* Erom the Departments of Radiology and Pediatrics, University of Oklahoma M edical Center, Oklahoma City, Oklahoma.

VOL. 103, No. 2

277
DEM ONSTRATION OF THE DISTAL ESOPHAGEAL
POUCH IN ESOPHAGEAL ATRESIA
W ITHOUT FISTULA*
By LEONARD E. SW ISCHUK, M .D.
OKLAHOM A CITY, OKLAHOM A
T HE selection of an appropriate surgical
procedure for correction of esophageal
atresia without fistula is dependent on the
length ofthe proximal and distal esophageal
pouches. If they are long and generous, an
end-to-end esophageal anastomosis is pos-
sible, whereas if they are short and far
apart, a colon interposition is required.
Preoperative assessment of the size of the
esophageal pouches is therefore of consider-
able significance and is accomplished pri_
m arily by roen tgenographic techniques.
The proximal pouch is usually first identi-
fied on the plain roentgenogram as an air
filled blind sac; confirmation is then ob-
tained with contrast studies. Visualization
of the distal pouch has not received similar
attention. It is the purpose of this paper to
demonstrate the roentgenographic delinea-
tion of this pouch.
Utilizing the fact that many normal new-
born infants reflux gastric content into the
esophagus,25 a technique for regurgitation
of barium into the distal esophageal pouch
was evolved. The procedure, simple and
innocuous, consists of introducing barium
into the stomach after a gastrostomy has
been performed. Thereafter, under fluoro-
scopic control, barium is refluxed into the
distal esophageal pouch with maximal fill-
ing being obtained by turning the infant on
his left side. At this point spot roentgeno-
grams are obtained and assessed with the
roentgenograms demonstrating the proxi-
mal pouch. Utilizing these two studies an
accurate estimation of the gap between
the proximal and distal pouches is derived.
Recently Altman et al. indicated success
with a similar maneuver and suggested its
use as a routine investigation procedure in
esophageal atresia without fistula. In view
of the fact that it is a simple and easily per-
formed procedure, and because it provides
immediate useful information to the sur-
geon, the author believes that reiteration
with the following 4 cases is justified.
REPORT OF CASES
CASE I. L. L., a 3 day old premature infant,
weighing 5 lb. 2 oz., was admitted to the
Childrens M emorial Hospital, Oklahoma City
on June 3, 1963 with a typical history of respi-
ratory distress and choking on feeding. A tube
could not be passed into the stomach and
roentgenography showed an air filled proximal
esophageal pouch and an airless abdom en.
Contrast medium studies of the upper pouch
showed that it extended to the level of T3
(Fig. iA). On the following day a feeding gas-
trostomy was performed and retrograde filling
of the distal esophageal pouch was achieved.
The small, short pouch was noted to extend to
the level ofT9 (Fig. iB).
Because of the extensive gap between the
proximal and distal esophageal pouches, it was
thought that direct anastomosis was impossible
and plans were made for a colon interposition.
Unfortunately, 2 days later tlue infant de-
veloped a gastric perforation and peritonitis.
A laparotomy was performed and the perfora-
tion sealed but the infant did poorly and ex-
pired the next day. At postmortem examina-
tion, in addition to the esophageal atresia and
gastric perforation, a complex cardiac anomaly
was found in the form of an arteriovenous
communis and a single ventricle.
CASE II. D. L., a day old premature infant
was admitted to the Childrens M emorial
Hospital, Oklahoma City, on June 23, 1964,
with a diagnosis of esophageal atresia without
fistula. A history similar to that noted in Case
i was elicited and roentgenography again re-
vealed an airless abdomen and an air filled
proximal pouch extending to the level of T3.
This was confirmed with contrast medium
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278 Leonard E. Swischuk JUNE, 1968
4
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lit;. 2. Case ii. (4) The proximal pouch extends to approximately the inferior aspect of T3. (B) Ihe exceed-
ingly long distal pouch extends to about the level of T3-4. A v;tgue outline of the proximal pouch is seen
(arrows). The pouches, in this case, were exceptionally close together and an easy end-to-end ;tnastomosis
was accomplished.
lic. I. Case i. (A) There is a proximal pouch extending to the inferior aspect of T3. (B) A very small distal
esophageal pouch extends to the inferior aspect of T9. The distance between the two pouches was long
and colon interposition was the procedure of choice.
studies (Fig. 2 /) and 3 days later a gastrostomy
was performed. Approximately 3 weeks later a
barium study of the distal esophageal pouch was
carried out, and an extremely long distal pouch,
extending to the level of 13-4 was demonstrated
(Fig. 2B). Because of these findings a direct
esophageal anastomosis was planned and per-
formed 2 months later. The infant did well
postoperatively and in subsequent follow-up.
CASE III. C.M ., a c8 hour old infant was ad-
mitted to tile Childrens M emorial Hospital,
Oklahoma City, on October 31, 1966. The usual
history of choking with feeding was elicited l!ld
roentgenographv revealed a rather large air
filled proximal esophageal pouch extending to
the level of T (Fig. 3d). In addition, no air
was seen in tile abdoinen and on tile basis of
these findings it was thougilt that the patient
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11G. 4. Case iv. (A) An air filled proximal pouch (arrows) extends to the level of I3. (B) The barium tlis-
tended distal pouch extending to the superior aspect tOl) of T9 is shown. Because of the extensive gap
between the two Pouches a colon interposition was planned.
\OL. 103, No 2 Esophageal Atresia without Fistula 279
li;. . Case III. (1) There is an exceedingly generous and large proximal pouch distended with air (arrows).
It extends down to tile level of 1 -6. Note the l)ariunl filled distal pouch at the bottom. Ibis is more
clearly shown in (B), where the distal Pouch extends to the level of 18. In view of the rather generous
pmoxim al pouch an end-to-end anastomosis was performed.
had esOI)h ageal atresia wit ilou t fistu I a. A gas-
trostomv was performed and 7 days later tile
distal pouch was (lenulnstrated with barium. It
eXteil(led to tile level (If IS (Fig. 38).
I)espite tue llle(Iitinl length of tile distal
esoph ageal pouch, a direct esopil ageal an asto-
illosis W as planned in hopes (If utilizing the ex-
trenlelv generous proximal pouch. ihe anasto-
1110515 was performed approximatel v I 111011 til
later and tile infant did well in tile ililillediate
postoperative period. One week later, however,
complications developed witil a breakdown of
the anastomosis and an associated right side
empyenla. lile empyen a was drained, the dis-
till esopilageal pouch closeti, and a cervical
esophagostoni V j)erforflled. hiie pittieil t did
well thereafter and t colon interposition was
being planned.
iv. B.M ., ;t 36 hour oltI, 3 lb. 6 oz. in-
fant was adnlitted to tile Ciliidrens M emorial
Hospital, Oklahoma Cits on January 6, 1967
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280 JUNE, 1968 Leonard E. Swischuk
with respiratory distress and choking with feed-
ing. Roentgenography showed an airless ab-
domen. An air filled proximal esophageal pouch
extending to the level ofT3 was noted and was
subsequently confirmed with contrast medium
studies (Fig. 4A). A gastrostomy was then per-
formed and 3 days later the distal esophageal
pouch was dem onstrated by refluxing barium
from the stomach into the pouch (Fig. 4B). It
was noted to extend to the level of T9 and be-
cause of the rather long distance between the
ends of the two pouches it was decided that a
colon interposition would be performed at a
later date. Unfortunately, before this could be
accomplished, the patient developed a severe
gastroenteritis with septicemia and expired.
DISCUSSION
It is believed that the ability to demon-
strate the distal esophageal pouch in each
of the 4 presented cases was of considerable
value in the preoperative assessment of
each patient. In Cases i and iv the distance
between the two pouches was rather long
(from T3 to T9) and colon interpositions
were planned for these patients. On the
other hand, in Cases II and In, the pouches
were rather generous and end-to-end esoph-
ageal anastomoses were performed. In Case
II the distal pouch almost met the proximal
pouch and, of course, lent itself to easy an-
astomosis. In Case in the distal pouch did
not extend as high as in Case ii, but when
considered along with the extremely gen-
erous proximal pouch, it was thought that
a direct end-to-end esophageal anastomosis
was feasible. This latter case, in some re-
spects, is akin to the cases recently reported
of end-to-end esophageal anastomosis after
surgical elongation of the proximal pouch.34
The difference, in our case, was that the
proximal pouch was large enough naturally
and surgical elongation was not required.
CONCLUSION
Refluxing of contrast material from the
stomach into the esophagus for delineation
of the distal esophageal pouch in esopha-
geal atresia without fistula is a relatively
simple maneuver to perform. The informa-
tion obtained, regarding the length and
size of the distal esophageal pouch, is ex-
tremely useful to the surgeon, as he decides
upon the most appropriate procedure for
correction of the anomaly. It is suggested,
therefore, that this procedure be attempted
in every case of esophageal atresia without
fistula before definitive surgery is under-
taken.
SUMMARY
Demonstration of the distal esophageal
pouch in esophageal atresia without fistula
was accomplished in 4 cases. The simplicity
of the procedure is pointed out and, in view
of the helpful information it provides, it is
suggested that it become a routine proced-
ure in the preoperative assessment of eso-
phageal atresia without fistula.
The information obtained is of aid to
the surgeon in deciding upon the appropri-
ate surgical procedure for correction of this
anomaly.
Departm ent of Radiology
University of Oklahoma M edical Center
8oo N. E. 13th Street
Oklahoma City, Oklahoma 73104
REFERENCES
1. ALTM AN, D. H., MENCIA, L. F., Lirr, R. E., and
GILBERT, M . G. Esophageal atresia: sim ple ra-
diological technic to facilitate surgical m anage-
m ent. Radiology, 1966, 86, 1112-1114.
2. BLANK, L., and PEW , W . L. Cardio-esophageal
relaxation (chalasia): studies on norm al infant.
AM . J. ROENTGENOL., RAD. THERAPY & Nu-
CLEAR M ED., 1956, 76, 540-550.
3. HOWARD, R., and M YERS, N. A. Esophageal atre-
sia: technique for elongating upper pouch. Surg-
ery, 1965, 8, 725-727.
4. JOHNSTON, P. W . Elongation of upper segment in
esophageal atresia: report of case. Surgery, 1965,
58, 741-744.
. SINGLETON, E. B. X-Ray Diagnosis of the Ali-
mentary Tract in Infants and Children. Year
Book Publishers, Inc., Chicago, 1959, p. 42.
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