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Review Article: Assessment and Surgical Management of Oesophageal Disease

This article comprises a brief overview of the investigation and surgical treatment options for various oesophageal disorders.

History and Clinical Presentation.

fig.1 - fishing hook lodged in mid thoracic oesophagus.

Timing, speed of onset and progression of clinical signs may narrow a likely differential list; congenital problems such as stricture secondary to vascular ring anomaly or non-acquired myasthenia gravis may have shown progressive signs for months, or even years.  Such animals will often be underweight, but may otherwise appear clinically normal.  Foreign bodies may have an accompanying history of ingestion of the offending object, but the level of distress exhibited by the patient is usually dependant on the degree of oesophageal compromise (fig.1).

The majority of affected animals will regurgitate their food.  However, it can sometimes be difficult for owners to determine the difference between passive regurgitation and active retching.  Careful history taking and a period of hospitalisation for close observation can be useful in stable cases.  Despite this, animals with gastric motility disorders may mimic signs of oesophageal dysfunction.  In addition, animals with oesophageal disease may have concurrent GI problems which can complicate clinical findings. With peracute onset, patients may be seen to drool excessively, or may present in shock, secondary to sepsis or metabolic disturbances.

Initial Assessment.

Cervical oesophageal masses and foreign bodies may be palpable in thin animals if located in the mid-cranial portion of the neck.  Haematology may reveal a leucocytosis, particularly if there is secondary aspiration pneumonia or necrosis of the oesophageal wall, with dissecting cellulitis or, worst case, mediastinitis.  Routine biochemistry may reveal electrolyte disturbances and/ or hypoproteinaemia due to malnutrition which might have implications for wound healing.

Further Investigations.

fig.2 - Parasagittal MR-scan of the peri-oesophageal tissues; there is a high signal (cellulitis) dorsal to the larynx with voiding of signal centrally;the stick fragment.

Endoscopy is indispensible where a stricture is suspected, as balloon-dilatation may be performed without delay.  It is also used for rapid, non-invasive biopsy of lumenal masses and manipulation of foreign bodies. 

fig.3 - Transverse T2W MR-scan of the cervical region of an eight-year-old Springer Spaniel presenting with regurgitation, anorexia and dyspnoea; there is an expansile. infiltrative mass, involving the oesophagus which compressing the trachea.

MRI is very useful when attempting to locate perioesophageal foreign bodies (e.g. stick fragments, see fig. 2) or assessment of neoplastic masses with respect to surgical planning (fig. 3).

 

Treatment.

Management of medical conditions is outside the scope of this article.  Historically, healing of the oesophagus has been described as poor.  However, careful tissue-handling with preservation of the blood-supply (including possible augmentation of the repair with an omental pedicle) will result in much lower rates of dehiscence.  A successful  outcome will be further aided by peri-operative placement of a gastrostomy feeding tube to ensure adequate nutrition during the critical early healing phase.  However, post-operative stricture formation remains a common complication of oesophageal surgery; it should be recognised early and managed aggressively to minimise long term problems.

fig.4 - lateral radiograph of crossbred dog with a bone-fragement lodged at heart-base in thoracic oesophagus

Various surgical approaches to the oesophagus are used, depending on the location and nature of the oesophageal lesion—it may be worth considering an open thoracotomy in cases where there is a risk of causing further trauma when trying to remove an embedded foreign body in a mistaken attempt to avoid thoracic surgery (e.g. fig. 1).  Nevertheless, many foreign bodies can be gently pushed passed the site of obstruction (commonly dorsal to the heart-base as in fig. 4) into the stomach to be removed via gastrotomy as necessary.  Alternatively, it may be possible to remove the object per os using grasping forceps, ideally under endoscopic guidance.

fig.5 - lateral, positive contrast radiograph of a 10-month-old Rough Collie with a prestenotic diverticulum secondary to vascular ring anomaly

Strictures may occur secondary to vascular ring anomalies.  In chronic cases, a secondary, pre-stenotic diverticulum may form, but such cases should be given a guarded prognosis for return to normal function post surgery (fig. 5).

In summary, early diagnosis and appropriate planning of surgical management can result in a favourable outcome in many cases of oesophageal disease, especially in the acute case.