Retrograde esophageal intubation

Abstract

Intrathoracic esophageal injury can be treated using conventional surgical techniques, including buttressed closure, T-tube drainage, resection, and exclusion with diversion. If esophageal replacement is necessary, stomach, left or right colon, and jejunum are commonly used conduits. Problems arise when esophageal drainage and diversion is necessary in patients with prior gastrectomy. This problem compounds when planning esophageal reconstruction in those with previous colectomy because preserving esophageal length is crucial. We developed the technique of retrograde esophageal intubation, and we have successfully used it in three patients requiring total or near total gastrectomy and concomitant colon resection as part of damage control laparotomy. The injuries resulted from penetrating trauma in two patients and a failed gastric bypass in one. The technique involved retrograde placement of an Ewald tube through the skin into the open, distal esophagus, creating a controlled esoghagocutaneous fistula. The restoration of gastrointestinal continuity was performed 6 months after the initial injury. The reconstructive procedure was based on the precise anatomy involved. Esophagogastrostomy, loop gastrojejunostomy, and Roux-en-Y esophojejunostomy were used in one patient. Each developed an anastomotic leak, which all resolved with simple drainage. Retrograde esophageal intubation is simple, can be used long-term, and allows control of esophageal secretions without cervical esophagostomy. Esophageal length is preserved and can be used as part of a damage control operation.