv generous proximal pouch. ihe anasto- 1110515 was performed approximatel v I 111011 til later and tile infant did well in tile ililillediate postoperative period. One week later, however, complications developed witil a breakdown of the anastomosis and an associated right side empyenla. lile empyen a was drained, the dis- till esopilageal pouch closeti, and a cervical esophagostoni V j)erforflled. hiie pittieil t did well thereafter and t colon interposition was being planned. iv. B.M ., ;t 36 hour oltI, 3 lb. 6 oz. in- fant was adnlitted to tile Ciliidrens M emorial Hospital, Oklahoma Cits on January 6, 1967 D o w n l o a d e d
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280 JUNE, 1968 Leonard E. Swischuk with respiratory distress and choking with feed- ing. Roentgenography showed an airless ab- domen. An air filled proximal esophageal pouch extending to the level ofT3 was noted and was subsequently confirmed with contrast medium studies (Fig. 4A). A gastrostomy was then per- formed and 3 days later the distal esophageal pouch was dem onstrated by refluxing barium from the stomach into the pouch (Fig. 4B). It was noted to extend to the level of T9 and be- cause of the rather long distance between the ends of the two pouches it was decided that a colon interposition would be performed at a later date. Unfortunately, before this could be accomplished, the patient developed a severe gastroenteritis with septicemia and expired. DISCUSSION It is believed that the ability to demon- strate the distal esophageal pouch in each of the 4 presented cases was of considerable value in the preoperative assessment of each patient. In Cases i and iv the distance between the two pouches was rather long (from T3 to T9) and colon interpositions were planned for these patients. On the other hand, in Cases II and In, the pouches were rather generous and end-to-end esoph- ageal anastomoses were performed. In Case II the distal pouch almost met the proximal pouch and, of course, lent itself to easy an- astomosis. In Case in the distal pouch did not extend as high as in Case ii, but when considered along with the extremely gen- erous proximal pouch, it was thought that a direct end-to-end esophageal anastomosis was feasible. This latter case, in some re- spects, is akin to the cases recently reported of end-to-end esophageal anastomosis after surgical elongation of the proximal pouch.34 The difference, in our case, was that the proximal pouch was large enough naturally and surgical elongation was not required. CONCLUSION Refluxing of contrast material from the stomach into the esophagus for delineation of the distal esophageal pouch in esopha- geal atresia without fistula is a relatively simple maneuver to perform. The informa- tion obtained, regarding the length and size of the distal esophageal pouch, is ex- tremely useful to the surgeon, as he decides upon the most appropriate procedure for correction of the anomaly. It is suggested, therefore, that this procedure be attempted in every case of esophageal atresia without fistula before definitive surgery is under- taken. SUMMARY Demonstration of the distal esophageal pouch in esophageal atresia without fistula was accomplished in 4 cases. The simplicity of the procedure is pointed out and, in view of the helpful information it provides, it is suggested that it become a routine proced- ure in the preoperative assessment of eso- phageal atresia without fistula. The information obtained is of aid to the surgeon in deciding upon the appropri- ate surgical procedure for correction of this anomaly. Departm ent of Radiology University of Oklahoma M edical Center 8oo N. E. 13th Street Oklahoma City, Oklahoma 73104 REFERENCES 1. ALTM AN, D. H., MENCIA, L. F., Lirr, R. E., and GILBERT, M . G. Esophageal atresia: sim ple ra- diological technic to facilitate surgical m anage- m ent. Radiology, 1966, 86, 1112-1114. 2. BLANK, L., and PEW , W . L. Cardio-esophageal relaxation (chalasia): studies on norm al infant. AM . J. ROENTGENOL., RAD. THERAPY & Nu- CLEAR M ED., 1956, 76, 540-550. 3. HOWARD, R., and M YERS, N. A. Esophageal atre- sia: technique for elongating upper pouch. Surg- ery, 1965, 8, 725-727. 4. JOHNSTON, P. W . Elongation of upper segment in esophageal atresia: report of case. Surgery, 1965, 58, 741-744. . SINGLETON, E. B. X-Ray Diagnosis of the Ali- mentary Tract in Infants and Children. Year Book Publishers, Inc., Chicago, 1959, p. 42. D o w n l o a d e d