|Year : 2018 | Volume
| Issue : 2 | Page : 41-50
Corrosive pharyngoesophageal stricture – A challenge to surgeon: A tertiary center experience
Sagar Ramesh Kurunkar1, Ramkrishna Y Prabhu1, Chetan Kantharia1, Sharvari Pujari1, Vikram Chaudhari2, Avinash Supe1
1 Department of Surgical Gastroenterology and Liver Transplant, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
2 Department of GI HPB Oncosurgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||29-May-2018|
Dr. Ramkrishna Y Prabhu
Department of Surgical Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Pharyngoesophageal stricture with laryngeal involvement due to corrosive ingestion is rare, and limited literature is available regarding management. Outcome is unpredictable due to progressive scaring of anastomosis and associated respiratory complications. Here, we share our experience of managing this challenging entity.
Materials and Methods: Of 57 corrosive ingestion patients, we reviewed 15 patients of isolated pharyngoesophageal stricture managed in our unit of a tertiary care center between 2008 and 2016. The medical records, initial management, operative data, postoperative course, and follow-up data of these 15 patients were reviewed. These 15 patients divided into Group A of endless string insertion and dilatation and Group B of five patients who underwent additional colonic interposition.
Results: Of 15 patients, 10 patients belonged to Group A of endless string insertion and dilatation and five patients belonged to Group B with additional coloplasty. All the 10 patients were successfully dilated with endless string insertion, whereas in coloplasty group, four patients out of five are taking normal diet, and one patient succumbed due to nonoperative cause. All 15 patients had no respiratory complication postoperatively, and five patients who were on tracheostomy before surgery are weaned off completely. All 14 patients have no dysphagia, have no respiratory complications, and have gained weight.
Conclusion: Severe upper aerodigestive injury is rare and its management is herculean task, but satisfactory functional reconstruction can be achieved in the majority of patients without the need for permanent tracheostomy or feeding jejunostomy by our technique giving good quality of life.
Keywords: Corrosive strictures, endless string, pharyngoesophageal strictures
|How to cite this article:|
Kurunkar SR, Prabhu RY, Kantharia C, Pujari S, Chaudhari V, Supe A. Corrosive pharyngoesophageal stricture – A challenge to surgeon: A tertiary center experience. Saudi Surg J 2018;6:41-50
|How to cite this URL:|
Kurunkar SR, Prabhu RY, Kantharia C, Pujari S, Chaudhari V, Supe A. Corrosive pharyngoesophageal stricture – A challenge to surgeon: A tertiary center experience. Saudi Surg J [serial online] 2018 [cited 2022 Aug 16];6:41-50. Available from: https://www.saudisurgj.org/text.asp?2018/6/2/41/233492
| Introduction|| |
In India, the ingestion of corrosives is not rare and usually occurs among adults as a suicide attempt or as accidental injuries in adults as well as children. There are articles in print which address the management of esophageal and gastric either together or individually; however, strictures involving cervical esophagus or hypopharynx associated with laryngotracheal injuries are particularly very difficult to manage. They require not only a long-segment esophageal substitute but also due to proximity with larynx, some laryngotracheal strictures deteriorate the treatment outcome. Hence, surgical results of these patients are unpredictable, progressive scaring of hypopharyngeal anastomosis is not uncommon. Patients who underwent treatment for these pharyngeal or high esophageal injuries are peculiar to treat in view of anastomosis outcome and risk of associated respiratory complications.
Strictures of the hypopharynx and upper cervical esophagus are particularly challenging since the anastomosis at this level is prone to anastomotic leakage, early postoperative stenosis, and disarrangement of the deglutition mechanism, resulting in recurrent aspirations., Revision of the anastomosis (occurring in 7%–12%) and construction of a permanent feeding gastrostomy or feeding jejunostomy (FJ) (4%) with associated tracheostomy are additional grave complications.
We here discuss our experience regarding the management strategies for complex pharyngoesophageal strictures with associated laryngeal involvement, by stratifying patients as to who will need endless string insertion and modified dilatation (Group A) or colonic interposition (Group B).
| Materials and Methods|| |
Of a total of 57 cases of corrosive ingestion injuries, we reviewed 15 patients with complex pharyngeal or high esophageal strictures associated with laryngotracheal injuries, managed in our unit between 2008 and 2016. The medical records, initial management, operative data, postoperative course, and follow-up data of these 15 patients were reviewed.
All patients were referred to us in view of high corrosive injuries with airway involvement. The initial treatment investigations included barium swallow, upper gastrointestinal (GI) endoscopy and along with complete hemogram, and blood biochemistry. All the patients were referred to us with indwelling FJ. Assessment of the airways was performed both by direct laryngoscopy and fibro-optic bronchoscopy by our ENT colleagues in view of airway involvement and tracheostomy in five patients. Psychiatry counseling was done in all patients before the start of treatment. Patients were counseled regarding their disease process and need for long duration treatment and follow-up. Due to high stricture, the esophagus below could not be assessed. Surgical intervention was decided mainly by neck exploration to assess the status of the cervical esophagus. Patients were divided into two groups, one group of patients who can recover with dilatation using endless string (Group A) and other requiring subsequent coloplasty (Group B). Colonoscopy was performed to assess the status of colon later in the course of patients who require coloplasty.
The patients with scarring of laryngeal inlet were evaluated by ENT specialist and underwent laser adhesiolysis by infra-red light [Figure 1]a and [Figure 1]b. Attempts were made to release at least one pyriform fossa and improve the movement of epiglottis, for facilitating further intervention and avoiding aspiration. This may need one multiple sitting to get satisfactory results.
|Figure 1: Released epiglottis, cicatrized pharyngoesophageal dimple. (a) Cicatrized laryngopharynx|
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Operative strategy – stage one
Initially, all patients underwent cervical exploration from left oblique incision anterior to left sternocleidomastoid. Cervical esophagus was assessed. Cervical esophagotomy site was comparatively unaffected area of the esophagus, which was placed at a site that was close to the stricture and at the same time could be bought out to skin surface if needed [Figure 2]. After getting lumen of esophagus, we tried to insert Ryles tube (RT)/Eschmann bougie in retrograde direction which was passed with the help of laryngoscope per orally. If RT could not be passed we tried to open fibrous stricture with a hemostat forceps gently or with the help of guide wire. Once we got access to high strictured area Ethilon no. 1 (endless string technique) was used to bring one end through nose and other end through cervical esophagostomy site. We plan our cervical esophagostomy below laryngeal inlet level so that if the patient has distal esophageal involvement which is not amenable for dilatation, we can do colonic interposition with our anastomosis of conduit comes below laryngeal inlet; as a result, we could make patient phonate and eat properly without any respiratory complications or without permanent tracheostomy.
|Figure 2: Eschmann bougie passed through esophagostomy and brought out through mouth|
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At the same time, distal esophagus was assessed whether lumen was accessible. Even if small lumen was accessible, we planned laparotomy and got access to abdominal esophagus lumen through gastrostomy. Again, if we got access to lumen, we tried getting guide wire or small bore RT or nasojejunal tube in retrograde fashion from abdominal esophagus till cervical esophagus. Endless string was kept (loop Ethilon no. 1) from cervical esophagus through stomach and string was brought out of abdomen [Figure 3]. Gastrostomy tube was also kept. The patients in whom we got access of endless string from nose to stomach belong to group of dilatation (Group A) and patients in whom distal esophagus could not be accessed were evaluated for coloplasty (Group B).
|Figure 3: Endless string from nose (thick arrow) to abdomen (thin arrow) with Ryles tube in place|
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Patients with endless string were called for first dilatation 4 weeks after the surgery; check esophagogram was taken after first smallest Savary-Gilliard (SG) dilator dilatation. Furthermore, stomach outlet obstruction was assessed using gastrostomy tube gram. Patients were then called for successive dilatation every 2nd week. Dilatation was performed using SG dilators from no. 8, 10, 12, and 14. Dilatation continued in this group till we achieved dilatation using 14 no. SG dilator. We followed the same rule of three of endoscopic dilatation. Since we had endless string in cervical as well as distal esophagus, continuity of esophagus maintained with one string from nose to stomach and brought out through the abdomen with gastrostomy tube in situ. Once we achieved adequate dilatation, patients in the absence of gastric outlet obstruction were taught self-esophageal dilatation using gum elastic bougie [Table 1].
|Table 1: Group A patients - endless string insertion with regular dilatation|
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Operative strategy – stage two
Patient with stricture in pharynx or in higher esophageal stricture, endless string was kept from nose till cervical esophagostomy site. These were the patients where we could not get access to distal esophagus (belong to Group B) [Table 2]. These patients were maintained on nutrition through FJ. Patients were called every 2nd weekly and underwent dilatation of high cervical esophagus stricture and pharyngeal stricture [Figure 4] with SG dilatators no. 8, 10, 12, and 14. Dilatations were done using local anesthetic, lignocaine spray on posterior pharyngeal wall, and lignocaine jelly. One of the endless string from nose was brought out through mouth then tied to SG dilator keeping opposite end of the string taught SG dilator was pulled and brought out through cervical esophagostomy site. Dilator was kept in position for 3 min initially and later for 5 min as the patient tolerated the procedure. At the end of procedure with the help of other endless string, it is replaced by loop Ethilon no. 1.
|Figure 4: Serial dilatation of high esophageal stricture with Savary-Gilliard dilators guided with endless string|
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Patients were taught to do routine dilatations at home using Hegars dilator through cervical esophagostomy site. Meanwhile, patients were taught to swallow solid food and liquids per orally by our speech and swallow rehabilitation experts. Since these patients may have been associated laryngotracheal corrosive injuries, epiglottis is fixed in scar tissue and does not occlude laryngeal inlet properly; furthermore, larynx does not move upward and forward due to corrosive injury; these patients are prone for aspiration and repeated respiratory infections. These dilatations were done till we achieved dilatation of esophagus with SG no. 14 easily and these patients underwent coloplasty after adequate dilatation.
Operative strategy – stage three
Once dilatation of strictured esophagus was achieved with SG dilator no. 14 patient was able to swallow without aspiration and nutritional status is improved. Then, we planned final stage of coloplasty.
We usually prefer to take left-sided colon in view of vascular arcade being predictable and fixed. In one case, we had taken right-sided colon where adequate length of left colon conduit was not achieved. Patients who had strictured stomach underwent gastrectomy. We do not remove native esophagus which was damaged by corrosive ingestion. Colon conduit was taken up retrosternally. We do not prefer to divide clavicle. Once conduit was prepared, vascularity was confirmed. We started dissection of neck. We take incision over skin 0.5 cm around cervical esophagostomy leaving behind rim of skin around esophagostomy site [Figure 5] and extend incision on either side parallel to the left sternomastoid. We try not to dissect too much circumferentially around esophagus as it can hamper the vascularity and also esophagus would retract inside. We raise the skin flap on either side well close to midline medially and laterally beyond sternomastoid. Colon conduit which was brought is anastomosed with esophagus using PDS 3–0 in single layer, interrupted fashion [Figure 6] and [Figure 7]. Corrugated drain is kept inside the neck.
|Figure 5: Circum-esophagostomy incision along anterior border of sternomastoid|
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|Figure 6: Right colonic conduit brought to cervical region retrosternally|
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|Figure 7: Right colonic conduit anastomosed to cervical esophagostomy edge|
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We keep endless string through nose and conduit which is brought out through abdomen which can help us to tide over anastomosis stricture problem. FJ is kept till we are sure that patient is taking adequate nutrition per orally.
Conduit continuity is maintained by doing cologastric or colo-jejunal (depending on if gastrectomy was needed) and colocolic anastomosis.
Postoperatively, these patients received anticoagulation in the form of heparin low-dose dopamine may be used as we had used in one. On the 5th postoperative day, we take conray-gram to look for esophago-conduit anastomotic patency. Once there is no leak, patients were started on oral diet.
In Group A patients, where we got access through distal esophagus and endless string present from nose to abdomen, regular two weekly dilatations are done using SG dilators 8, 10, 12, and 14. These patients were encouraged to take oral feeds as well as jejunostomy tube feed to maintain the nutrition. Once dilatation with no. 14 SG dilator was achieved and patient is nutriotionally maintained, the patients were taught to do self-gum-elastic bougie dilatation (32–36 French) at home. These are the group of patients where we avoided doing coloplasty and taught our patients regular self dilatation.
| Results|| |
There was a male preponderance (8/15) in sex distribution with most of our patients are young adults. The presentation was 1 month to 2 years after corrosive ingestion. All had combined pharyngeal and higher esophageal injuries associated with laryngotrachaeal injuries. There was intent to commit suicide in nine patients with six had accidental ingestion of corrosive.
Patients, as mentioned in [Table 2], in Group B underwent cervical esophagostomy and regular dilatation of cervical esophagus, after adequate dilatation of cervical esophagus, they underwent coloplasty. As the anastomosis was below, laryngeal inlet level risk of aspiration decreased. Postsurgery, these patients had minimal or no dysphagia and able to speak normally and gained weight. Two patients with high cervical stricture on assessing cervical esophagus, underwent coloplasty without dilatation. There were two patients who developed superficial surgical site infection in coloplasty group; none of our patients developed anastomotic leak. One patient expired after 4 months of surgery due to pulmonary tuberculosis. At present, four patients in coloplasty group on regular follow-up with no dysphagia, no difficulty in speech and patients have gained weight.
In Group A 10 patient belonging to endless string insertion, we treated them with only dilatation without coloplasty. Once adequate esophageal dilatation was achieved, cervical esophagostomy healed spontaneously.
In seven cases, we did cervical exploration only to get access distally; once distal access was achived, we closed cervical esophagectomy. We were able to keep endless string from nose till stomach in nine patients for future dilatations, while one patient underwent total gastrectomy with Roux-en-Y esophagojejunostomy. All the ten patients in the second group are able to swallow with good weight gain without any sequel of airway injury, except one patient of ours who has change in voice due to nerve injury before the surgery.
We retrospectively analyzed our patients in two groups and we came across some interesting facts based on which we can divide these patients in two groups.
To predict which patients belong to which group in treatment plan, we divided them based on history, barium findings, indirect laryngoscopy findings, and intraoperative assessment; we named this criteria as “KEM CRITERIA” [Table 3] for complex upper esophageal or pharyngeal strictures.
Although claims have been made that acids tend to injure the stomach preferentially, the esophagus and stomach are probably equally affected.,
Immediately postsurgery, patients belonging to coloplasty group were able to swallow comfortably without aspiration or any difficulty to swallow. Further, none of our patients had any complaint of change in voice or hoarseness. However, after a mean period of 1 year, these patients had difficulty in swallowing which could be attributed to stricture at anastomotic site in neck due to skin edge which was incorporated during coloplasty. These patients successfully managed with serial dilatations with SG dilator and they were taught self-dilatation at home with gum elastic bougie. Patients are comfortable with good quality of life since none of our patient had tracheostomy or aspiration problems postoperatively.
Patient belonging to group of endless string and dilatation, i.e. Group A, immediate postsurgery, patient continued to have jejunostomy feeds and their nutritional status was improved. Repeated psychiatric counseling was done and patients were motivated. After 4 weeks of primary surgery of endless string insertion, these patients were called for dilatations. First dilatation was done under anesthesia using SG dilator, and oral conray-gram was done before any intervention. Later, these patients underwent dilatation every 2 weeks using SG dilator serially until we achieved SG dilatation with no 14. This was achieved over a mean period of 4 months with patients requiring mean 8 sittings of dilatation. After first dilatation, subsequent dilatations were done under local anesthesia. Once stricture is stabilized, these patients were taught to do self-esophageal dilatation with gum elastic bougie. Patients are doing self-dilatation as a routine part of their life. These groups of patients are comfortable and happy without any dysphagia or respiratory problems.
| Discussion|| |
In India like many other developing countries, due to unregulated access to caustic chemicals, corrosive injury to aerodigestive tract is common entity.
Pharyngeal involvement in upper GI corrosive stricture is an infrequent, but critical complication reported in 0.7%–6.0% of patients after caustic ingestion. Pharyngeal strictures management is challenging because reconstruction is difficult, as it interferes with swallowing and needs airway protection from aspiration. Tracheostomy is often required for airway protection from recurrent aspiration either before or after pharyngo-coloplasty.
Experience with pharyngo-coloplasty following pharyngeal involvement in caustic strictures is limited because of its infrequent occurrence. With very limited literature is available regarding management of this complex disease, the main surgical problem raised by the combined hypopharyngeal and high esophageal stenosis is restoration of digestive continuity which itself may interfere with the processes of deglutition and respiration.
Strictures involving high level of the esophagus or hypopharynx are particularly difficult to manage because they require a long-segment esophageal replacement and some laryngotracheal strictures themselves deteriorate the treatment due to recurrent chest complications. Hence, surgical results of these sequelae are not satisfactory and progressive scaring of hypopharyngeal anastomosis is not rare. The cicatrization that follows caustic injury to the upper digestive tract is a progressive process that may affect the results of pharyngo-coloplasty. This process is believed to slow down after 6 months of the initial injury. A delay of esophago-coloplasty by 5–6 months decreases the occurrence of anastomotic stricture.
Most corrosive ingestions in adults are suicidal, and almost all fatal outcomes are in patients with suicidal intent as compared to accidental cases. In surviving patients, continuous psychological and family support is must. Surgical treatment to restore swallowing, which often requires multiple complex operations, should be done when the patient is in good and stable state of mind, patient should have improved nutritionally, and also patient has familial support. Patient and family need to be explained regarding prolonged, staged treatment and associated morbidity. Otherwise, there is risk of suicide during staged reconstruction.
Similarly, failure of reconstruction left the patient dependent on FJ and may carry a high risk of subsequent suicide.
Pharyngo-coloplasty requires a conduit which can bridge the stricture between abdomen and neck. Although the stomach, right colon, and left colon have all been used in such clinical settings, we prefer a long-segment left colon based on the left colic artery for this indication. The blood supply of the left colon is more constant, predictable; further, the left colon has a better propulsive capacity for peristalsis of a solid food bolus, and a long-segment is almost always available for harvesting to reach the neck. If left colon conduit fails, still we have used right colon for rescue.
When upper airway stricture occurs along with pharyngoesophageal stricture preservation of swallowing, airway protection is compromised. Depending on the amount and type of corrosive ingested, larynx may be scared that reconstruction is not feasible necessitating permanent tracheostomy.
Although the upper digestive tract may often be relatively spared in corrosive injury, severe damage to the pharynx and larynx occurs in approximately 2% of patients. Urgent tracheostomy may be required, and in the recovery phase, cicatricial stenosis may be very severe, resulting in fixity of the tongue, destruction of the epiglottis, fixation of epiglottis, synechiae in between vocal cords, obliteration of the pharynx, obliteration of pyriform fossae, and severe trismus that may hinder adequate examination. In this group of patients, the role of ENT surgeons is important to achieve a near-normal functional anatomy. Our ENT colleagues release these adhesions and synechiae with the help of laser, which helps us during cervical exploration to get at least one pyriform fossa, and also, release of epiglottis and adhesions between vocal cords prevents patients from aspiration risk.
However, it is surprising how much preservation of speech and swallow we can improve by reconstructing these corrosive stricture in these apparently hopeless patients, even limited aim of restoration of ability to swallow saliva may be regarded as worthy for patient. We advise waiting for 6 months after corrosive ingestion which helps in initial inflammatory response to subside before going for pharyngeal reconstruction.
There are many techniques of pharyngeal reconstruction after radical pharyngolaryngectomy for cancer; however, when larynx is preserved, there will be recurrent respiratory complications after pharyngeal reconstruction. These challenging problems have been well-reviewed by Popovici. Ogura et al., who are pioneers in functional restoration of upper digestive tract, restored the function of swallowing in pharyngeal stricture, and after excising the part of thyroid cartilage, right colon interposition graft is anastomosed to the pyriform sinus. Later, by transhyoid approach, they excised irreversibly cicatrized epiglottis and aryepiglottic fold. These authors reported successful outcomes in five of six patients. Gupta et al. reported on a single patient with severe pharyngeal stenosis in whom stomach tube was anastomosed to the posterior midline part of pharynx, with restoration of swallowing and speech.
Further experience with these approaches was reported by Huy and Celerier, who classified pharyngeal stenoses into two types, Type 1, in which at least one pyriform sinus remained open, whereas in Type 2, both pyriform fossae are completely obliterated. They suggested that in Type 1 strictures after excising portion of thyroid cartilage, anastomosis was done to one of the pyriform fossae, whereas in Type 2 strictures, posterior midline approach was used as described by Gupta et al. Authors preferred isoperistaltic retrosternal right colon conduit with anastomosis of terminal ileum to the pharynx. They reported satisfactory swallowing and speech in 11 of 18 patients without any operative mortality.
However, significant postoperative complications occurred, including necrosis of the graft, empyema, cervical and abdominal fistulae, and restenosis. One patient required subsequent laryngectomy for complete laryngeal stenosis unresponsive to a laryngofissure procedure.
Ananthakrishnan et al. described their experience of pharyngoesophageal stricture management in 51 patients, in which they divided patients into groups based on pharyngeal stricture severity and associated extent of distal esophagus involvement, based on this management of patients decided. For assessment of stricture distal to pharynx, they used computed tomography after swallowing air. For patients having pharyngoesophageal stricture, initially, cervical esophagostomy was done on right side and repeatedly dilated to achieve adequate dilatation, following which esophago-coloplasty was done to achieve distal continuity. This kind of surgery was done in five patients. Furthermore, in patients who had nondilatable stricture of pharyngoesophageal junction with normal distal esophagus, pectoralis major myocutaneous flap has been done in 11 patients while later author changed to local sternocleidomastoid muscle myocutaneous inlay flap due to cosmetic reason. Along with flap, these patients also underwent additional procedure like dilatation or coloplasty. Overall, 45 out of 51 patients satisfactory swallowing were achieved.
The algorithm followed at our institute [Figure 8] in patients with high strictures iss effective. Our immediate postoperative results were satisfactory; no anastomotic leaks occurred in five coloplasty patients. We believe our mucosal-inverting technique of anastomosis, tension-free anastomosis, and adequate mobilization of colon; conduit with good vascularity is a key to success. Further, we plan our colonic conduit anastomosis below the laryngeal inlet and we do not mobilize cervical esophagostomy circumferentially which prevents the retraction of esophagostomy site which consequently prevents respiratory complications, and last but not least, we delay the final reconstruction for more than 6 months as it is the last chance for the patient for definitive reconstruction of enteral pathway of food. Rehabilitative training for deglutition was required in all patients preoperatively in view of high cervical esophageal injury; our speech and swallow training colleagues taught patients to swallow without aspiration with various maneuvers such as flexing and bending head toward left. This lasted between 2 weeks and 5 months after which swallowing was restored to near-normal without aspiration.
Strictures of the hypopharynx and upper cervical esophagus are particularly challenging since the anastomoses at this level are prone to anastomotic leakage, early postoperative stenosis, and disarrangement of the swallowing mechanism, resulting in recurrent respiratory complications., Revision of the anastomosis (occurring in 7.0%–12%) and construction of a permanent feeding gastrostomy or FJ (4%) are additional grave complications.
A potential disadvantage of retrograde access of pharyngeal stricture through cervical esophagostomy technique is creation of false passage in esophageal layers during first attempts of dilatation when esophageal lumen is not clearly seen. However, according to our experience, there is always a detectable lumen allowing the passage of a thin probe toward the pharynx from distal esophagus. Hence, with the help of that, we keep endless string in esophagus which guides us for subsequent dilatations.
Because of the prolonged nature of the treatment required, the surgeon often develops a close bonding with the patient and provides a supportive role, regular counseling, boosting the moral of the patient which is very important which should be continued in the vulnerable period immediately after discharge from the hospital and also on repeated interventions. It is not only efforts from the surgeon but also team efforts from surgeon, anesthetists, ENT specialist, psychiatrist, and speech and swallow rehabilitation center, which made these patients swallow and speak which gave patients the confidence to do better in their personal and professional life.
By our approach, safe treatment of high esophageal and pharyngeal stricture is feasible. In addition, the functional and anatomic integrity of the swallowing mechanism is preserved to near-normal. Consequently, the need for reoperation and permanent tracheostomy in these patients was not required. Further confirmation of these positive results from application of our experience in larger scale patients of pharyngeal and high cervical esophageal strictures can be done in this select group of patients.
| Conclusion|| |
Ingestion of corrosive acids or alkalis, either accidentally or with a suicide attempt, is a rare but challenging event that sometimes takes major demands on health resources. Severe upper aerodigestive injury is rare and its management is herculean task, but satisfactory functional reconstruction can be achieved in the majority of patients without the need for permanent tracheostomy or lifelong permanent FJ by our technique, giving good quality of life to the patients and boosting the confidence of the patients, as these patients able to maintain both speech and swallowing mechanism giving one more chance to live the social and professional life.
We would like to Dr. Ravindra D Bapat, Professor Emeritus, Department of Surgical Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Dr. Prerana Shah, Professor (Additional), Department of Anaesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, email – firstname.lastname@example.org, and Dr. JyotiPDabholkar, Professor and Head of Department, Department of ENT, Seth GS Medical College and KEM Hospital, Mumbai.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]