Anastomosis instead of resection: An unusual approach for the treatment of a cervical esophageal duplication cyst

Katharina Wenke, Konrad Reinshagen
2014 Journal of Pediatric Surgery Case Reports  
We report of a 5 year old boy with severe dysphagia. He was operated upon a tubular esophageal duplication located in the upper right mediastinum. Due to the existing severe esophageal stricture the malformation was not resected but unified with the originary lumen of the esophagus using a stapled anastomosis. Access was chosen via low collar incision. During follow up no further stricture occurred. The resection of esophageal duplications is the therapy of choice. In our case, union with the
more » ... e, union with the originary organ was performed due to its distinctive anatomical conditions. Besides the collar incision, as an access to an upper mediastinal mass, is a rather uncommon but safe technique to manage such malformations in children. Follow up investigations to eliminate formation of malignancies are recommended. The operative technique in this case is uncommon and has not been described in esophageal duplications yet. It should be considered as an operative strategy for specific anatomical conditions. Ó 2014 The Authors. Published by Elsevier Inc. Esophageal duplication cysts are rare, mostly asymptomatic, congenital anomalies. Most of them are located in the distal thoracic part of the esophagus. Localization in the upper part of the esophagus is rather uncommon and is a challenge to pediatric surgeon. Symptoms are caused by the compressive effect on mediastinal structures or due to local infection [1e4]. Localization in the upper part of the esophagus can lead to dyspnea, particularly in the infant [2] . Dysphagia, as in our case, represents the most common symptom in the older child or adolescent [1]. Surgical resection is indicated in all symptomatic lesions and has to be considered for asymptomatic cysts to prevent complications [2,4e6]. Case report A five year old boy was referred to our hospital with a history of dysphagia since birth. He regurgitated while swallowing lumpy food so an esophageal stricture was suspected. The child was hospitalized in a different institution where an endoscopy and an MRI were carried out. The endoscopy showed an esophageal stricture of unknown origin. Biopsies showed inflammation of the mucosa but the etiology remained unresolved. An MRI-study showed a mass in the upper dorsal mediastinum. The patient was then transferred to the department of radiology of our institution. An additionally conducted CT-scan ( Fig. 1) verified the upper esophageal stricture with a shift of the trachea to the right caused by a mass of the upper mediastinum. No concomitant malformations were seen in other sites. The radiological aspects lead to the suspect of a foregut duplication cyst or a lyomyoma. A contrast study showed a double lumen of the esophagus (Fig. 2) , so that the diagnosis of a tubular esophageal duplication was most likely. Thus an intervention under general anesthesia was arranged. Performing inversion in esophagoscopy (Fig. 3) a septum in the distal esophagus was detected and the diagnosis of a tubular duplication cyst of the esophagus with distal communication was verified. To clarify anatomy of the proximal esophageal wall in the cervicothoracic junction, where the duplication was assumed, the operation was planned via a low transverse collar (Kocher's) incision. Identifying the trachea which was put aside with hooks, the esophagus could easily be exposed and armed. The esophagus appeared slender in the very proximal part and thicker in the subsequent (duplicated) part in the thoracic inlet. The outer esophageal wall appeared homogenous. This finding was compatible with a tubular esophageal duplication. In the esophagus the nasogastric tube was palpable. The esophagus was opened and the gastric tube was identified. Since the right sided esophagus appeared to be thick walled, a second esophagotomy on the right side of the esophagus was carried out. Thus a second lumen could
doi:10.1016/j.epsc.2014.01.013 fatcat:luthcr4jg5ha3n4rez5jg2caje