ILMU BEDAH KHUSUS VETERINER

TEKNIK OPERASI OESOPHAGOTOMY DAN

OESOPHAGOSTOMY

DISUSUN OLEH:
Varhan Dwiyan Indra 1809511044
Ferdy Olga Saputra 1809511050
Maharani Lisna Wulandari 1809511056
Kelas B

FAKULTAS KEDOKTERAN HEWAN

UNIVERSITAS UDAYANA
DENPASAR
2021
 KATA PENGANTAR
Puji syukur kami panjatkan atas kehadiran Tuhan Yang Maha Esa karena
atas berkat dan rahmat-Nya kami dapat menyelesaikan tugas mata kuliah Ilmu
Bedah Khusus Veteriner yang berjudul “Teknik Operasi Oesophagotomy dan
Oesophagostomy” dengan sebagaimana mestinya.

Penulisan tugas yang berjudul “Teknik Operasi Oesophagotomy dan

Oesophagostomy” ini bertujuan untuk memenuhi tugas mata kuliah Ilmu Bedah
Khusus Veteriner yang diberikan. Selain itu, penulisan tugas ini juga bertujuan
untuk menambah wawasan dan pengetahuan pembacanya. Segala kritik dan saran
sangat penulis harapkan demi kebaikan dari tulisan ini, dan tak lupa penulis
ucapkan banyak terima kasih.

Denpasar, 2 Oktober 2021

Hormat kami,

Penulis

ii
 DAFTAR ISI

KATA PENGANTAR ........................................................................................... ii

DAFTAR ISI ......................................................................................................... iii
DAFTAR GAMBAR ............................................................................................ iv
BAB I PENDAHULUAN ...................................................................................... 1
1.1 Latar Belakang............................................................................................... 1
1.2 Rumusan Masalah ......................................................................................... 1
1.3 Tujuan ............................................................................................................ 1
1.4 Manfaat .......................................................................................................... 2
BAB II TINJAUAN PUSTAKA ........................................................................... 3
2.1 Terminologi ................................................................................................... 3
2.2 Indikasi .......................................................................................................... 3
2.3 Anestesi dan Premedikasi .............................................................................. 4
2.4 Preoperasi ...................................................................................................... 4
2.5 Operasi........................................................................................................... 5
2.6 Pascaoperasi .................................................................................................. 8
BAB III PENUTUP ............................................................................................... 9
3.1 Kesimpulan .................................................................................................... 9
3.2 Saran .............................................................................................................. 9
DAFTAR PUSTAKA .......................................................................................... 10

iii
 DAFTAR GAMBAR
Gambar 1. Pencukuran Rambut .............................................................................. 5
Gambar 2. Irisan Ventral Midline Cervicalis .......................................................... 5
Gambar 3. Muskulus Strenohyoideus dan Sternocleidomastoideus Kiri dan Kanan
Dipreparasi .............................................................................................................. 5
Gambar 4. Irisan pada Esophagus dibuat Secara Longitudinal ............................... 6
Gambar 5. Membuat sayatan kecil sampai mengenai ujung forceps bagian kanan 7
Gambar 6. Membuka forceps, pegang ujung distal dari saluran esophagostomy, dan
mengunci forceps .................................................................................................... 7
Gambar 7. Gunakan hemostat untuk meligasi saluran esophagus .......................... 7
Gambar 8. Ketika sudah ditempatkan dengan benar, akhir feeding selang akan
"dibengkokkan" dari caudal ke cranial. .................................................................. 7

iv
 BAB I
PENDAHULUAN
1.1 Latar Belakang
Oesophagotomy adalah tindakan operasi yang dilakukan dengan mengincisi
pada dinding esophagus untuk membuka lumen esophagus. Oesophagotomy
dapat dilakukan secara longitudinal atau transversal tergantung dari tujuan
dilakukannya esophagotomy tersebut. Incisi sebaiknya di buat pada bagian
esophagus yang sehat dengan panjang incise yang di sesuaikan dengan
kebutuhan pembedahan.untuk pengeluaran benda asing tarikan perlahan pada
esophagus dapat dilakukan.
Oesophagostomy pada dasarnya memiliki kesamaan dengan esophagotomy,
yang membedakan di antara keduanya adalah hasil akhir dari proses
pembedahan tersebut. Pada esophagostomy pembukaan pada lumen esophagus
bertujuan untuk memasukkan feedingtube atau selang untuk pemberian pakan
secara langsung ke lambung Esofagotomi disarankan ketika semua metode lain
untuk menghilangkan obstruksi telah gagal, dan karena itu dianggap sebagai
semacam upaya "pilihan terakhir" untuk menyelamatkan nyawa hewan
(Hutson, 1940).

1.2 Rumusan Masalah

1. Apa yang dimaksud dengan Oesophagectomy dan Oesophagostomy?
2. Apa saja indikasi Oesophagectomy dan Oesophagostomy?
3. Bagaimana anestesi dan premedikasi Oesophagectomy dan
Oesophagostomy?
4. Bagamana tindakan praoperasi Oesophagectomy dan Oesophagostomy?
5. Bagaimana teknik operasi Oesophagectomy dan Oesophagostomy?
6. Bagaimana tindakan pascaoperasi Oesophagectomy dan Oesophagostomy?

1.3 Tujuan
1. Untuk mengetahui apa yang dimaksud dengan Oesophagectomy dan
Oesophagostomy.
2. Untuk mengetahui indikasi Oesophagectomy dan Oesophagostomy.
3. Untuk mengetahui bagaimana anestesi dan premedikasi Oesophagectomy
dan Oesophagostomy?

1
 4. Untuk mengetahui bagamana tindakan praoperasi Oesophagectomy dan
Oesophagostomy.
5. Untuk mengetahui bagaimana teknik operasi Oesophagectomy dan
Oesophagostomy.
6. Untuk mengetahui bagaimana tindakan pascaoperasi Oesophagectomy dan
Oesophagostomy

1.4 Manfaat
Manfaat dari penulisan paper ini adalah dapat bermanfaat bagi pembaca
khususnya mahasiswa Fakultas Kedokteran Hewan dan dapat memahami
mengenai Teknik operasi Oesophagectomy dan Oesophagostomy dan
indikasi penggunaanya. Selain itu diharapkan mampu menjadi referensi untuk
penulisan selanjutnya.

2
 BAB II
TINJAUAN PUSTAKA
2.1 Terminologi
Oesophagotomy adalah tindakan operasi yang dilakukan dengan mengincisi
pada dinding esophagus untuk membuka lumen esophagus. Indikasi terjadi bila
terdapat obstruksi esophagus atau untuk mengeluarkan benda asing. Tempat
operasi dapat ditentukan dengan cara palpasi untuk menentukan letak sumbatan
esophagus oleh adanya benda asing. Oesophagotomy dapat dilakukan secara
longitudinal atau transversal tergantung dari tujuan dilakukannya
esophagotomy tersebut. Incisi sebaiknya di buat pada bagian esophagus yang
sehat dengan panjang incise yang di sesuaikan dengan kebutuhan
pembedahan.untuk pengeluaran benda asing tarikan perlahan pada esophagus
dapat dilakukan.

Oesophagostomy pada dasarnya memiliki kesamaan dengan esophagotomy,

yang membedakan di antara keduanya adalah hasil akhir dari proses
pembedahan tersebut. Pada esophagostomy pembukaan pada lumen esophagus
bertujuan untuk memasukkan feeding tube atau selang untuk pemberian pakan
secara langsung ke lambung. Kelebihan penggunaan feeding tube
dibandingkan dengan penggunaan infuse adalah komplikasi pasca pemasangan
infus seperti infeksi akibat cateter yang tidak steril maupun karena
ketidakseimbangan elektrolit pada tubuh hewan tersebut. Pemasangan feeding
tube pada esophagus lebih dipilih karena kemudahan dalam proses pemasangan
dan juga sedikitnya komplikasi yang akan terjadi, dan juga karena proses
pemberian pakan dapat dilakukan oleh pemilik.

2.2 Indikasi
Indikasi terjadi bila terdapat obstruksi esophagus atau untuk mengeluarkan
benda asing, selain itu untuk membantu hewan yang mengalami anoreksia,
atresia esophagus, achalasia atau cedera kaustik hewan yang mengalami
trauma pada faring (cedera faring) dan dapat di lakukan pada hewan yang
mengalami mucositis.

3
2.3 Anestesi dan Premedikasi
Premedikasi merupakan suatu tindakan pemberian obat sebelum
pemberian anestesi yang dapat menginduksi jalannya anestesi. Premedikasi
dilakukan beberapa saat sebelum anestesi di lakukan. Tujuan premedikasi
adalah untuk mengurangi kecemasan, memperlancar induksi, mengurangi
keadaan gawat anestesi, mengurangi timbulnya hipersalivasi, bradikardia dan
muntah selama anestesi. Pada operasi Oesophagectomy dan Oesophagostomy
premedikasi dapat dilakukan dengan acepromazine 0,02 mg/kg BB dan
bruphenorphine 0,02 mg/kg BB melalui intramuscular (IM). Setelah dilakukan
premedikasi selang beberapa menit baru dilakukan anesthesia. Anestesi yaitu
hilangnya rasa sakit. Anestesi yang digunakan adalah anestesi umum.
Pemilihan obat anestesi umum harus didasarkan atas beberapa pertimbangan,
yaitu jenis operasi, lamanya operasi, temperamen hewan, fisiologis hewan dan
spesies hewan. Pada pelaksanaan pembedahan obat anesthesia umum yang
lebih sering dipakai dalam bentuk kombinasi dari pada tunggal, karena
pemberian secara tunggal relatif tidak diperoleh hasil yang memuaskan. Untuk
pemberikan anestesi harus dengan dosis yang disesuaikan dengan umur dan
berat badan hewan.

2.4 Preoperasi
• Pasien: Pasien dipuasakan selama 12 jam sebelum operasi dengan tujuan
untuk menghindari muntah akibat dari pemberian anestesi dan juga untuk
mengosongkan esophagus agar tidak terkontaminasi saat dilakukan
pembedahan.

• Alat: Peralatan yang digunakan dalam pembedahan ini adalah scalpel

holder, needle holder, towel clamp, blade, jarum, needle, drepe, tampon,
benang operasi (silk untuk kulit dan chromic untuk organ dalam).

• Bahan: bahan-bahan yang digunakan antara lain premedikasi, yaitu

atropine. Bahan anesthetikum, yaitu xylazine dan ketamine, dalam
pembedahan ini, hewan dapat juga digunakan alcohol 70%, iodium tincture
3%, NaCL fisiologis, obat premedikasi (Atropin sulfat), obat anestesi (ketamin
dan xylazine), benang catgut cromic dan nilon.

4
2.5 Operasi
• Teknik operasi Oesophagotomy
⎯ Sebelum dilakukan operasi hewan harus di persiapkan terlebih dahulu,
rambut dicukur dan kulit dipersiapkan secara aseptis.

Gambar 1. Pencukuran Rambut

⎯ Setelah teranestesi hewan dibaringkan pada posisi dorsal recumbency

(hewan kecil) dan dibaringkan ke sebelah kanan (hewan besar).
⎯ Pada hewan kecil dilakukan irisan pada bagian tengah ventral leher
(ventral midline cervicalis) dari larynx ke sternum

Gambar 2. Irisan Ventral Midline Cervicalis

⎯ Muskulus strenohyoideus dan sternocleidomastoideus kiri dan kanan

dipreparasi secara tumpul sehingga terlihat trachea.

Gambar 3. Muskulus Strenohyoideus dan Sternocleidomastoideus

Kiri dan Kanan Dipreparasi

5
 ⎯ Esophagus terletak disebelah kiri daripada trachea dan dengan preparasi
tumpul terlihat lebih jelas. Irisan pada esophagus dibuat secara
longitudinal dan benda asing (corpora aliena) dikeluarkan.

Gambar 4. Irisan pada Esophagus dibuat Secara Longitudinal

⎯ Esophagus dijahit dengan 4-0 chromic catgut secara simple interrupted.

Muskulus tidak perlu dijahit, kulit dijahit dengan benang non
absorbable secara simple interrupted.
• Teknik Operasi Oesophagostomy
⎯ Hewan yang telah teranestesi dibaringkan secara lateral recumbency
dan semua rambut yang mungkin mengkontaminasi pada daerah leher
yang akan di insisi atau dapat mengganggu daerah insisi dicukur.
⎯ Untuk menentukan bagian yang di insisi dapat dimasukkan forceps
kedalam rongga mulut menuju esophagus.
⎯ Setelah berada di esophagus forceps di angkat ujungnya untuk
membuat benjolan pada esophagus yang menandakan bagian yang akan
di insisi.
⎯ Insisi dilakukan untuk membuka kulit dan kemudian esophagus yang
besar sayatannya bergantung pada besaran tube yang akan dipasang.
⎯ Tube dimasukkan dengan bantuan forceps tadi kemudian di balikkan
menuju lambung.
⎯ Setelah itu tube dapat di fiksasi dengan menggunakan bantuan perban
ataupun plester agar tidak bergerak ataupun berpindah.

6
Gambar 5. Membuat sayatan kecil sampai mengenai ujung forceps bagian
kanan

Gambar 6. Membuka forceps, pegang ujung distal dari saluran

esophagostomy, dan mengunci forceps

Gambar 7. Gunakan hemostat untuk meligasi saluran esophagus

Gambar 8. Ketika sudah ditempatkan dengan benar, akhir feeding

selang akan "dibengkokkan" dari caudal ke cranial.

7
2.6 Pascaoperasi
Setelah operasi hewan dipuasakan selama 4-6 hari, makanan diberikan
secara parenteral (infuse), dan diberi pengobatan. Pada kasus Oesophagostomy
pantau peletakan feeding tube dan perawatan luka pasca operasi. Untuk
mencegah infeksi dapat diberikan antibiotik secara intramuskuler maupun
multivitamin untuk menjaga kondisi tubuh.

8
 BAB III
PENUTUP
3.1 Kesimpulan
Oesophagotomy adalah tindakan operasi yang dilakukan dengan
mengincisi pada dinding esophagus untuk membuka lumen esophagus.
Indikasi terjadi bila terdapat obstruksi esophagus atau untuk mengeluarkan
benda asing. Tempat operasi dapat ditentukan dengan cara palpasi untuk
menentukan letak sumbatan esophagus oleh adanya benda asing.
Oesophagotomy dapat dilakukan secara longitudinal atau transversal
tergantung dari tujuan dilakukannya esophagotomy tersebut. Anestesi yang
digunakan adalah anestesi umum. Untuk mencegah infeksi pascaoperasi dapat
diberikan antibiotik secara intramuskuler maupun multivitamin untuk menjaga
kondisi tubuh.

3.2 Saran
Koreksilah paper ini, jika terdapat kesalahan kata dan kalimat yang
disengaja maupun tidak sengaja serta kesalahan kami dalam pemahaman
materi. Jika ada yang tidak dimengerti dari paper ini, penulis menyarankan
untuk membaca teksbook dan jurnal mengenai Oesophagotomy dan
Oesophagostomy.

9
 DAFTAR PUSTAKA
Cavalcanti, et all, 2005. Cervical esophagostomy using indwelling catheter for
analysis of gastric physiology in dogs. Acta Cirúrgica Brasileira - Vol 20
(5) 2005 – 405
Deroy, C., Corcuff, J. B., Billen, F., & Hamaide, A. (2015). Removal of
oesophageal foreign bodies: comparison between oesophagoscopy and
oesophagotomy in 39 dogs. Journal of Small Animal Practice, 56(10), 613-
617.
Dos Santos, Carlos Eduardo Meirelles, Sheila Canevese Rahal, Débora Cristina
Damasceno, and Rogério Saad Hossne. 2009. Esophagectomy and
substitution of the thoracic esophagus in dogs. Acta Cirúrgica Brasileira
- Vol. 24 (5) 2009
Hutson, L. R. (1940). Oesophagotomy in a Cow. Canadian journal of comparative
medicine and veterinary science, 4(10), 299.
Lee, H., et all. 2008. Reconstruction of the oesophagus using pedicle diaphragm
and omentum flaps in a dog: a case report. College of Veterinary Medicine,
Chonbuk National University. Jeonju. Republic of Korea. Veterina
Medicina 53 vol 4. Page 224-228.
SHYU, Ching-Lin, et all. 2009. Case Report: Isolation of Aeromonas hydrophilia
from a Dog with Esophageal Foreign Body Obstruction. Taiwan Vet J 35
(4): 248-252.
Sudisma, I.G.N., Putra Pemayun, I.G.A.G, Jaya Warditha, A.A.G., dan Gorda,
I.W. 2006. Ilmu Bedah Veteriner dan Teknik Operasi. Denpasar:
Pelawa Sari Denpasar.
Von Werthern, C. J., & Wess, G. (2001). A new technique for insertion of
esophagostomy tubes in cats. Journal of the American Animal Hospital
Association, 37(2), 140-144.

10
ttp://www.bsava.com PAPER

Removal of oesophageal foreign bodies:

comparison between oesophagoscopy
and oesophagotomy in 39 dogs
C. Deroy*,†, J. Benoit Corcuff‡, F. Billen* and A. Hamaide*

*Department of Clinical Sciences (Companion Animals), College of Veterinary Medicine, University of Liège, 4000 Liège, Belgium
†Veterinary Hospital Frégis, Small Animal Surgery, 94110 Arcueil, France
‡Université de Bordeaux, 33000 Bordeaux, France

OBJECTIVES: To compare complication rates and outcomes after removal of oesophageal foreign bodies
by endoscopy or by oesophagotomy.
METHODS: Retrospective evaluation of medical records of dogs with oesophageal foreign bodies treated
by endoscopy and/or oesophagotomy. Postoperative clinical signs, management, length of hospitali-
sation, type and rate of complications, and time interval to return to eating conventional diet were
compared.
RESULTS: Thirty-nine dogs diagnosed with oesophageal foreign bodies between 1999 and 2011 were
included in the study. Most common breeds included West Highland white terrier, Jack Russell terrier
and shih-tzu. Successful endoscopic removal was possible in 24 out of 32 cases (Group 1), while sur-
gical removal was successful in 15 out of 15 cases (7 of which had unsuccessful attempts at endo-
scopic removal) (Group 2). Length of hospitalisation, time to removal of gastrostomy tube and time to
eat conventional diet did not differ between the groups. After foreign body removal, the incidence of
oesophagitis, oesophageal stricture and perforation observed during repeated endoscopy were similar
between the groups.
CLINICAL SIGNIFICANCE: In this retrospective study, removal of oesophageal foreign bodies either by
oesophagoscopy or oesophagotomy had a similar outcome.

Journal of Small Animal Practice (2015) 56, 613–617

DOI: 10.1111/jsap.12386
Accepted: 10 June 2015; Published online: 19 August 2015

INTRODUCTION and oesophagotomy. Improvements in fibreoptic endoscopes

Obstruction of the oesophagus by a foreign body should be con-
sidered an emergency because the longer an object remains in
the oesophagus, the higher the risk of aspiration and oesophageal
wall injury through pressure necrosis (Zimmer 1984, Houlton
et al. 1985, Spielman et al. 1992, Leib & Sartor 2008).
Several techniques have been described to remove oesopha-
geal foreign bodies (OFB), such as endoscopy, fluoroscopy
C. Deroy’s current address is CHV Frégis, Unité de Chirurgie, 94110 Arcueil,
France
make endoscopic retrieval the treatment of choice when dealing
with retained OFB. Fluoroscopy is a valuable method (Moore
2001) but appropriate radiological protection precautions must
be taken, the equipment is expensive and not readily available.
Surgical removal is indicated when endoscopic removal fails
(Parker et al. 1989, Kyles et al. 2003), or when forcing forceps
extraction represents a high risk of causing or enlarging an
oesophageal perforation (Kyles et al. 2003, Leib & Sartor 2008).
Surgical exploration is also preferred when there is severe oesoph-
agitis (Rousseau et al. 2007) or when retrieving penetrating OFB
located at the base of the heart because of the risk of lacerating
the aorta or pulmonary vessels.

Journal of Small Animal Practice • Vol 56 • October 2015 • © 2015 British Small Animal Veterinary Association 613
 C. Deroy et al.

Removal of OFB by endoscopy has been described in dogs Early complications were recorded at short-term follow-up in
(Houlton et al. 1985, Spielman et al. 1992, Gualtieri 2001, Moore both groups (within 3 weeks of foreign body removal). Oesopha-
2001, Rousseau et al. 2007, Leib & Sartor 2008). Postoperative goscopy was repeated in all dogs that presented with vomiting/
management and outcome of dogs undergoing transthoracic regurgitation, dysphagia and/or hypersalivation after the proce-
oesophagotomy for OFB removal have been reported (Sale & dure and oesophageal wall damage was assessed.
Williams 2006). Reported complications after endoscopic or Late complications were recorded via an owner questionnaire
surgical removal of OFB include oesophagitis, oesophageal conducted by a single investigator. Queries were related to the
stricture or aspiration pneumonia (Moore 2001, Genné et al. presence and duration of postoperative clinical signs, time inter-
2006, Rousseau et al. 2007, Leib & Sartor 2008). Less common val to spontaneous feeding, and time interval to eat a conven-
complications include perforation, which can lead to pneumo- tional diet without difficulty.
thorax, pneumomediastinum or pyothorax. Haemothorax and
broncho-oesophageal fistula have also been reported (Cohn et al.
RESULTS
2003, Jergens 2005, Keir et al. 2010). To the authors’ knowledge,
comparison of clinical outcomes after endoscopic and surgical A total of 40 dogs were initially evaluated in the study. One dog
removal of OFB in dogs has not yet been published. was excluded because the owner declined surgery after unsuccess-
Therefore, the objectives of this study were (1) to report clini- ful endoscopy secondary to severe oesophageal lesions. Therefore,
cal signs, pre- and postoperative management, plus follow-up, a total of 39 dogs were included in the study. The groups are
after foreign body removal via endoscopy or oesophagotomy, detailed in Table 1. Group 1 included dogs with removal of OFB
(2) to compare the complication rates and outcomes between by endoscopy (n=24) and Group 2 included dogs with removal
procedures. of OFB by oesophagotomy (n=15). The mean age was 5·7 ±0·8
years (range: 2 months to 18 years). Terriers represented 64%
(n=25) of the study population and 95% (n=37) of affected dogs
MATERIALS AND METHODS
were considered to be of a small breed.
A history of foreign body swallowing was provided in 28 cases
Medical records of dogs diagnosed with OFB between 1999 and (71%). In 18 cases (49%), dogs were presented within the first
2011 and with radiographic records were included in the study 48 hours after ingestion of the FB or after the first clinical signs;
(n=39). An owner questionnaire was used to record signalment, the duration of clinical signs ranged from 2 days to 1 week in
history, clinical signs, duration of clinical signs before presenta- 15 cases (41%), and was more than 1 week in 5 cases (14%).
tion, test results, treatments and procedures, length of hospitali- Duration of clinical signs was not reported for two dogs.
sation, time interval to return to eating conventional diet, time to
removal of gastrostomy tube, early postoperative complications,
as well as late complications. Table 1. Comparison of Group 1 (endoscopic removal),
Group 2 (surgical removal) and euthanised dog with
Initial thoracic radiographs and oesophagoscopy findings were
regard to age, breed, duration of clinical signs, location
reviewed by a board-certified specialist for location and type of and type of OFB, as well as hospitalisation time. Age, time
OFB and to assess secondary changes or damage induced by the to presentation and hospitalisation time are expressed as
OFB. Oesophageal wall damage was characterised at endoscopy mean ±SEM
using the Savary-Miller classification: grade I - oesophagitis with Variable Group 1 (n=24) Group 2 (n=15)
single erosion and congestion; grade II and III – oesophagitis Age (years) 5·4 (±0·8) 6·1 (±1)
with confluent or circular erosion; grade IV – oesophagitis with Breed
ulceration, necrosis, stenosis or perforation (Ollyo et al. 1992). West Highland white terrier 4 3
Jack Russell 7 0
Dogs with OFB were allocated to two groups: dogs with suc-
shih-tzu 3 1
cessful endoscopic retrieval (Group 1) and dogs treated surgically Bulldog 1 1
(Group 2). Group 2 included dogs treated surgically, either by Bull terrier 1 2
first choice or after unsuccessful attempts at endoscopic removal. Cairn terrier 1 2
Bichon 1 1
For surgical removal of thoracic OFB, the procedure con-
Others 6 5
sisted of a standard left intercostal thoracotomy (fourth to ninth Duration of clinical signs before 4·9 (±1) 4·1 (±0·9)
intercostal space depending on the location of the OFB). After presentation (days)
isolation of the oesophagus with laparotomy sponges, a longi- Location of FB
Cervical oesophagus 1 1
tudinal incision was made into the oesophageal lumen and the Thoracic inlet 6 3
foreign body was grasped by gentle manipulation. After inspec- Heart base 4 4
tion of the integrity of the oesophageal wall, the oesophagotomy Distal oesophagus 13 7
incision was closed using a single layer continuous appositional Type of FB
Bone 17 12
suture pattern with monofilament absorbable suture material Sharp object 1 1
(polydioxanone 1·5 metric; PDS, Ethicon). The thoracic cavity Soft 6 1
was lavaged with warm sterile saline, a thoracostomy tube was Stick 0 1
placed and the thoracotomy incision was closed routinely. Hospitalisation time (days) 3·3 (±0·6) 5·0 (±1)

614 Journal of Small Animal Practice • Vol 56 • October 2015 • © 2015 British Small Animal Veterinary Association
 Oesophagoscopy and oesophagotomy comparison

The most common clinical signs were vomiting or regurgita- Table 2. Comparison of time to removal of gastrostomy
tion (36), decreased appetite (14), lethargy (10), hypersalivation tube between Group 1 (successful endoscopic removal)
(8), anorexia (7), dysphagia (7) and respiratory distress (3) and Group 2 (successful surgical removal)
(n=39). During physical examination, one dog with emphysema Time to removal of No tube <10 days >10 days
in the left shoulder region was in septic shock. Bones and, most gastrostomy tube
commonly, lamb chops were encountered in 29 cases (76%). Group 1 (n=24) 11 (46%) 3 (13%) 10 (41%)
For one case, there was no information about the type of foreign Group 2 (n=15) 8 (53%) 0 (0%) 7 (47%)

body (Table 1).

Foreign body opacity on plain radiographs or oesophagogram
using barium allowed the detection of 35 (90%) and 5 (13%) Table 3. Comparison of short-term clinical signs (type
and duration) between Group 1 (successful endoscopic
OFB, respectively. Of those five dogs undergoing oesophago- removal) and Group 2 (successful surgical removal)
gram, two had shown only oesophageal dilatation on plain radio-
Clinical signs Group <1 week >1 week >1 month
graphs and three had no abnormalities on plain radiographs but
Group 1 (n=16) 3 3 1
clinical suspicion for OFB. In 10 cases (26%), secondary changes Dysphagia
Group 2 (n=11) 2 1
such as thoracic effusion (3), severe oesophageal dilation adja- Group 1 (n=16) 3 2
Weakness
cent to the OFB (3), pneumomediastinum (2), subcutaneous Group 2 (n=11) 3 1
emphysema (2), alveolar lung pattern in the ventral parts of the Vomiting/ Group 1 (n=16) 4 4 1
regurgitation Group 2 (n=11) 3 1
middle and caudal lobes consistent with aspiration pneumonia
Group 1 (n=16) 2
or pulmonary oedema (2), or pneumothorax (1) were visible on Pain
Group 2 (n=11) 5
plain radiography. The foreign body was located in the cervical
oesophagus, at the thoracic inlet, at the heart base or in the distal
oesophagus in 2, 9, 8 and 20 cases, respectively (Table 1). Table 4. Comparison of early complication rate at
Oesophagoscopy was performed in 31 out of the 39 cases. The repeated endoscopy between Group 1 (successful
OFB was successfully removed endoscopically from the oesopha- endoscopic removal) and Group 2 (successful surgical
gus in 24 of these cases (Group 1). Grade I, Grade II–III, Grade removal)
IV oesophagitis and laryngeal oedema were present in 9/21, Variables Group 1 (n=16) Group 2 (n=11)
6/21, 6/21 and 1/21 cases, respectively. For three cases, no spe- Complications
cific information was reported in the medical records. Oesophagitis 8 (50%) 4 (36%)
Stricture 2 (13%) 2 (18%)
Endoscopic removal was unsuccessful in seven cases (23%)
Perforation 1 (6%) 1 (9%)
because the OFB was too adherent to the oesophageal wall
(n=4), too porous and crumbly (n=1), or because the severity of
oesophageal wall damage (deep laceration, severe necrosis and/ after endoscopic removal and 5 dogs after surgical removal) and
or high suspicion of perforation) precluded the completion of revealed the presence of oesophageal lesions (oesophagitis, OS
the retrieval (n=3). All of these cases underwent surgical removal. and OP) (Table 4). Mean interval for repeated endoscopy was 2
Endoscopic removal was not attempted in 8 cases (21%) weeks (range: 4 days to 3 weeks). Dogs with oesophagitis received
because of (1) prior evidence of perforation identified by radiog- medical treatment consisting of oral administration during 2 to
raphy (pneumomediastinitis, subcutaneous emphysema, thoracic 4 weeks of histamine-receptor antagonists, 2 mg/kg ranitidine
effusion) or/and by oesophagoscopy (n=3), (2) position of the (Zantac®; GlaxoSmithKline) twice a day; proton pump inhibi-
foreign body at the base of the heart with excessive risk of lac- tors, 1 mg/kg omeprazole (Losec®; Bayer) once a day and sucral-
erating large vessels (n=4) (King 2001, Cohn et al. 2003, Keir fate three times a day (Ulcogant®; Merck). Two of the four dogs
et al. 2010), and (3) an embedded fishhook (n=1). Furthermore, with oesophageal stricture underwent conservative management
five of these cases presented with severe oesophagitis with fibrosis (same treatment as oesophagitis) while two underwent dilatation
identified by oesophagoscopy. procedures every 5 or 7 days (up to a total of 4 and 5 dilata-
Surgical removal was performed in 15 cases (38%) (Group tions, respectively). Dilatation was followed almost immediately
2) after unsuccessful attempts at endoscopic removal (n=7) or by clinical improvement. Post-dilatation treatment included oral
directly without any attempt to remove the OFB endoscopically prednisolone, treatment of oesophagitis and placement of a gas-
(n=8). trostomy tube.
Gastrostomy tubes were placed in 54% (n=13) of dogs from Two dogs had oesophageal perforation, and were managed for
Group 1 and in 60% (n=9) of dogs from Group 2 (Table 2). oesophagitis with broad spectrum antibiotherapy, 12·5 mg/kg
Follow-up was available for 27 dogs: 16 dogs in Group 1 and amoxicillin-clavulanic acid (Augmentin; GlaxoSmithKline) three
11 dogs in Group 2 (3 dogs with endoscopic removal attempt times a day. This treatment was successful in one dog (Group 2),
before surgery and 8 dogs with surgical removal alone). At short- while the other dog (Group 1) developed a pyothorax and died,
term follow-up (within 3 weeks of foreign body removal), 19 out despite placement of a thoracostomy tube.
of these 27 dogs (70%) showed persistent clinical signs (Table 3). Long-term follow-up time was available for 27 dogs (mean:
Endoscopy was repeated on all dogs that presented with vomit- 46 months – range: 6 months to 10 years). Four dogs (2/16 from
ing or regurgitation, dysphagia and/or hypersalivation (11 dogs Group 1 and 2/11 from Group 2) still had problems eating 1–9

Journal of Small Animal Practice • Vol 56 • October 2015 • © 2015 British Small Animal Veterinary Association 615
 C. Deroy et al.
years after OFB removal. These complications included dys-
phagia, vomiting and/or regurgitation when being fed with dry
food (these dogs were managed by feeding wet food). No further
investigation was performed on these cases.
DISCUSSION
The signalment of the affected dogs was similar to that in previ-
ous studies (Spielman et al. 1992, Sale & Williams 2006). In
dogs, bones or bone fragments are the most commonly reported
OFB (Moore 2001, Rousseau et al. 2007), as reported in the
present study. In this study, all dogs presented with clinical signs,
in contrast with Gianella et al.’s study (2009), in which some
dogs did not present with any clinical signs.
The overall success rate of 77% for endoscopic removal of OFB
in the present study is comparable to the study by Juvet et al.
(2010), which described successful endoscopic removal of OFB
in 68% of cases. This overall success rate is, however, lower than
others previously described (Rousseau et al. 2007, Gianella et al.
2009). Indeed, success rates for removing FBs either endoscopically
(drawing them through the mouth) or by dislodgement (pushing
them aborally into the stomach) have been reported to be as high
as 95% and 86%, respectively (Rousseau et al. 2007, Gianella et al.
2009). Our lower success rate for endoscopic removal may be
explained by a possible higher proportion of OFB deeply embed-
ded in the oesophageal wall in comparison with previous reports,
which could be the result of the nature of the OFB. Other poten-
tial explanations could be a higher proportion of foreign bodies
located at the heart base leading to a higher risk of vessel laceration
(King 2001, Cohn et al. 2003, Kyles 2003, Keir et al. 2010) or a
less perseverant approach during oesophagoscopic removal and a
more rapid decision to convert to a surgical technique.
Compared to previously reported mortality rates of more
than 10% (Rousseau et al. 2007, Leib & Sartor 2008), the mor-
tality rate in the present study was low (2·5%). This could be
due to the low proportion of perforations at presentation and
the low rate of complications associated with efforts at OFB
removal. Indeed, it must be emphasised that when OFB were
firmly embedded in the oesophageal wall, surgical removal was
rapidly selected before causing potentially serious deleterious
damage by oesophagoscopic removal. In the present study, 38%
of dogs underwent oesophagotomy, which is higher than the 15
to 25% previously reported in other studies (Moore 2001, Leib
& Sartor 2008, Juvet et al. 2010). Dogs managed by transtho-
racic oesophagotomy in earlier reports had a survival rate of 70%
(Ryan et al. 1975, Houlton et al. 1985, Spielman et al. 1992)
although Sale & Williams (2006) reported a survival rate after
transthoracic oesophagotomy of 93%. In the present study,
transthoracic surgery was successful in all cases and the complica-
tion rates were similar between endoscopic and surgical removal.
We therefore suggest that when straightforward endoscopic
removal is not possible, prompt surgical removal is advisable to
avoid prolonged anaesthetic time and potential iatrogenic dam-
age to the oesophagus (Duncan & Cohen 1987). Nevertheless, it
must be emphasised that non-surgical methods of removal prior
616 Journal of Small Animal Practice
to any surgical intervention should remain the initial treatment.
Surgical removal of OFB was associated with more pain than
endoscopic removal and, indeed, thoracotomy is a major surgi-
cal procedure, which may cause changes in pulmonary function
because of postoperative pain (Flecknell et al. 1991). Further-
more, oesophageal surgery can be associated with life-threatening
complications such as oesophageal wound dehiscence or leakage,
pyothorax, mediastinitis and pleuritis (Ryan et al. 1975, Houlton
et al. 1985, Spielman et al. 1992, Sale & Williams 2006, Leib &
Sartor 2008, Juvet et al. 2010).
Oesophagitis and stricture were diagnosed in 12 and 4 of 27
dogs, respectively. Those complications required medical man-
agement, which involves protection of the oesophageal mucosa
from additional injury (Rance & Willard 2003). Dogs may need
a gastrostomy tube to rest the oesophagus and provide nutrition
(Leib & Sartor 2008). In case of stricture, concurrent glucocorti-
coids may be used as well, with the purpose of reducing oesopha-
geal inflammation, inhibiting the formation of fibrous connective
tissues and thereby minimizing the risk of stenosis (Harai et al.
1995, Leib & Sartor 2008). Older studies reported that stricture
secondary to OFB was rare (Spielman et al. 1992, Moore 2001),
but in the study by Juvet et al. (2010), ~25% were suspected of
having a stricture. However, the diagnosis of stricture was based
on the owner’s report of regurgitation and not on oesophagos-
copy. In the studies by Leib & Sartor (2008) and Rousseau et al.
(2007), 24% and 30% of dogs, respectively, developed a stricture
as diagnosed by endoscopy. The higher percentage of stricture
in those studies was explained by the severe diffuse oesophageal
damage and the characteristics of the OFB. Owing to the retro-
spective aspect of the present study and the lack of description
about the oesophagoscopy, a correlation between severe oesopha-
gitis and OS cannot be made.
Oesophageal perforation was present in 2 dogs, 1 of which
(Group 1) died from pyothorax while the other healed spontane-
ously with treatment for oesophagitis. During surgery, necrosis
of the oesophageal wall was observed in one dog from Group
2, which can explain the oesophageal wound leakage. The prin-
cipal goals of treating perforation are to treat infection, provide
nutritional support and restore the digestive tract integrity and
continuity (Chirica et al. 2010). Small perforations can be man-
aged medically, but larger perforations require surgical treatment
to remove septic debris and close the oesophageal defect (Whyte
et al. 1995, Altorjay et al. 1997, Brinster et al. 2004, Leib &
Sartor 2008). Indeed, Parker et al. (1989) reported spontane-
ous healing of perforations up to 12 mm long. If perforation
is accompanied by fever and mediastinitis or pleuritis, surgical
repair is indicated (Okten et al. 2001). The overall mortality rate
associated with oesophageal perforation can approach 20%, and
delaying treatment by more than 24 hours can result in a dou-
bling of mortality (Attar et al. 1990, Okten et al. 2001, Brinster
et al. 2004). Barium sulphate was used in all oesophagrams in
this study. Nevertheless, in cases of suspected OP, iodinated con-
trast is the preferred initial contrast agent because there is a con-
cern that extravasation of barium sulphate into mediastinum can
lead to an intense inflammatory response, resulting in fibrosing
mediastinitis (Ginai et al. 1985).
• Vol 56 • October 2015 • © 2015 British Small Animal Veterinary Association
 Oesophagoscopy and oesophagotomy comparison
To conclude, this study demonstrates that endoscopic and sur-
gical removal of OFB was associated with a low overall complica-
tion rate that was similar between the two methods. In cases in
which endoscopic removal is unsuccessful or may lead to further
iatrogenic oesophageal damage, oesophagotomy is an effective
and valuable method and can be performed with good outcomes.
Further prospective studies on a larger number of cases would be
needed to test these propositions.
Conflict of interest
None of the authors of this article has a financial or personal
relationship with other people or organisations that could inap-
propriately influence or bias the content of the paper.
References
Altorjay, A., Kiss, J., Voros A. (1997) Non operative management of esophageal
perforation is it justified? Annals of Surgery 225, 415-421
Attar S., Hankins J. R., Suter C. M., Coughlin T. R., Sequeira A., McLaughlin J. S.
(1990) Esophageal perforation: A therapeutic challenge. Annals of Surgery 50,
45-49
Brinster, C. J., Singhal, S., Lee, L., et al. (2004) Evolving options in the manage-
ment of esophageal perforation. The Annals of Thoracic Surgery 77, 1475-1483
Chirica, M., Champault, A., Dray, X., et al. (2010) Esophageal perforations.
Journal of Visceral Surgery 147, 169-181
Cohn, L. A., Stoll, M. R., Branson, K. R., et al. (2003) Fatal hemothorax following
management of an esophageal foreign body. Journal of the American Animal
Hospital Association 39, 251-256
Duncan, P. G. & Cohen M. M. (1987) Post-operative complications: factors of
significance to anaesthetic practice. Canadian Journal of Anaesthesia 34, 2-8
Flecknell, P. A., Kirky, A. J. B., Lues, J. H., et al. (1991) Post-operative analgesia
following thoracotomy in the dog: an evaluation of the effects of bupivacaine
intercostal nerve block and nalbuphine on respiratory function. Laboratory
Animals 25, 319-324
Genné, D., Sommet, R., Kaiser, L., et al. (2006) Analysis of factors that contribute
to treatment failure in patients with community-acquired pneumonia. European
Journal of Clinical Microbiology and Infectious Diseases 25, 159-166
Gianella, P., Pfammater, N. S., Burgener, I. A. (2009) Oesophageal and gastric
endoscopic foreign body removal: complications and follow-up of 102 dogs.
Journal of Small Animal Practice 50, 649-654
Ginai, A. Z., Ten Kate, F. J. W., Ten Berg, R. G. M., et al. (1985) Experimental evalu-
ation of various available contrast agents for use in the upper gastrointestinal
tract in case of suspected leakage. Effects on mediastinum. The British Journal
of Radiology 58, 585-592
Gualtieri, M. (2001) Esophagoscopy. Veterinary Clinics of North America: Small
Animal Practice 31, 605-630
Journal of Small Animal Practice • Vol 56 • October 2015 • © 2015 British Small Animal Veterinary Association
Harai, B. H., Johnson, S. E., Sherding, R. G. (1995) Endoscopically guided bal-
loon dilatation of benign esophageal strictures in 6 cats and 7 dogs. Journal of
Veterinary Internal Medicine 9, 332-335
Houlton, J. E. F., Herrtage, M. E., Taylor, M.P., et al. (1985) Thoracic oesophageal
foreign bodies in the dog: a review of ninety cases. Journal of Small Animal
Practice 26, 521-536
Jergens, A. E. (2005) Disease of the esophagus. In: Textbook of Veterinary Internal
Medicine. 6th edn. Elsevier Saunders, St Louis, MO, USA. pp 1298-1310
Juvet, F., Pinila, M., Shiel, E.R., et al. (2010) Oesophageal foreign bodies in dogs:
factors affecting success of endoscopic retrieval. Irish veterinary journal 63,
34-43
Keir, I., Woolford, L., Hirst, C., et al. (2010) Fatal aortic oesophageal fistula fol-
lowing oesophageal foreign body removal in a dog. Journal of Small Animal
Practice 51, 657-660
King J. M. (2001) Esophageal foreign body and aortic perforation in a dog.
Veterinary Medicine 96, 828
Kyles, A. E. (2003) Esophagus, In: Textbook of Small Animal Surgery. Eds D.
Slatter. Saunders, Philadelphia, PA, USA. pp 573-592
Leib, M. S. & Sartor, L. L. (2008) Esophageal foreign body obstruction caused by
a dental chew treat in 31 dogs (2000-2006). Journal of the American Veterinary
Medical Association 232, 1021-1035
Luthi, C. & Neiger, R. (1998) Esophageal foreign bodies in dogs: 51 cases (1992-
1997). European Journal of Comparative Gastroenterology 3, 7-11
Moore, A. H. (2001) Removal of oesophageal foreign bodies in dogs: use of fluo-
roscopic method and outcome. Journal of Small Animal Practice 42, 227-230
Okten, I., Cangir, A. K., Ozdemir, N., et al. (2001) Management of esophageal
perforation. Surgery Today 31, 36-39
Ollyo, J. B., Fontolliet C. H., Brossard, E. (1992), Savary’s new endoscopic clas-
sification of reflux esophagitis. Acta Endoscopica 22, 307-320
Parker, N. R., Walter, P. A., Gay, J. (1989) Diagnosis and surgical management
of esophageal foreign perforation. journal of the American Animal Hospital
Association, 587-594
Rance, K. & Willard, M. S. (2003) Esophagitis and esophageal strictures.
Veterinary Clinics of North America: Small Animal Practice 33, 945-967
Rousseau, A., Prittie, J., Broussard, J. D., et al. (2007) Incidence and charac-
terization of esophagitis following esophageal foreign body removal in dogs:
60 cases (1999-2003). Journal of Veterinary Emergency and Critical Care 17,
159-163
Ryan, W. W. & Green, R. W. (1975) The conservative management of esophageal
foreign bodies and their complications: a review of 66 cases in dogs and cats.
Journal of the American Animal Hospital Association 28, 570-574
Sale, C. S. H. & Williams, J. M. (2006) Results of transthoracic esophagotomy
retrieval of esophageal foreign body obstruction in dogs: 14 cases (2000-
2004). Journal of the American Animal Hospital Association 42, 450-456
Spielman, B. L., Shaker, E. H., Garvey, M. S. (1992) Esophageal foreign body in
dogs: a retrospective of 23 cases. Journal of the American Animal Hospital
Association 28, 570-574
Whyte, R. I., Iannettoni, M. D., Orringer, M. B. (1995) Intrathoracic esophageal per-
foration. The merit of primary repair. The Journal of Thoracic and Cardiovasularc
Surgery 109, 140-146
Zimmer, J. F. (1984) Canine esophageal foreign bodies: endoscopic, surgical, and
medical management, Journal of the American Animal Hospital Association 20,
669-677
617
 A new technique for insertion of esophagostomy tubes
in cats

C. J. von Werthern, Dr. med. vet., Dipl. ECVS 1, G. Wess, med. vet. 2

From the Departments of Small Animal Surgery 1 and Small Animal Internal
Medicine 2, Zurich University, 8057 Zurich, Switzerland

Abstract
A new percutaneous insertion technique for esophageal feeding tubes in cats is
presented. It has been successfully applied in 12 feline patients. The placement
technique is simple. It takes only 5 minutes and requires a scalpel blade, a
curved hemostat and an applicator for the insertion of the feeding tube. In
contrast to other esophageal tube placement techniques, the tube is inserted
into the definitive aboral position in a one-step procedure. The shoehorn
principle of the applicator allows the tube to be inserted into the esophagus
safely and precisely. Placement of the tube in the midcervical area does not
interfere with the function of the pharynx and avoids having the animal irritated
by the presence of the tube. The chosen diameter of the tube is large enough to
permit feeding of diluted, blended commercial canned food. In our patients,
feeding was started after recovery from anesthesia, and tubes were removed
without complications once the animal had started to eat voluntarily.

Introduction
It has become increasingly common in veterinary medicine to provide nutritional
support as there is now a greater awareness of the negative influence of
malnutrition on morbidity and mortality in critically ill patients (1).
There are two main ways of providing nutritional support: the parenteral route
mostly using a central vein catheter; and the enteral route which involves the
insertion of a feeding tube.
With total parenteral nutrition all essential nutrients are administered
intravenously. The patient has to be monitored closely to prevent complications
such as catheter-associated infections, catheter obstructions or electrolyte
imbalances (2). It is expensive and work intensive.
The enteral route is a more physiological way of giving nutritional support (3, 4),
but can only be applied if the gastrointestinal tract is functional.
Enteral feeding can be performed easily in every private practice. It is less
costly than total parenteral nutrition and involves few complications (5). Feeding
can also be managed at home by the owners.
Various techniques for enteral feeding have been developed. They vary
according to the entrance site of the tube (nasal, pharyngeal, esophageal,
gastric, jejunal) and the technique of placement itself (5 - 13).
Esophageal feeding tubes have been shown to be well tolerated by small
animal patients and are associated with minimal complications. Homogenized
commercial canned food as well as commercial liquid diets can be used for
feeding.
Different techniques for inserting esophageal feeding tubes have been
described (7, 10, 12, 13). In all techniques an esophageal stoma is first created.
The tube is then inserted into the esophagus and exteriorized through the oral
cavity. For the final positioning, the esophageal feeding tube has to be
redirected back into the distal esophagus. This step may be difficult and is
avoided by applying the presented technique. The esophageal feeding tube can
be inserted in a one step procedure into the correct aboral position in the
esophagus by means of a simple applicator a. The principle of this applicator is
basically that of a shoehorn. The short surgical procedure takes 5 minutes and
has been successfully applied in 12 cats.

2
Materials and Methods

Figure 1: Esophageal feeding tube applicator. The aboral end (right) is a

groove which guides the feeding tube. The bulb reinforcement makes insertion
of the feeding tube easier. The applicator can be manipulated with the handle
(left).
A prospective clinical study was undertaken to evaluate a new insertion
technique for esophageal feeding tubes in 12 cats with a special tube
applicator.
The slightly bowed applicator has a length of 250 mm. The outer diameter of
the bulb is 16 mm and the groove is 8 mm wide.
Enteral feeding using an esophageal tube was integrated in the therapeutic plan
in the following cases:
Number Indication Comment
of cats
6 jaw fracture unable to eat after operation
2 anorexia of unknown provide nutrition
origin
1 repair of a caudal obese cat, provide nutrition
abdominal hernia immediately after surgery to
prevent the development of hepatic
lipidosis
1 chronic foreign body, obese cat, provide nutrition
resection of small immediately after surgery to
intestine prevent the development of hepatic

3
 lipidosis
2 nasal exploration procedure can result in anorexia

In each case, the patient was anesthetized and intubated with a cuffed
endotracheal tube. The cat was placed in right lateral recumbency. The left side
of the neck was clipped and aseptically prepared for tube placement. A 18
French red rubber tube b was used in all cats. To ensure that the distal end of
the tube was not placed through the gastroesophageal junction, it was
premeasured from the entrance site in the neck to the eighth rib and marked
with a permanent marker.
The esophageal applicator [Figure 1] then was introduced into the mouth with
the groove oriented dorsally. After the bulb of the applicator had passed the
hyoid apparatus, it was advanced further into the esophagus [Figure 2]. The
correct midcervical position of the bulb, which is halfway between the head and
the shoulder, was verified by palpation. The applicator was then rotated 90
degrees clockwise [Figure 3a]. The groove of the applicator was palpated easily
through the skin and a 1 - 2 cm skin incision was performed with a number 10
scalpel blade over the bulb [Figure 3b]. Leveling the applicator slightly towards
the lateral side of the neck helped to shift important periesophageal structures
away from the side of incision by means of the bulb of the applicator.
Subcutaneous tissue and cervical musculature was bluntly dissected down to
the esophagus by using a mosquito forceps [Figure 3c]. After a stab incision
[Figure 3d] through the esophageal wall with the number 10 scalpel blade had
been made, the tube was inserted into the esophagus up to the mark on the
tube. Correct placement of the tube into the esophagus was confirmed visually
and by finding minimal resistance during insertion. The applicator was then
withdrawn [Figure 4] and the skin incision left unsutured. The wound was
covered with an antiseptic ointment.

4
Figures 2 - 4 : 2 Introduction of the esophageal feeding tube applicator; 3
a - d Creation of the esophageal incision and insertion of the tube (see
text); 4 Removal of the applicator.
Premature dislodgment of the feeding tube was prevented by gluing a
selfadhesive tape in a butterfly fashion to the tube adjacent to the incision. This

5
 0
tape was then sutured to the skin. The tube was bent 180 caudally and
wrapped in a light neck bandage once the patient was awake. Twice a week the
insertion site of the tube was inspected clinically, cleaned if necessary and
covered with an antiseptic ointment and a new bandage.
Tube feeding was started immediately after full recovery from anesthesia. The
d
cats were fed up to 200 - 300 kcals per day of special diluted canned food .
Initially 5 - 15 ml of the liquefied food were administered over 5 minutes through
the tube every two to three hours. During the next four days the amount was
increased gradually up to 60 ml. The food was administered as a bolus over 10
minutes four times a day. After feeding the tube was flushed with warm water to
prevent clogging of the tube. Once the animal started to eat voluntarily, the tube
was removed without anesthesia and the stoma healed by second intention.

Results
There were no serious complications seen either during placement of the tube
or during tube feeding. In one cat a minor complication was bleeding from the
cervical musculature during placement. It stopped spontaneously. Four of the
first 5 cats were obviously disturbed by the presence of the tube in the vicinity of
the head. They tried to remove the tube and/or showed repetitive shaking of the
head. In the following 7 cats the tube was placed further caudally midway
between head and shoulder and no such complication was seen.
The median duration of tube placement was 5 days (1 - 15 days). The
esophagostomy stoma healed by second intention after removal of the feeding
tube. No complication such as problems with deglutination or wound healing
was seen during the 3 month follow-up.
Two cats were euthanised because of the severity of the underlying disease 3
days and 12 days after insertion of the tube. Histology of the tissue around the
esophageal stoma showed moderate infiltration with neutrophils, formation of
granulation tissue in the deeper layers and ingrown capillaries. No bacteria were
detected histologically.

6
Discussion
Various enteral feeding techniques have been described in the literature, but
they all have disadvantages.
Nasogastric feeding tubes can be placed without anesthesia. They have small
diameters that require special liquid diets. Complications include obstruction,
misplacement, premature dislodgment of the tube and epistaxis (14, 15).
Pharyngostomy tube placement needs general anesthesia. Complication rates
tend to be high due to damage to neurovascular structures during surgery (16).
Further complications reported include airway obstruction, aspiration pneumonia
and problems with deglutition (16, 17).
Gastrostomy tube placement also requires general anesthesia. During
placement there is a risk of laceration of abdominal organs (18). Further
complications may include inadequate gastric emptying, vomiting, local cellulitis
or abscess formation and premature dislodgment of the tube (18). To prevent
the development of peritonitis caused by leakage of gastric contents, feeding is
started 12 - 24 hours after placement and the tube should stay in place for a
minimum of 5 days (18 - 20).
Jejunostomy tubes are surgically placed feeding tubes for critically ill patients
with pancreatic, hepatobilary or gastrointestinal disease, neoplasm or peritonitis.
They have small diameters which require special liquid diets. Diarrhea,
premature dislodgment of the tube and peritonitis secondary to leakage are the
major complications in these patients (21, 22).
Esophagostomy feeding tubes were developed in the early 50s in human
medicine (23) and first used in the 80s (7) in veterinary medicine as an
alternative to other enteral feeding procedures. It is among the most reliable
methods and has few complications.
Surgical insertion of an esophageal feeding tube takes less than 5 minutes and
animals need only short-term general anesthesia. No special diet is required
and feeding with blended regular canned food can be started as soon the
animal has recovered from the anesthesia. Cats and dogs also are able to eat
easily with the esophagostomy tube in place. It has been reported that an
esophagostomy tube has been removed only one day after insertion without

7
complications (10). Long-term nutritional support is documented as being well-
tolerated by dogs and cats (10).
Nevertheless there are complications associated with esophageal
feeding tubes described in the literature (7, 8, 9, 12, 13), but all can be handled
fairly simply. They include wound infection at entrance site, vomiting, scratching
and kinking of the tube during its placement.
Moderate wound infection was observed in three of our cats but all were
successfully managed by daily application of antiseptic ointments.
Vomiting was not a problem in our patients. With our technique the correct
position of the end of the tube cranial to the cardia was premeasured before
insertion. The placement of the distal end of the tube through the
gastroesophageal junction may initiate vomiting (10). Wrong placement can be
corrected by retraction of the tube. Positioning the distal end of the tube in the
distal esophagus also minimizes injuries to the mucosa of the esophagus
secondary to gastric reflux (24).
If vomiting causes dislodgment of the feeding tube into the oral cavity, a larger
tube should be used (8, 10, 11). A 18 French tube b, such as the one we used
in this study with cats, seems to be large enough to prevent displacement and
did not interfere with spontaneous food consumption (10). This is in contrast to
Crowe´s (9) recommendation to use smaller tube sizes.
Vomiting did also not occur during feeding. We fed blended diets d which were
administered slowly at room temperature over 5 - 10 minute periods, and the
volume of a single bolus was only increased gradually (see material and
methods).
Head shaking and scratching was only a problem in four of the first five cats
where the insertion site of the tube was obviously too close to the head.
Kinking of the esophagostomy tube during its placement, as reported with a
different insertion technique (9), did not occur with the new technique.
Four different surgical techniques for insertion of esophageal feeding
tubes have been described (7, 10, 12, 13). One additional method is the
percutaneous intravenous needle catheter placement (7). The catheter,
however, only allows for administration of fluids and liquid diets and will not be
discussed further.

8
All these insertion techniques involve two-step procedures: Insertion of the tube
into the esophagus, followed by its definitive placement.
Before the feeding tube is inserted, an esophageal stoma has to be created.
The recently published techniques (10, 13) use a special, intraluminally placed
tube applicator c to perforate the esophagus from inside by means of a trochar.
In the original technique (7), a Carmalt forceps introduced through the mouth
was used to bluntly perforate the esophagus. The fourth procedure (12)
requires a stiff guide tube, a venous catheter, a Carmalt forceps and a separate
flexible tube.
In all four techniques, the feeding tube is exteriorized through the oral
cavity after its insertion in the stoma. Definitive placement is achieved by
redirecting the tip of the tube back through the oropharynx to its aboral position.
This can be done with (10) or without (7) the help of a stylet. One technique first
withdraws the tube back to the insertion stoma and redirects it than aborally (12,
13). Redirecting the tip caudally through the oropharynx is mechanically difficult
as the pharynx is anatomically narrow. It can accidentally lead to entrapment of
the feeding tube around the endotracheal tube (10, 11).
In the new technique described in this paper, the tube is placed in its definitive
aboral position at the beginning of the operation. This means that the step
involving the exteriorization of the tube through the mouth and its redirection
into the esophagus including the described complications is eliminated.
Misplacement of the feeding tube in the mediastinum or periesophageal
adventitia, which is reported to be a danger with one technique (8), is less likely
with this new technique because the tube is inserted under visual control.
Further its correct position is confirmed by the minimal resistance of the tube
during its introduction. The appropriate midcervical tube position can be
reached by gliding the applicator down the esophagus to the optimal location.
This is not an option with the technique described by Crowe (7, 8). Too cranial a
placement had been shown in our case study that the animal can be irritated by
the presence of the feeding tube.
No misplacement or other complications, such as damage to the adjacent
neurovascular structures which has been reported to occur with another
technique (8), were observed in this study. In the new technique the wall of the

9
esophagus is stretched over the bulb of the applicator, which facilitates making
the stab incision and the insertion of the tube. The bulb of the applicator also
pushes the neurovascular structures away from the insertion site, which
prevents them being damaged. The shoehorn principle, in which the blade is
protected inside the applicator, guarantees that the stab incision into the
esophagus is safe and complete.
Although extensive fibrosis and fistulation are reported complications with
cervical esophagostomy in horses (25), no such complications have been found
in cats (11) and none were observed in our study.
The new technique for inserting esophagostomy tubes described in this paper
has been shown to work well with cats. It is to be expected that, with
appropriately sized applicators, the technique can also be successfully applied
in the enteral feeding in dogs.

Footnotes
a Esophageal feeding tube applicator, manufacturer not yet determined
b Ruesch Katheter, Pro Vet AG, CH - Lyssach
c ELD Tube applicator, Pro Vet AG, CH - Lyssach
d Hills prescription a/d diet; Pro Vet AG, CH - Lyssach

Literature
1. Green S. Anorexia and hospitalized cats.Vet Tech 1992; 13: 580 - 6.
2. Lippert AC, Armstrong PJ. Parenteral nutritional support. Kirk RW editor,
Current Veterinary Therapy X, Philadelphia, WB Saunders Company, 1989; 25 -
30.
3. Lippert AC, Faulkner JE, Evans AT, et al. Total parenteral nutrition in
clinically normal cats. J Am Vet Med Assoc 1989; 5: 669 - 76.
4. Lo CW, Walker WA. Changes in the gastrointestinal tract during enteral or
parenteral feeding. Nutr Rev 1989; 47: 193 - 7.
5. Wheeler SL, McGuire BH. Enteral nutritional support. RW Kirk editor, Current
Veterinary Therapy X, Philadelphia, WB Saunders Company, 1989; 30 - 7.

10
6. Armstrong PJ, Hand MS, Frederick GS. Enteral nutrition by tube. Vet Clin
North Am (Small Anim Pract) 1990; 20: 237 - 75.
7. Crowe DT. Nutritional support for the hospitalized patient: an introduction to
tube feeding. Comp Cont Ed Pract Vet 1990; 12: 1711 - 21.
8. Crowe DT, Devey JJ. Esophagostomy tubes for feeding and decompression:
clinical experience in 29 small animal patients. J Am Anim Hosp Assoc 1997;
33: 393 - 403.
9. Crowe DT, Devey JJ. Esophagostomy tube placement and use for feeding
and decompression. Bojrab MJ editor, Current Techniques in Small Animal
Surgery, Williams & Wilkins, Baltimore 1998; 161 - 7.
10. Devitt CM, Seim HB. Clinical evaluation of tube esophagostomy in small
animals. J Am Anim Hosp Assoc 1997; 33: 55 - 60.
11. Levine PB, Smallwood LJ, Buback JL. Esophagostomy tubes as a method
of nutritional management in cats: a retrospective study. J Am Anim Hosp
Assoc 1997; 33: 405 - 10.
12. Rawlings CA. Percutaneous placement of a midcervical esophagostomy
tube: new technique and representative cases. J Am Anim Hosp Assoc 1993;
29: 526 - 30.
13. Rawlings CA, Bartges JW. Esophagostomy tube placement: alternative
technique. Bojrab MJ editor, Current Techniques in Small Animal Surgery,
Williams & Wilkins, Baltimore 1998; 167 - 70.
14. Abood SK, Buffington CA. Improved nasogastric intubation technique for
administration of nutritional support in dogs. J Am Vet Med Assoc 1991: 5: 577 -
9.
15. Abood SK, Buffington CA. Enteral feeding of dogs and cats: 51 cases (1989
- 1991). J Am Vet Med Assoc 1992; 4: 619 - 22.
16. Crowe DT, Downs MO. Pharyngostomy complications in dogs and cats and
recommended technical modifications: Experimental and clinical investigations.
J Am Anim Hosp Assoc 1986; 22: 493 - 503.
17. Lantz GC, Cantwell HD, VanVleet JF, et al. Pharyngostomy tube induced
esophagitis in the dog: an experimental study. J Am Anim Hosp Assoc 1983;
19: 207 - 12.

11
18. Armstrong PJ, Hardie EM. Percutaneous endoscopic gastrostomy. J Vet Int
Med 1990; 4: 202 - 6.
19. Fulton RB, Dennis JS. Blind percutaneous placement of a gastrostomy tube
for nutritional support in dogs and cats. J Am Vet Med Assoc 1992; 201: 697 -
700.
20. Mauterer JV, Abood SK, Buffington CA, et al. New technique and
management guidelines for percutaneous nonendoscopic tube gastrotomy. J
Am Vet Med Assoc 1994; 4: 574 - 9.
21. Orton EC. Enteral hyperalimentation administered via needle catheter-
jejunostoma as an adjunct to cranial abdominal surgery in dogs and cats. J Am
Vet Med Assoc 1986; 188: 1406 - 11.
22. Swann HM, Sweet DC, Michel K. Complications associated with use of
jejunostomy tubes in dogs and cats: 40 cases (1989 - 1994). J Am Vet Med
Assoc 1997; 12: 1764 - 7.
23. Klopp CT. Cervical esophagostomy. J Thorac Cardiovasc Surg 1951; 21:
490 - 1.
24. Balkany TJ, Baker BB, Bloustein PA, et al. Cervical esophagostomy in dogs.
Endoscopic, Radiographic, and Histopathologic Evaluation of esophagitis
induced by feeding tubes. Ann Otol 1977; 86: 588 - 93.
25. Stick JA, Derksen FJ, Scott EA. Equine cervical esophagostomy:
complications assocciated with duration and location of feeding tubes. Am J Vet
Res 1981; 42: 727 - 732.

12
Case Report Veterinarni Medicina, 53, 2008 (4): 224–228

Reconstruction of the oesophagus using pedicle

diaphragm and omentum flaps in a dog: a case report
H.B. Lee1, M.R. Alam2, N.S. Kim1
1
College of Veterinary Medicine, Chonbuk National University, Jeonju, Republic of Korea
2
Faculty of Veterinary Science, Bangladesh Agricultural University, Mymensingh, Bangladesh

ABSTRACT: A two-years-old, intact female, Shih-Tzu dog weighing 5 kg was presented to the Chonbuk Animal
Medical Centre, College of Veterinary Medicine, Chonbuk National University, with the history of bone ingestion
before two days. The survey radiographs of the thorax revealed a bone at the caudal thoracic oesophagus. An
oesophagram was performed which did not reveal any oesophageal leakage or perforation. The left caudolateral
thoracotomy was performed and the caudal oesophagus was found partially necrosed, friable and inflamed. The
necrosed, friable part was removed and the oesophageal defect was reconstructed using a full-thickness muscle
flap collected from the diaphragm. A part of the omentum was mobilized from the abdomen and sutured over
the reconstructed site of the oesophagus to aid healing. Oesophagoscopy after nine days postoperatively showed a
good adhesion of the diaphragm flap. The patient showed normal activity after 12 days and no complications were
observed during a one-year follow up period. The pedicle flap collected from the left hemidiaphragm in addition
to the omentum flap can be successfully used to reconstruct the circumferential oesophageal defect.

Keywords: oesophageal reconstruction; diaphragm flap; omentum flap; dog

Stricture and fibrosis of the thoracic oesophagus
may occur after segmental resection and anasto-
mosis which result at least in part from the lo-
calized disruption of blood supply (Hayari et al.,
2004). The ideal protocol would be a resection of
oesophageal injury followed by anastomosis of the
remaining segments with no tension. However,
in cases of extensive damage in the oesophageal
wall, approaching the borders after the dissec-
tion may not be possible (Delikaris et al., 1999).
Such situations require the use of substitutes in
order to reestablish the continuity of the organ.
Several materials have been used for substitutive
oesophagoplasty procedures, amongst which are:
the rhomboid muscle (Lucas et al., 1982), autog-
enous pericardium and jejunal segment (Smith et
al., 1999). Diaphragmatic pedicles have been used
in substitutive oesophagoplasty in men since 1948
(Mineo and Ambrogi, 1995). The diaphragm is a
strong, elastic, and well vascularizated muscle, also
resistant to necrosis, and bearer of a good regen-
eration capability. Its vascularization derives from
the lower phrenic arteries, pericardium phrenic ar-
teries, intermammary and intercostal arteries. Its
enervation has a peripheral distribution originating
from branches of the phrenic nerve, allowing the
section of the muscle without the denervation of
the remaining diaphragm. It is possible to remove
wide bands of the diaphragm and still close the
defect without tension.
An extensive oesophageal injury may require re-
construction following a massive resection, which
is associated with a high risk of postsurgical com-
plications as a consequence of tension and less
vascularity. The segmental blood supply is one of
the most important features of the anatomy of the
oesophagus from a surgical aspect (Fujiwara et al.,
1997; Wu et al., 1998). During the operative prepa-
ration, small supply vessels are injured, and the
operation is therefore carried out on an organ with
a poor blood supply. Accordingly, the complication
rate is high (Young et al., 2000a,b; Kim et al., 2001).

Supported by the Second Stage Brain Korea (BK) 21 research project in 2007.

224
Veterinarni Medicina, 53, 2008 (4): 224–228 Case Report
The omentum has been used some times in the
most varied general surgical operations in order to
improve the blood supply of a given organ in the
abdominal cavity (Adams et al., 1992). However,
its use outside the abdominal cavity is not rou-
tine. In previous studies, the omentum was found
to be an adequate host organ for angiogenesis in
different tissues (Goldsmith et al., 1975; Zhang nd
Yang, 1987). The omentum is a highly vascularized
tissue and was shown to enhance anastomotic heal-
ing when added as an adjuvant to reconstruction
procedures (Fekete et al., 1981; Zhang and Yang,
1987). The purpose of this study is to evaluate the
surgical technique, complications and final func-
tional outcomes of oesophagoplasty using a pedicle
diaphragm and omentum flaps in a dog.
Case presentation
A two-years-old, 5 kg, intact female, Shih-Tzu
dog was presented with dysphagia, regurgitation
and a history of bone ingestion before two days.
The physical examination revealed the patient to
have 7% dehydration. The complete blood count
and serum biochemistry were performed, which
revealed leukocytosis (20.4 × 103/µl; normal range
6–15 × 103/µl), a high BUN level (30 mg/dl; normal
range10–25 mg/dl) and hyperproteinaemia (8 g/dl;
normal range 5.5–7.8 g/dl). The blood gas analy-
sis and urinalysis findings were within the normal
range. The survey radiographs of the thorax re-
vealed a bone at the caudal thoracic oesophagus.
An oesophagram was performed to evaluate the
oesophageal leakage and revealed no perforation.
The dog was sedated with acepromazine (Sedazect
Inj®, Samwoo Pharm. Co. Ltd., Korea) 0.2 mg/kg,
i.v., ketamine (Ketamine Inj ®, Yhan Pharm. Co.
Ltd., Korea) and it was attempted to push the for-
eign body into the stomach using a balloon cath-
eter but it failed. The patient was given intravenous
crystalloid fluids (10 ml/kg/h) for correction of de-
hydration. The surgical area was shaved and pro-
phylactic antibiotic, cephalexin (Methilexin Inj®,
Union Korea Pharm. Co. Ltd., Korea) 25 mg/kg,
i.v., was administered one hour before surgery. The
patient was premedicated with atropine sulphate
(Atropin Sulfate Inj ®, Dai Han Pharm. Co. Ltd.,
Korea) 0.05 mg/kg, s.c., the anaesthesia was induced
using propofol (Anepol Inj®, Hana Pharm. Co. Ltd.,
Korea) 6 mg/kg, i.v., and was maintained with en-
flurane and oxygen. Supportive fluid therapy was
maintained throughout the procedure. The patient
was positioned on the right lateral recumbency and
draped. The left caudo-lateral thoracotomy was
performed. The visceral pleura were transected,
and the dorsal and ventral branches of the vagus
nerve were carefully retracted. The location of the
oesophageal foreign body was identified and the
oesophagus was isolated from the thorax with wet
gauge. Stay sutures were placed proximally and dis-
tally to the foreign body to facilitate the manipula-
tion of the oesophagus and prevent leakage of the
intraluminal contents. A perforation (5 mm/3 mm)
on left side of the oesophagus was observed at the
point of lodgment of the foreign body and the area
was thickened, friable and inflamed. The right side
of the oesophagus was also friable and inflamed.
After removing the foreign body, the friable and
inflamed part of the left side of oesophagus was
removed (Figure 1), which created a longitudinal
defect measuring 3.3 cm × 1.8 cm. The oesopha-
geal defect was reconstructed using a pedicle dia-
phragm flap. A full-thickness of flap (10 cm × 3 cm)
was collected from the left side of the diaphragm.
The diaphragm flap was approximated over the
oesophageal defect and sutured using 4-0 polydi-
oxanone double layer simple continuous sutures.
The first suture connected the mucosa to the sub-
mucosa and a knot was tied on the intraluminal
oesophagus. The second suture was placed from
the submucosa to the serosa and was tied on the
Figure 1. Photograph showing the lodged foreign body,
thickened, inflamed and friable wall on the left side of
the oesophagus
225
Case Report Veterinarni Medicina, 53, 2008 (4): 224–228
Figure 2. Photograph showing reconstruction of the
oesophageal defect using a flap collected from the dia-
phragm
outer aspect of the oesophagus wall (Figure 2). A
gastrotomy tube was placed into the stomach and
part of the omentum was mobilized in the thorax
through the diaphragmatic defect created from flap
after the left paracostal incision. The omentum was
sutured over the surgical wound and the inflamed
area of the oesophagus. The diaphragmatic defect
was closed with simple continuous sutures. The
thoracic cavity was lavaged thoroughly with a warm
saline solution three times, and a chest tube was
inserted before closure. The wound was closed in
a usual manner.
Postoperative treatment was given with butopha-
nol (Butopan Inj®, Hana Pharm. Co. Ltd., Korea)
0.4 mg/kg, i.m, every 12 h for three days, cephalexin
(Methilexin Inj ®, Union Korea Pharm. Co. Ltd.,
Korea) 25 mg/kg, i.v., every 12 h for seven days,
prednisolone (Prednisolon Inj®, Samwoo Pharm.
Co. Ltd., Korea) 1 mg/kg, i.m, every 12 h for three
days and cimetidine (Cimetidin Inj ® , Dae woo
Pharm. Co. Ltd., Korea) 10 mg/kg, i.v., every 12 h
for three days. The intravenous fluid therapy was
given for three days. The thorax was aspirated by
a chest tube every hour after surgery until only a
minimal volume (2 ml/kg/day) of air or fluid was
obtained. The chest tube was removed after three
days. Water and food were withheld for 48 hours.
Small amounts of soft food were fed through the
gastrostomy tube for nine days.
Nine days later, oesophagoscopy revealed good
adhesion between the diaphragm flap and the
oesophagus (Figure 3). The dog showed a normal
226
Figure 3. Oesophagoscopy nine days postoperatively
revealed adhesion of the diaphragm flap and healing of
the oesophagus
activity after 12 days. The dog did not show any
vomiting or regurgitation during a one-year fol-
low up period.
DISCUSSION
Successful reconstruction of the oesophagus can
be a challenge in small animal practice. The goal of
oesophageal reconstruction is to restore both swal-
lowing and a barrier to the gastroesophageal reflux
with minimal mortality and morbidity (Young et al.,
2000a,b). In oesophageal surgery, there is a higher
risk of complications than in any other portion of
the alimentary tract (Flanders, 1989; Lerut et al.,
2002). This is believed to be a result of the absence of
a serosa, segmental blood supply, constant motion
and poor suture holding as compared to other parts
of the alimentary tract (Lerut et al., 2002; Ranen et
al., 2004). Less vascularity and excessive tension at
the suture site appear to be the major reasons for
the healing problems. It is important to choose the
appropriate surgical techniques in order to reduce
the excessive tension and to facilitate vasculariza-
tion. In our case, the oesophagus was inflamed and
friable, and had a 3.3 cm × 1.8 cm defect on the left
side after debridement of necrosis and inflamed part
of the left side of the oesophagus. A resection of more
3 to 5 cm of the oesophagus increased the risk of
dehiscence (Hedlund, 2002). Anastomosis after the
oesophagectomy was not indicated in this case be-
cause of the greater anastomotic tension. Therefore,
Veterinarni Medicina, 53, 2008 (4): 224–228 Case Report
it was necessary to reconstruct the oesophageal de-
fect without causing excessive wound tension, which
is considered to be an important etiologic factor for
wound dehiscence. For oesophageal reconstruction,
various muscle flaps such as diaphragm, pleural,
and intercostal muscle flap have been studied as
a means of repairing an oesophageal defect and
perforation depending on the location of the injury
(Bouayad et al., 1992; Jones and Ginsberg, 1992;
Richardson, 2005). The diaphragm muscle flap has
been used to repair caudal oesophageal perfora-
tion in humans (Richardson, 2005) and animals
(Paulo et al., 2007). The diaphragm is a strong,
elastic and well vascularizated muscle, also resist-
ant to necrosis, and bearer of a good regeneration
capability. In repairing an oesophageal defect, the
diaphragm is thick, pliable and easy to handle. The
diaphragmatic flap was used in this case to fill up
the oesophageal defect and reduce the excessive
tension, and it showed a good result. This result is
in agreement with previous reports (Richardson,
2005; Paulo et al., 2007).
An omentum flap has been advocated in oesopha-
geal injuries with severe inflamed infection (Fekete
et al., 1981; Zhang and Yang, 1987). The omen-
tum has a rich vascular, lymphatic tissue and has
been shown to enhance anastomotic healing when
added as an adjuvant for reconstruction procedures
(Dicks et al., 1998; Nishimaki et al., 2001; Hayari
et al., 2004). In our case, the omentum was placed
at the friable, inflamed area and on the suture line
to facilitate healing. In addition, it was used to
reinforce the surgical site and good healing was
observed. This result is in agreement with the pre-
vious reports (Dicks et al., 1998; Nishimaki et al.,
2001; Hayari et al., 2004). Stricture is one of the
most common complications after oesophagus
surgery (Dicks et al., 1998; Nishimaki et al., 2001;
Hayari et al., 2004). However, there was no stric-
ture formation in our case, which was confirmed by
oesophagram performed six months after surgery.
The incidence of oesophageal stricture formation
after reconstruction with muscle and omentum flap
is lower than that in the primary closure of the
oesophagus (Zhang and Yang, 1987; Bouayad et
al., 1992). This might be related to the abundant
elastic fibres of the diaphragm and rich vascular
omentum.
The two-layer simple interrupted closure results
in greater wound strength, good tissue apposition,
and improved healing compared with the single-
layer simple interrupted closure (Oakes et al., 1993;
Bardini et al., 1994). The operation time of the con-
tinuous suture pattern is faster than the interrupted
suture pattern. In our case, the diaphragm flap was
sutured at the oesophagus using a double-layer
continuous closure pattern and sufficient holding
strength was obtained to prevent the oesophagus
motion. This suture pattern seemed to give greater
wound strength.
Oesophagram and oesophagoscopy are useful for
identifying the oesophagus. However, oesophageal
perforation may not be observed on an oesopha-
gram because the foreign body may prevent the
leakage of the contrast agent (Kyles, 2002). In our
case, the same thing happened; we did not know
there was an oesophagus perforation until it was
found during surgery.
In this case, an oesophageal defect, which oc-
curred during oesophagotomy to remove a firmly
lodged foreign body, was reconstructed using the
full-thickness diaphragm flap and omentum flap
resulted in a good prognosis. The patient showed
normal activity after 12 days. The important rea-
son for the good prognosis is believed to be due to
revascularization and reduced wound tension. The
pedicle diaphragm flap in addition to the omentum
flap can be considered for the reconstruction of the
circumferential oesophageal defect.
REFERENCES
Adams W., Cterecteko G., Bilous M. (1992): Effect of an
omental wrap on the healing and vascularity of com-
promised intestinal anastomoses. Diseases of the Co-
lon and Rectum, 35, 731–738.
Bardini R., Bonavina L., Asolati M., Ruol A., Castoro C.,
Tiso E. (1994): Single-layered cervical oesophageal
anastomoses: a prospective study of two suturing tech-
niques. The Annals of Thoracic Surgery, 58, 1087–
1089.
Bouayad H., Caywood D.D., Alyakine H., Lipowitz A.J.,
Liepold H.W. (1992): Surgical reconstruction of partial
circumferential oesophageal defect in the dog. Journal
of Investigative Surgery, 5, 327–342.
Delikaris K.P.H., Hatzipantelis K.P., Filintatzi C., Ko-
takidou R.E., Kitis G., Raptopoulus D. (1999): The use
of a dura mater patch to cover oesophageal defects of
different sizes: an experimental study in chickens. The
European Journal of Surgery, 165, 151–157.
Dicks J.R., Majeed A.W., Stoddard C.J. (1998): Omental
wrapping of perforated oesophagus. Diseases of the
Esophagus, 11, 276–278.
227
Case Report Veterinarni Medicina, 53, 2008 (4): 224–228
Fekete F., Breil P., Ronsse H., Tossen J.C., Langonnet F.
(1981): EEA stapler and omental graft in esophagogas-
trectomy: Experience with 30 intrathoracic anastomo-
ses for cancer. Annals of Surgery, 193, 825–830.
Flanders J.A. (1989): Problems and complications as-
sociated with oesophageal surgery. Problems in Vet-
erinary Medicine, 1, 183–194.
Fujiwara H., Kuga T., Esato K. (1997): High submucosal blood
flow and low anastomotic tension prevent anastomotic
leakage in rabbits. Surgery Today, 27, 924–929.
Goldsmith H.S., Dukett H., Chenp F. (1975): Prevention
of cerebral infarction in the dog by intact omentum.
American Journal of Surgery, 130, 317–320.
Hayari L., Hershko D.D., Shoshani H., Maor R., Morde-
covich D., Shoshani G. (2004): Omentopexy improves
vascularization and decreases stricture formation of
oesophageal anastomoses in a dog model. Journal of
Pediatric Surgery, 39, 540–544.
Hedlund C.S. (2002): Surgery of the digestive system,
In: Fossum T.W. (ed.): Textbook of Small Animal Sur-
gery. 2nd ed. St. Louis, MO, Mosby. 274–449.
Jones W.G. 2nd, Ginsberg R.J. (1992): Esophageal per-
foration: a continuing challenge. The Annals of Tho-
racic Surgery, 53, 534–543.
Kim S.H., Lee K.S., Shim Y.M., Kim K., Yang P.S. Kim
T.S. (2001): Esophageal resection: indications, tech-
niques, and radiologic assessment. Radiographics, 21,
1119–1137.
Kyles A.E. (2002): Esophagus. In: Slatter D. (ed.): Text-
book of Small Animal Surgery. 3rd ed. Saunders, Phil-
adelphia, PA. 573–592.
Lerut T., Coosemans W., Decker G., De Leyn P., Nafteux
P., Van Raemdonck D. (2002): Anastomotic complica-
tions after oesophagectomy. Digestive Surgery, 19,
92–98.
Lucas A.E., Snow N., Tobin G.R., Flint Jr. L.M. (1982): Use
of the rhomboid major muscle flap for oesophageal re-
pair. The Annals of Thoracic Surgery, 33, 619–623.
Mineo T.C., Ambrogi V. (1995): Early closure of the
postpneumonectomy bronchopleural fistula by pedi-
cled diaphragmatic flaps. The Annals of Thoracic
Surgery, 60, 714–715.
Nishimaki T., Ono K., Tada T., Hatakeyama K. (2001):
Successful primary reinforced repair of oesophageal
Corresponding Author:
Dr. Nam-Soo Kim, Associate Professor, Department of Surgery, and Director, Animal Medical Centre,
College of Veterinary Medicine, Chonbuk National University, Jeonju 561-756, Republic of Korea
Tel. +82 63 270 2800, fax +82 63 270 3778, e-mail: namsoo@chonbuk.ac.kr
228
perforation using a pedicled omental graft through a
transhiatal approach. Diseases of the Esophagus, 14,
155–158.
Oakes M.G., Hosgood G., Snider T.G. 3rd., Hedlund C.S.,
Crawford M.P. (1993): Esophagotomy closure in the
dog. A comparison of a double-layer appositional and
two single-layer appositional techniques. Veterinary
Surgery, 22, 451–456.
Paulo N.M., Miranda W., Atayde I.B., Junior J.T.D.S.,
Azevedo E.M.R., Lima F.G.D., Franco L.G., Faria
C.M.C. (2007): Reconstruction of thoracic oesophagus
with pediculated diaphragmatic flap in dogs. Acta
Cirurgica Brasileira, 22, 8–11.
Ranen E., Shamir M.H., Shahar R., Johnston D.E. (2004):
Partial esophagectomy with single layer closure for
treatment of oesophageal sarcomas in 6 dogs. Veteri-
nary Surgery, 33, 428–434.
Richardson J.D. (2005): Management of oesophageal
perforations: the value of aggressive surgical treat-
ment. American Journal of Surgery, 190, 161–165.
Smith D.F., Ott D.J., Mcguirt W.F., Albertson D.A., Chen
M.Y.M., Gelfand D.W. (1999): Free jejunal grafts of the
pharynx: surgical methods, complications, and radio-
graphic evaluation. Dysphagia, 14, 176–182.
Wu M.H., Sun Y.N., Huang S.T., Chang H.Y. (1998): Blood
supply of oesophageal stumps. Hepato-Gastroenterol-
ogy, 45, 2055–2059.
Young M.M., Deschamps C., Allen M.S., Miller D.L.,
Transtek V.F., Schleck C.D., Pairolero P.C. (2000a):
Esophageal reconstruction for benign disease: self-as-
sessment of functional outcome and quality of life.
The Annals of Thoracic Surgery, 70, 1799–1802.
Young M.M., Deschamps C., Transtek V.F., Allen M.S.,
Miller D.L., Schleck C.D. Pairolero P.C. (2000b): Es-
ophageal reconstruction for benign disease: Early
morbidity, mortality, and functional results. The An-
nals of Thoracic Surgery, 70, 1651–1655.
Zhang K., Yang Y.H. (1987): Use of pedicled omentum
in oesophagogastric anastomosis: Analysis of 100
cases. Annals of the Royal College of Surgeons of Eng-
land, 69, 209–211.
Received: 2007–08–27
Accepted after corrections: 2008–04–08
 4 – ORIGINAL ARTICLE
Alimentary Tract

Esophagectomy and substitution of the thoracic esophagus in dogs1

Esofagectomia e substituição do esôfago torácico em cães

Carlos Eduardo Meirelles dos SantosI, Sheila Canevese RahalII, Débora Cristina DamascenoIII, Rogério Saad HossneIV

I
Master, Department of Veterinary Surgery and Anesthesiology, School of Veterinary Medicine of Botucatu, UNESP, Sao Paulo, Brazil.
II
PhD, Chairman Full Professor, Department of Veterinary Surgery and Anesthesiology, School of Veterinary Medicine of Botucatu, UNESP, Sao Paulo,
Brazil.
III
PhD, Department of Gynecology and Obstetrics, School of Medicine of Botucatu, UNESP, Sao Paulo, Brazil.
IV
PhD, Assistant Professor, Department of Surgery, School of Medicine of Botucatu, UNESP, Sao Paulo, Brazil.

ABSTRACT
Purpose: To evaluate a technique to remove the thoracic esophagus without thoracotomy and two methods for thoracic esophageal
replacement in dogs. Methods: 27 ex-vivo dogs were divided into three groups in order to evaluate: G1 – total thoracic esophagectomy
by the everting stripping method; G2 – total thoracic esophagectomy and esophageal substitution using the whole stomach; G3 – total
thoracic esophagectomy and esophageal substitution using fundus rotation gastroplasty. After esophageal resection in G1, the integrity
of the intrathoracic route was evaluated by endoscopy and tested with 1% methylene blue solution. Results: Visceral pleural rupture
was observed in all animals. However, this intrathoracic route made it possible to bring both esophagus substitutes (G2 and G3) to be
anastomosed to the cut end of the cervical esophagus. Conclusions: Thoracic esophageal substitution using the whole stomach
showed less anastomotic tension and was less technically demanding than the fundus rotation gastroplasty method. The ex-vivo
results support further studies to validate the techniques in clinical cases.
Key words: Surgery. Esophagectomy. Esophagus. Endoscopy. Dogs.

RESUMO
Objetivo: Avaliar, em cadáveres de cães, uma técnica para remoção do esôfago torácico sem toracotomia e dois métodos de substituição
do esôfago torácico. Métodos: Foram utilizados 27 cadáveres de cães. Estes foram aleatoriamente divididos em três grupos de nove
animais, em que se estudou: G1 – esofagectomia torácica total pelo método de invaginação retrógrada; G2 – esofagectomia torácica
total com substituição esofágica pelo estômago inteiro; G3 – esofagectomia torácica total com substituição esofágica por um gastrotubo
confeccionado de acordo com a técnica de Büchler de gastroplastia por rotação do fundo. Após a ressecção esofágica no grupo 1, a
integridade da rota intratorácica foi avaliada por endoscopia e solução de azul de metileno a 1%. Resultados: A ruptura da pleura
visceral ocorreu em todos os animais, especialmente no terço caudal. Entretanto, a rota transtorácica mediastinal permitiu a elevação
de ambos os substitutos esofágicos (G2 e G3) para a realização da anastomose com a extremidade caudal do esôfago cervical.
Conclusões: A substituição por estômago inteiro apresentou menor tensão na anastomose, maior facilidade e rapidez comparada à técnica
de gastroplastia por rotação do fundo. Os resultados em cadáveres suportam a realização de estudos clínicos para validação da técnica.
Descritores: Cirurgia. Esofagectomia. Esôfago. Endoscopia. Cães.
1
Research performed at Experimental Laboratory of Department of Veterinary Surgery and Anesthesiology, School of Veterinary Medicine of Botucatu,
State University (UNESP), Sao Paulo, Brazil.

Introduction advantages and disadvantages5. These organs are mobilized to be

Esophageal diseases have sometimes been considered a
therapeutic challenge in dogs. If major areas of the esophagus have
been compromised complex surgical procedures to repair, to
remove or to substitute the compromised area are required1,2,3.
Esophagectomy that consists of a complete or partial
resection of the esophagus is usually used in human medicine4.
Total thoracic esophagectomy is performed, in general, using the
transthoracic route, transhiatal approach without thoracotomy
or by thoracoscopy. The removed esophagus is replaced using
the stomach, colon, or small bowel, and each procedure has
anastomosed to the cut end of the cervical esophagus using several
routes.
The ideal esophageal substitute should conform in size
and in function to the original structure especially regarding
peristaltic activity; it should not occupy too much space in the
thorax; and the patient should be able to swallow normally and
experience no reflux symptoms4. Additionally, in pediatric patients
the esophageal substitute should be able to withstand without
deterioration during temporal evolution4.
In dogs, thoracic esophageal replacement by small
intestine or colon is hampered by limited mobility of the vascular

353 - Acta Cirúrgica Brasileira - Vol. 24 (5) 2009


pedicle 2 . In addition the use of free colon autograft with
microvascular anastomosis has shown unsatisfactory results in
experimental studies6. In this way, substitutes for the esophagus
created from the stomach may be a better alternative.
The use of the whole stomach or gastric tubes as
substitutes for the esophagus are common procedures in human
patients7, but there are few clinical reports of their use in small
animals1. The present study evaluated a technique to remove the
thoracic esophagus without thoracotomy and two methods for
thoracic esophageal replacement in dogs, ex vivo, aiming at the
treatment of diseases associated with this species.
Methods
This study followed the guidelines for the care and use of
laboratory animals and was approved by the Ethics Committee of
our Veterinary School.
Twenty-seven dogs that had died or been euthanatized
due to reasons unrelated to this study were used; 12 males and 15
females, weighing 2-20 kg (median 6 kg), and aged 2 months to 10
years old (median 3 years and 2 months). The time between death
and accomplishment of the experiment did not exceed 24 hours.
FIGURE 1 – Illustration of the gastric vessels and the ligatures of their tributaries: (RG) Right gastric artery. (LG) Left gastric artery.
(SG) Short gastric arteries. (RGE) Right gastroepiploic artery. (LGE) Left gastroepiploic artery
Esophagectomy and substitution of the thoracic esophagus in dogs
The dogs were randomly divided into three groups of nine
animals each in order to evaluate: G1 – total thoracic esophagectomy
by the inverting stripping method; G2 – total thoracic
esophagectomy and esophageal substitution using the whole
stomach; G3 – total thoracic esophagectomy and esophageal
substitution using fundus rotation gastroplasty.
Surgical procedures
GROUP 1
Each dog was positioned in dorsal recumbency. The
ventral neck, thorax and abdomen were clipped, prepared, and
draped. A semi-rigid latex was orally placed into the lumen of the
stomach. The surgical procedure consisted of three main steps:
1. The abdomen was opened via midline incision
extending from the xiphoid to the caudal to the umbilicus. The
right gastric branches, right and left gastroepiploic branches were
ligated, but the vascular arcades were preserved. The short gastric
vessels and the left gastric vessels were ligated (Figure 1) and
the liver were retracted to expose the esophageal hiatus. The
gastroesophageal junction area was bluntly isolated.
Acta Cirúrgica Brasileira - Vol. 24 (5) 2009 - 354
Santos CEM et al
2. A ventral midline skin incision was made from the
middle third of the neck to the manubrium. To expose the caudal
cervical esophagus, the trachea and right carotid sheath were
retracted to the right.
3. The orogastric tube was pulled out through the
mouth so that two atraumatic clamps could be placed in the
gastroesophageal junction. An incision was made between the
clamps, and the cranial clamp was removed (Figure 2). The tube
was pulled caudally to protrude through the abdominal cavity,
FIGURE 2 – Points of incision of the esophagus (arrows) (cervical
esophagus and gastroesophageal junction)
355 - Acta Cirúrgica Brasileira - Vol. 24 (5) 2009
maintaining its proximal tip at the level of thoracic entrance. The
cervical esophagus was transected obliquely about 2cm from the
thoracic entrance (Figure 2). The caudal edge of the esophagus
incision was held to the tube’s proximal tip using four equidistant
simple interrupted sutures (Figure 3). The tube protruding from
the abdominal cavity was pulled gently and caudally, allowing the
esophagus inverting stripping. The esophagus was pulled through
the thorax in the direction of the abdominal cavity (Figure 3). The distal
esophagus remained attached to the diaphragm, and it was occluded.
FIGURE 3 – The edge of the esophagus incision was held to the tube’s
proximal tip using four equidistant simple interrupted sutures (arrow A).
The tube protruding from the abdominal cavity was pulled gently and
caudally (arrow B), allowing the esophagus inverting stripping
 Esophagectomy and substitution of the thoracic esophagus in dogs

4. The integrity of the intrathoracic route was evaluated
by videoendoscopy. The endoscopy was advanced to the heart base
level since after this point the visceral pleura could be injured. 1%
methylene blue solution was used to test for leaks. For this, the
operating table was elevated at 15 degrees and a cranial portion of
the sternum was removed for better observation.
GROUP 2
The dogs were positioned and prepared as previously
described for Group 1. The vessels and branches were isolated and
ligated as previously described for Group 1, for mobilization of
the greater and lesser curvature of the stomach. Heineke-Mikulicz
pyloroplasty was performed. The gastroesophageal junction was
divided, and the cut edge of the stomach was closed in two layers
with the first using a continuous suture and the second layer using
a continuous inverting seromuscular suture.
Total thoracic esophagectomy by the inverting stripping
method was performed as in Group 1. However, a second tube was
sutured together with the orogastric tube and the edge of the
esophagus, one inside the other (Figure 4). The orogastric tube
was removed during esophagectomy. The most distal part of the
second tube was sutured to the fundus region of the stomach using
four simple interrupted seromuscular sutures.
The stomach was pulled through the thorax in the
direction of the cervical region by pulling the proximal tip of
the second tube (Figure 5). After tube removal, a stomach stoma
was made and anastomosed to the cut end of the cervical
esophagus. Three equidistantly suture stitches were initially
placed. Additional full-thickness simple continuous pattern
sutures were then placed between the stitches until completely
closed.
The mobilized stomach wall was anchored to
diaphragmatic hiatus with two simple interrupted sutures to
prevent subsequent herniation. The celiotomy incision was closed
in a routine manner.
The esophagus and mobilized stomach were evaluated
using videoendoscopy.

FIGURE 4 – Esophagus removal by traction of the main tube and maintenance of the accessory
tube in the thoracic course

FIGURE 5 - (a) Accessory tube with one of its extremities in the cervical region and another sutured to
the stomach. (b) Traction of the accessory tube and exteriorization of the stomach in the cervical region

Acta Cirúrgica Brasileira - Vol. 24 (5) 2009 - 356

Santos CEM et al

GROUP 3

The gastric vessel ligatures, piloroplasty,

exposure and cut of the cervical esophagus were
similar to those described in Group 2.
Gastroplasty was performed beginning by
a horizontal cut of the lesser curvature distally to
the gastric stoma. The cut was extended following
the greater curvature toward the fundus-corpus
region 3 cm from the pyloric antrus and redirected
toward the lesser curvature to a point 1-2 cm
distally to the starting point. The gastric tube with
2 to 3 cm in diameter was built by the fundus, and
most of the gastric corpus and antrus formed the
neostomach (Figure 6). The edges of the
neoesophagus and neostomach were double-layer
apposed.
Total thoracic esophagectomy by the
inverting stripping method was performed as
described in Group 2, and the most distal part of
the second tube was sutured externally to the
neoformed gastric tube stoma. The neoformed
gastric tube was pulled through the thorax in
the direction of the cervical region by pulling
the proximal tip of the tube orally. The other
procedures were performed as described in
Group 2.

C o r re l a t i o n b e t w e e n a n a t o m i c a l
proportions and anastomotic tension

Because of the need to compare the

interferences of the anatomical measures in the
result of the surgical techniques in different sized
animals, it was necessary to have the individuals’
made uniform through the calculation of their
anatomical proportions. The anatomical proportions
were calculated for G2 and G3 dogs: between the
distance from the larynx to the pubis and from the
larynx to the xiphoid (proportion I); between the
esophageal substitute length and the distance of
the hiatus to the gastroesophageal anastomosis FIGURE 6 – Illustration of the steps for construction of a gastric tube according to
(proportion II); between the distance from the the fundus rotation gastroplasty technique
larynx to the xiphoid and the esophageal substitute
length (proportion III); between the distance from
the gastroesophageal anastomosis to the larynx
and the distance from the larynx to the pubis Results
(proportion IV); between the distance that the
esophageal substitute transcended the cut end of GROUP 1
the cervical esophagus and the distance from the
larynx to the pubis (proportion V). Esophagectomy by the inverting stripping method showed to be
easily performed in all animals since the esophagus was released by slight
Statistical analysis traction of the tube. According to endoscopic evaluation, small hemorrhage
points were observed in the medial (n=3) and caudal (n=1) thirds of the pleural
Pearson correlations were used when cavity. Pleural rupture was verified in three animals. The application of 1%
comparing Proportion V with the other Proportions. methylene blue aqueous solution showed pleural rupture in all animals, which
In order to compare Proportions V of Groups 2 was more frequent in the left caudal portion near the diaphragm (Table1).
and 3, the Wilcoxon nonparametric test for two The speed with which the solution filled the thoracic cavity was proportional to
independent samples was used. the extension and the number of ruptures.

357 - Acta Cirúrgica Brasileira - Vol. 24 (5) 2009

 Esophagectomy and substitution of the thoracic esophagus in dogs

TABLE 1 - Evaluation of the channel formed after thoracic esophagectomy by the inverting stripping method
as shown by endoscopic examination and methylene blue solution
Pleural rupture Pleural rupture Third of the Other
Dog
(endoscopic (methylene channel affected endoscopic
(number)
visualization) blue) by the rupture findings

1 P P RCr, LCr, LCa

2 A P LCa SP

3 A P LCa

4 P P RM

5 A P LM MHp

6 A P LCa SP/ MHp/ CaHp

7 A P LCa MHp

8 P P LCa , RCa

9 A P LCa

P, present. A, absent. RCr, right cranial. LCr, left cranial. LCa, left caudal. RM, right medial. LM, left
medial. RCa, right caudal. SP, slim pleura in the rupture locality. MHp, medial hemorrhagic point. CaHp,
caudal hemorrhagic point

GROUP 2

In one dog, the length of the short gastric vessels was
reduced, and the spleen was closely connected to the stomach. Seven
dogs showed direct extramural communication between the right
and left gastroepiploic arteries, and in two dogs such communication
was indirect. Removal of the thoracic esophagus by the inverting
stripping method was problematic in one dog showing an anatomic
curve proximally to the cardia, which prevented the tube from
reaching the stomach. Hence, the esophagogastric junction was
sectioned without passing the tube, and the accessory tube was
inversely pulled by endoscopic procedures. The esophageal
substitute reached the anastomotic region in all animals. The edge
of the suspended stomach exceeded the anastomotic region with
an average of 2.62% of the animals’ measure (Table 2).
Proportions II and III interfered with anastomotic tension
(Table 2), and there was no anastomotic tension for Proportion II
greater than 1.05 or Proportion III greater than 0.79. According to
the endoscopic evaluation, the region of the esophagogastric
anastomosis was closed during the first visualization, but it was
easily opened with a touch by a gastroscope in all animals. No
openings, leaks or lacerations were detected in the anastomotic
region. The esophageal channel consisting of the whole stomach
showed to be continuous and without obstructions (Figure 7).
The organ’s lumen was always greater than the esophageal lumen,
with longitudinal folds towards the stomach’s positioning.

TABLE 2 - Means of the anatomical proportionalities of dogs in groups 2 and 3

Proportion Proportion Proportion Proportion Proportion

I II * III* IV V (%)

G2 1.87 1.15* 0.85* 0.08 +2,62

G3 1.87 1.12* 0.83* 0.08 -0.46a / -7.05 b**

* p<0.05 (statistical comparison between Proportion V and the other Proportions). (a) neostomach inside
the thoracic cavity. (b) neostomach inside the abdominal cavity. **p<0.05 (statistical analysis between
groups 2 and 3); (+) opening of the gastric tube surpasses the esophageal section; (-) opening of the
gastric tube does not reach the esophageal section

Acta Cirúrgica Brasileira - Vol. 24 (5) 2009 - 358

Santos CEM et al
FIGURE 7 – Endoscopic evaluation of the esophagus replacement by the whole stomach:
lumen of the suspended stomach
GROUP 3
In one dog, the left artery and gastric vein were located
very close to the splenic vein and the caudal cava vein, and in
another the left gastric artery was adjacent to the gastric wall, which
required more careful dissection. In three animals, indirect extramural
communication between the right and left gastroepiploic arteries
was observed. In one dog, the rupture of the suture stitches applied
between the esophagus and the tube occurred when the esophagus
was removed, and further fixation was necessary. In all dogs, the
neostomach formed presented an appendix shape. Except for one
case in which gastric tube rupture occurred, the esophageal
substitute reached the distal cervical region of all animals;
however, that only took place when the neostomach was positioned
in the thoracic cavity. Five animals did not show tension in the
anastomotic region. The gastric tube extremity was away from the
anastomotic region with an average of 0.46% and 7.05% of the
animals’ measure when the neostomach was inside the thoracic
and abdominal cavities, respectively (Table 2). There was no
anastomotic tension for Proportion II greater than 1.13 or
Proportion III greater than 0.84 in the measurements taken with
the neostomach in the thoracic cavity. According to endoscopic
evaluation, the esophagogastric anastomotic region was closed
when firstly visualized, but it was later easily opened with a touch
by a gastroscope. No openings, leaks or lacerations were detected
in the anastomotic region. The course of the gastric tube was
continuous and regular, and showed a larger diameter than that of
359 - Acta Cirúrgica Brasileira - Vol. 24 (5) 2009
the cervical esophagus and a smaller diameter than the gastric
one. The “neostomach” had a larger diameter and, according to
retroflexion visualization, a type of sphincter was observed which
separated it from the gastric tube itself (Figure 8). In five dogs,
lateralization of the pylorus occurred, which made the passage of
the endoscope difficult (n=1) or impossible (n=4).
Discussion
The choice for the esophageal removal technique depends
on a number of factors such as type and location of the primary
lesion, safety and feasibility of the approach, patient condition, and
even the surgeon’s preference8. Esophagectomy by the inverting
stripping method as used in the present experiment was considered
to be a simple and effective procedure to remove the thoracic
esophagus in dogs, minimizing surgical time and the complications
associated with a thoracic approach. It was based on the technique
described by Ferreira9, who developed and successfully tested it
in 10 dogs, and further in human patients10.
Transhiatal resection has the advantages of avoiding
thoracotomy, reduced surgical trauma, and less pulmonary
complications5,11. The endoscopy performed after esophagectomy
in the dogs in Group 1 showed few and small areas of bleeding.
During evaluation 48 hours after esophagectomy without
thoracotomy in dogs, inexpressive hematoma, and no injury to
tissue and organs were observed by Ferreira9.

FIGURE 8 – Fundus rotation gastroplasty: retroflexion image showing the limit between
the gastric tube and the “neostomach”
An important limitation of esophagectomy by the
inverting stripping method is type and extension of the lesion.
In cases of infiltrative tumors for example, a direct vision of
compromised structures is necessary12. Esophagectomy without
thoracotomy has been used in human patients especially in cases
of megaesophagus8,10,13 or corrosive injuries5. Since the mediastinal
pleura is delicate and directly adhered to the adventice, pleural
rupture was observed, by endoscopy and the methylene blue
solution test in all animals in Group 1 after esophagectomy.
Hence, mechanical ventilation during the procedure and a
drainage system postoperative are necessary in cases in vivo.
There are several controversies concerning thoracic
esophageal replacement using the stomach as a tube, semitube or
whole stomach7,14. Besides the factors related to the adequacy of
blood supply, in dogs, the capacity of emptying the esophageal
substitute in a quadrupedal position should be considered.
Various techniques for isoperistaltic or antiperistaltic
gastric tubes have been proposed 15,16,17,18,19 . In the present
experiment, fundus rotation gastroplasty was used, which,
according to the authors20 has advantages in human patients, such
as the increase in the length of the gastric tube, increase in blood
flow at the tip of the gastric tube, and increase in the gastric reservoir
since it requires resection of a small part of the gastric corpus.
The tributaries of the right gastric vessels are maintained
in the fundus rotation gastroplasty used in human patients20.
However, in dogs, some differences were observed. The ligature
of the left gastric artery and vein was necessary to allow anastomosis
Esophagectomy and substitution of the thoracic esophagus in dogs
of the esophageal substitute with the cervical esophagus. For the
same reason, the ligature of the branches of right gastric vessels
was caudal rather than that usually used in human patients20. In
addition, in 8 dogs in Group 3, the gastric tube length was
inadequate for tension-free anastomosis, and the neostomach
was positioned inside the thoracic cavity. These differences are
probably associated with the length of the canine thorax.
On the other hand, esophageal substitution using the whole
stomach required less suture procedures. In addition, according to
the correlation between anatomical proportions and anastomotic
tension, the whole stomach technique, contrarily to fundus
rotation gastroplasty, surpassed the anastomotic region, indicating
that the use of whole stomach probably induces less anastomotic
tension. The significant relation between the absence of tension
and Proportion III enables the surgeon to obtain a previous
prognosis of the anastomotic tension by observing the patient’s
measures. The use of the measures of proportionalities allowed the
comparison of animals of different sizes, common in the studied
specie, therefore although their absolute measures are different,
the proportion among their anatomical segments is similar.
The whole stomach occupied more space in the thorax
than did the gastric tube, suggesting that the adjacent organs may
be compressed by alimentary content. However, radiographic studies
in human patients showed that the mobilized stomach acquires a
tubular shape during the course of time, and food is propelled chiefly
by gravity13. This last observation may be a problem in dogs.
Bemelman and others7 use a tubulized stomach without pyloroplasty
Acta Cirúrgica Brasileira - Vol. 24 (5) 2009 - 360
Santos CEM et al
and not the whole stomach because the gastric remnant must be
small and with a low compliance to prevent delayed gastric
emptying. In the present study, the gastric tube was smaller than
the whole stomach, but gastric tube tension with pylorus deviance
in 5 dogs made the endoscope passage difficult, thus suggesting
that the same may occur to the passage of food content.
According to the results, it was possible to conclude that
total thoracic esophagectomy by the inverting stripping method
was an effective procedure to remove the thoracic esophagus, and
the whole esophageal substitution using the whole stomach or
fundus rotation gastroplasty can be used for thoracic esophageal
replacement. The ex-vivo results support further studies to validate
the techniques in clinical cases of dogs requiring substitution of
the intrathoracic esophagus.
References
1- Colgrove DJ. Transthoracic esophageal surgery for obstructive lesions
caused by Spirocerca lupi in dogs. J Am Vet Med Assoc.
1971;158(12):2073-6.
2- Parker NR, Caywood DD. Surgical diseases of the esophagus. Vet Clin
North Am Small Anim Pract. 1987;17:333-57.
3- Ranen E, Shamir MH, Sharar R, Johnston DE. Partial essophagectomy
with single layer closure for treatment of esophageal sarcomas in 6 dogs.
Vet Surg. 2004;33(4):428-34.
4- Spitz L, Kiely E, Pierro A. Gastric transposition in children-a 21-year
experience. J Pediatr Surg. 2004;39(3):276-81.
5- Gupta NM, Gupta R. Transhiatal esophageal resection for corrosive
injury. Ann Surg. 2004; 239(3):359-63.
6- Holmberg DL, Kuzma AB, Miller CW. Free bowel transfer for
esophageal reconstruction in the dog. Microsurgery. 1991;12:140-4.
7- Bemelman WA, Taat CW, Slors JF, van Lanschot JJ, Obertop H.
Delayed postoperative emptying after esophageal resection is dependent
on the size of the gastric substitute. J Am Coll Surg. 1995;180(4):461-4.
8- Pinotti HW, Pollara WM, Raia AA. Tratamento cirúrgico do megaesôfago
avançado pela esofagectomia subtotal por via cérvico-abdominal sem
toracotomia com abertura do diafragma. Rev Assoc Med Bras.
1980,26(10):339-42.
Correspondence:
Dra Sheila Canevese Rahal
Department of Veterinary Surgery and Anesthesiology
Distrito Rubião Jr, s/n
18618-000 Botucatu – SP Brazil
Phone/Fax: (55 14)3811-6054
sheilacr@fmvz.unesp.br
How to cite this article
Santos CEM, Rahal SC, Damasceno DC, Hossne RS. Esophagectomy and substitution of the thoracic esophagus in dogs. Acta Cir Bras.
[serial on the Internet] 2009 Sept-Oct;24(5). Available from URL: http://www.scielo.br/acb
*Color figures available from www.scielo.br/acb
361 - Acta Cirúrgica Brasileira - Vol. 24 (5) 2009
9- Ferreira EAB. Subtotal esophagectomy through cervico-abdominal
incision and its possible use in the surgical management of megaesophagus.
Rev Paul Med. 1973;82:133-4.
10- Ferreira EAB. Esophagogastroplasty and esophagocoloplasty through
the posterior mediastinum without thoracotomy: a preliminary note.
Rev Paul Med. 1974;82:142.
11- Gockel I, Sultanov FS, Domeyer M, Goenner U, Junginger T.
Developments in esophageal surgery for adenocarcinoma: a comparison
of two decades. BMC Cancer. 2007;7:114.
12- Gockel I, Heckhoff S, Messow CM, Kneist W, Junginger T. Transhiatal
and transthoracic resection in adenocarcinoma of the esophagus. Does the
operative approach have an influence on the long-term prognosis? Word J
Surg Oncol. 2005;3:1-11.
13- Pinotti HW, Cecconello I, Rocha JM, Zilberstein B. Resection for
achalasia of the esophagus. Hepatogastroenterology. 1991;38:470-3.
14- Di Benedetto V, Dessanti A. Experimental technique of esophageal
substitution: intrathoracic interposition of a pedunculated gastric tube (PGT)
preserving cardiac function. Preliminary results. Hepatogastroenterology.
1998;45:2202-5.
15- Swenson O, Magruder LT. Experimental esophagectomy. Surgery.
1944;6:954-63.
16- Yamagishi M, Ikeda N, Yonemoto T. An isoperistaltic gastric tube.
Arch Surg. 1970;100:689-92.
17- Akiyama H, Hiyama M, Hashimoto C. Resection and reconstruction
for carcinoma of the thoracic oesophagus. Br J Surg. 1976;63:206-9.
18- Yamato T, Hamanaka Y, Hirata S, Sakai K. Esophagoplasty with an
autogenous tubed gastric flap. Am J Surg. 1979;137:597-602.
19- Lazar G, Kaszaki J, Abraham S, Horvath G, Wolfard A, Szentpali K,
Paszt A, Balogh A, Boros M. Thoracic epidural anesthesia improves the
gastric microcirculation during experimental gastric tube formation.
Surgery. 2003;134(5):799-805.
20- Büchler MW, Baer HU, Seiler Ch, Schilling M. A technique for
gastrosplasty as a substitute for the esophagus: fundus rotation gastroplasty.
J Am Coll Surg. 1996;182:241-5.
Acknowledgement
To Research Support Center (GAP-UNESP) for their
valuable contribution in statistical analysis and English review.
Conflict of interest: none
Financial source: FAPESP (Process nº 06/00133-7)
Received: March 23, 2009
Review: May 19, 2009
Accepted: June 25, 2009
 TEKNIK OPERASI
OESOPHAGOTOMY DAN
OESOPHAGOSTOMY

Varhan Dwiyan Indra 1809511044

Ferdy Olga Saputra 1809511050
Maharani Lisna Wulandari 1809511056
Kelas B
 Terminologi Indikasi
Insisi pada dinding esophagus • Obstruksi esophagus
untuk membuka lumen • Benda asing
esophagus. Oesophagotomy • Anoreksia
dapat dilakukan secara • Atresia esophagus
longitudinal atau transversal • Achalasia
tergantung dari tujuan. • Cedera kaustik mucositis
Oesophagotomy dan
oesophagostomy dibedakan
berdasar hasil akhir proses
pembedahan
Anestesi dan Premedikasi
• Premedikasi

ACP dan bruphenorphine (0.02 mg/kg BB)

IM

• Anestesi umum

Xylazine dan Ketamine

 Preoperasi
01 Pasien: Hewan dipuasakan selama 12 jam sebelum operasi dengan
tujuan untuk menghindari muntah akibat dari pemberian anestesi dan
juga untuk mengosongkan esophagus agar tidak terkontaminasi saat
dilakukan pembedahan.

02 Alat: Peralatan yang digunakan dalam pembedahan ini adalah scalpel

holder, needle holder, towel clamp, blade, jarum, needle, drepe, tampon,
benang operasi (silk untuk kulit dan chromic untuk organ dalam).

03 Bahan: bahan-bahan yang digunakan dalam pembedahan ini antara

lain alcohol 70%, iodium tincture 3%, NaCL fisiologis, obat
premedikasi (Atropin sulfat), obat anestesi (ketamin dan xylazine),
benang catgut cromic dan nilon.
 Operasi
1. Teknik operasi Oesophagotomy
● Sebelum dilakukan operasi hewan harus di persiapkan Gambar 1. Irisan Ventral
terlebih dahulu, rambut dicukur dan kulit dipersiapkan secara Midline Cervicalis
aseptis.
● Setelah teranestesi hewan dibaringkan pada posisi dorsal
recumbency (hewan kecil) dan dibaringkan ke sebelah kanan
(hewan besar).
● Pada hewan kecil dilakukan irisan pada bagian tengah ventral
leher (ventral midline cervicalis) dari larynx ke sternum
● Muskulus strenohyoideus dan sternocleidomastoideus kiri Gambar 2. Muskulus
dan kanan dipreparasi secara tumpul sehingga terlihat Strenohyoideus dan
trachea. Sternocleidomastoideus Kiri
● Esophagus terletak disebelah kiri daripada trachea dan dan Kanan Dipreparasi
dengan preparasi tumpul terlihat lebih jelas. Irisan pada
esophagus dibuat secara longitudinal dan benda asing
(corpora aliena) dikeluarkan.
● Esophagus dijahit dengan 4-0 chromic catgut secara simple
interrupted. Muskulus tidak perlu dijahit, kulit dijahit dengan
Gambar 3. Irisan pada
benang non absorbable secara simple interrupted. Esophagus dibuat Secara
Longitudinal
 2. Teknik Operasi Oesophagostomy
• Hewan yang telah teranestesi dibaringkan secara lateral recumbency dan semua rambut yang
mungkin mengkontaminasi pada daerah leher yang akan di insisi atau dapat mengganggu
daerah insisi dicukur.
• Untuk menentukan bagian yang di insisi dapat dimasukkan forceps kedalam rongga mulut
menuju esophagus.
• Setelah berada di esophagus forceps di angkat ujungnya untuk membuat benjolan pada
esophagus yang menandakan bagian yang akan di insisi.
• Insisi dilakukan untuk membuka kulit dan kemudian esophagus yang besar sayatannya
bergantung pada besaran tube yang akan dipasang.
• Tube dimasukkan dengan bantuan forceps tadi kemudian di balikkan menuju lambung.
• Setelah itu tube dapat di fiksasi dengan menggunakan bantuan perban ataupun plester agar
tidak bergerak ataupun berpindah.

Gambar 4. Membuat sayatan kecil Gambar 5. Membuka forceps, pegang Gambar 7. Ketika sudah ditempatkan
sampai mengenai ujung forceps ujung distal dari saluran Gambar 6. Gunakan hemostat dengan benar, akhir feeding selang
bagian kanan esophagostomy, dan mengunci forceps untuk meligasi saluran akan "dibengkokkan" dari caudal ke
esophagus cranial.
Pascaoperasi
Setelah operasi hewan dipuasakan selama 4-6 hari, makanan
diberikan secara parenteral (infuse), dan diberi pengobatan.
Pada kasus Oesophagostomy pantau peletakan feeding tube
dan perawatan luka pasca operasi. Untuk mencegah infeksi
dapat diberikan antibiotik secara intramuskuler maupun
multivitamin untuk menjaga kondisi tubuh.
Terima kasih