Veterinary Surgery

30:449-453, 2001

Esophagomyotomy and Esophagopexy to Create a Diverticulum

for Treatment of Chronic Esophageal Stricture in 2 Horses

JAMES D. LILLICH, DVM, MS, Diplomate ACVS, KARL E. FREES, DVM, KATHRINE WARRINGTON, DVM,
PHILIP D. VAN HARREVELD, DVM, MS, EARL M. GAUGHAN, DVM, Diplomate ACVS,
and WARREN L. BEARD, DVM, MS, Diplomate ACVS

We report use of esophagomyotomy and esophagopexy to create a diverticulum for relief of chronic
type I esophageal stricture in 2 horses. After esophagomyotomy, the mucosa was dissected free from
the muscularis for approximately 180° around the myotomy. Then, the tunica muscularis of
esophagus was sutured to the sternocephalicus muscle ventrally and the periesophageal tissues
dorsally to create a diverticulum without disruption of the esophageal mucosa. Clinical signs of
esophageal stricture were relieved, and the horses were fed normal diets without further esophageal
obstruction.
© Copyright 2001 by The American College of Veterinary Surgeons

S TRICTURE OR PARTIAL OBSTRUCTION of

the equine esophagus that is structural in nature
may result from external trauma, anatomic anomaly,
neoplasia, or sequela to acute, severe luminal ob-
struction, surgery, or rupture.1-7 Functional obstruc-
tion (spasm) of the esophagus is poorly defined in
horses.8
Strictures of the esophagus are classified as: type I,
strictures that involve the tunica muscularis and tunica
adventitia; type II, strictures resulting from scar tissue
involving the tunica mucosa and tunica submucosa; or
type III, strictures that are annular rings involving all
four layers of the esophagus.9
Surgical management of chronic esophageal stric-
ture is considered superior to medical management.1
Without strict adherence to dietary alteration require-
ments, horses managed medically are prone to recur-
rent episodes of acute complete obstruction and have
poor long-term survival.10 Esophageal surgery is tech-
nically demanding, and complications requiring fur-
ther surgical intervention are common. Reported sur-
gical techniques for correction of chronic strictures of
the equine esophagus include esophagomyotomy, par-
tial or segmental esophageal resection, esophago-
plasty, and mucosal fenestration.4,5,7,9-12 Muscle graft-
ing and esophageal replacement techniques are usually
used to treat leakage or when tissue deficits are
present.
Selection of surgical technique is generally based on
the type of stricture. For example, esophagomyotomy
has been suggested as the surgical procedure of choice
for type I strictures, because most are greater than 2
cm in length, making esophagoplasty less likely to
succeed. However, esophagomyotomy is often associ-
ated with stricture reformation and the need for further
surgical intervention. After several surgical attempts
have been made to relieve the type I stricture, creation
of a traction diverticulum, by tube esophagotomy, to
increase lumen diameter may be required.2
We report our experience in 2 horses with type I
esophageal strictures for which we surgically created a
diverticulum to increase esophageal lumen diameter.

From the Department of Clinical Sciences, Veterinary Medical Teaching Hospital, Kansas State University, Manhattan, KS; and the
Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, OH.
Address reprint requests to James D. Lillich, DVM, Department of Clinical Sciences, Veterinary Medical Teaching Hospital, Kansas
State University, Manhattan, KS 66506-5606.
© Copyright 2001 by The American College of Veterinary Surgeons
0161-3499/01/3005-0008$35.00/0
doi:10.1053/jvet.2001.25870

449
450 CHRONIC ESOPHAGEAL STRICTURE
Fig 1. Endoscopic photograph of the esophageal lumen of
horse 1, approximately 90 cm from the nostril. Note the small
lumen diameter and mucosal ulceration (arrows).
CLINICAL REPORT
Horse 1
A 9-year-old, 425-kg Quarter Horse stallion was
examined for recurrent episodes of esophageal ob-
struction over a 3-year period. During the week before
admission, the horse had three episodes of esophageal
obstruction that became increasingly difficult to re-
lieve. On admission, a bilateral mucoid nasal dis-
charge that contained feed material was evident; oth-
erwise, vital signs were considered normal. An
esophageal feed obstruction was identified approxi-
mately 90 cm from the nostril on endoscopic exami-
nation. The obstruction was relieved by sedation
(xylazine hydrochloride) and esophageal lavage with a
large-bore (1.8-cm diameter) nasogastric tube. The
large nasogastric tube could not be passed into the
stomach; however, a small-bore (1.1-cm diameter)
nasogastric tube could be passed after the obstruction
was relieved. Repeat endoscopic examination revealed
an area of mucosal ulceration approximately 90 cm
from the nostril, and passage of the endoscope aboral
to this point was difficult (Fig 1), suggesting a de-
crease in lumen size and indirectly supporting a
diagnosis of esophageal stricture.
The horse was treated medically for 3 days with
intravenous (IV) fluids (lactated Ringers solution, 50
mL/kg/24 hours), flunixin meglumine (1 mg/kg, IV,
every 12 hours), and trimethoprim-sulfa (15 mg/kg,
orally, every 12 hours). The horse was not fed for 3
days to allow healing of the esophageal mucosa. On
repeat endoscopic examination, the mucosal ulceration
had improved, but passage of the endoscope beyond
this site was difficult. A contrast esophagram con-
firmed the presence of esophageal stricture at the level
of the thoracic inlet. Surgical correction of the stricture
was recommended.
Surgical Procedure. Before induction of general
anesthesia, a large-bore (1.8-cm diameter) naso-
esophageal tube was passed to identify the stricture
site. The horse was positioned in right lateral recum-
bency, with the left forelimb caudally retracted and
secured to provide access to the left ventrolateral
aspect of the cervical region. After aseptic preparation,
a 15-cm linear skin incision was made ventral and
parallel to the jugular furrow and was centered on the
obstruction. The jugular vein and sternocephalicus
muscle were identified and retracted dorsally and
ventrally, respectively, to reveal the esophagus. A type
I esophageal stricture of firm fibrous tissue, approxi-
mately 1 to 2 cm in length, was identified.
The esophagus was elevated with Penrose drains,
and a ventrolateral esophagomyotomy that extended
approximately 3 to 4 cm oral and aboral to the point of
the stricture was made and the nasogastric tube was
passed beyond the stricture. The tunica muscularis of
the esophagus aboral to the stricture appeared to be
hypertrophied. The esophageal mucosa was dissected
from the muscularis approximately 180° around the
circumference of the stricture site. The esophagus was
replaced into its normal position. To prevent recur-
rence of type I stricture, the incised portions of the
ipsilateral muscularis were sutured to themselves with
3-0 polydioxanone, and were then sutured to the
sternocephalicus muscle ventrally and the periesoph-
ageal fascia dorsally. This resulted in an increased
circumference of the tunica muscularis and creation of
a diverticulum (Fig 2). A three-quarter-inch Penrose
drain was placed deeply at the aboral end of the
dissected esophagus, and the incision was closed with
simple interrupted sutures of 0 polyglactin 910 in the
deep layers, simple continuous sutures of 2-0 poly-
glactin 910 in the subcutaneous tissue, and cruciate
sutures of 0 polypropylene in the skin.
Postoperative care consisted of IV fluids (2 days),
flunixin meglumine (1 mg/kg, IV, every 12 hours for
5 days), and trimethoprim-sulfa (15 mg/kg, orally,
every 12 hours for 14 days). Free-choice water was
offered 1 day after surgery, and mash feedings con-
 LILLICH ET AL
Fig 2. Diagram of the surgical site. A diverticulum is created
by esophagopexy (suturing the incised edges of the tunica
muscularis of the esophagus to the sternocephalicus muscle
and the dorsal fascia). (A) Periesophageal tissues. (B) Incised
edge of the esophageal muscle sutured to itself and to the
surrounding periesophageal tissues. (C) Esophageal mucosa.
(D) Sternocephalicus muscle.
sisting of alfalfa pellets and Equine Senior (Purina
Mills Corporation, St. Louis, MO) were begun 2 days
after surgery. Feeding periods and amounts were
increased over 5 days to reach caloric maintenance
levels. No incisional complications occurred, and the
drain was removed 3 days after surgery. On endo-
scopic examination 12 days after surgery, the esoph-
ageal lumen diameter was enlarged at the previous
stricture site (Fig 3). The horse was discharged 14
days after surgery with instructions to restrict dry hay
feeding for 60 days.
Sixty-one days after surgery, the horse was re-
examined, and had gained 30 kg and was in good
condition. No episodes of esophageal obstruction had
occurred. On contrast esophagram, there was an en-
larged esophageal lumen diameter, outlining a diver-
ticulum with the neck being larger than the base. The
horse was released with instructions to begin feeding
dry hay, gradually returning to free-choice hay feeding
over 2 weeks. Eighteen months after surgery, the horse
had experienced no episodes of esophageal obstruction
and was being fed a diet of dry hay and grain.
Horse 2
A 7-year-old, 520-kg Quarter Horse stallion was
evaluated after several episodes of esophageal obstruc-
451
tion. The referring veterinarian (owner) had treated the
horse for a kick to the ventral neck sustained during
breeding, several months before admission. A large
hematoma and extensive swelling had been treated
with anti-inflammatory medications and hydrotherapy.
The horse was unable to ingest hay without acute
esophageal obstruction; however, the horse could be
managed with a diet consisting of mash feedings of
alfalfa pellets and Equine Senior (Purina Mills Corpo-
ration).
At the end of the breeding season, 5 months after
injury, the horse was re-admitted for endoscopy and a
contrast esophagram. No mucosal abnormality was
identified on endoscopic examination. However, there
was a stenotic area approximately 110 cm from the
nostril. An esophageal stricture located at the thoracic
inlet was confirmed on a contrast esophagram. Be-
cause dietary management was difficult, surgery was
recommended to increase the esophageal lumen size
and improve esophageal function.
Using an approach similar to that described for
horse 1, a type I stricture approximately 2 cm in length
was identified about 115 cm from the nostril. A 7- to
8-cm esophagomyotomy was centered at the stricture,
and a diverticulum was created by esophagopexy as
described for horse 1. Potassium penicillin (22,000
U/kg, IV, every 6 hours for 7 days), gentamicin sulfate
(6.6 mg/kg, IV, every 24 hours for 7 days), and
flunixin meglumine (1 mg/kg, IV, every12 hours for 3
Fig 3. Endoscopic appearance of the esophageal lumen from
horse 1, 12 days after esophagomyotomy and esophagopexy to
create a diverticulum. Note the increase in lumen diameter and
healing of the mucosal surface.
452 CHRONIC ESOPHAGEAL STRICTURE
days) were administered postoperatively. Because this
horse had been fed mash before surgery, mash feed-
ings were continued after anesthetic recovery. No
incisional complications occurred, and the drain was
removed 3 days after surgery. The horse was dis-
charged 10 days after surgery with instructions to
restrict feeding dry hay for another 50 days.
Fifty-six days after surgery, the horse was re-
examined, and had gained 20 kg body weight. A
contrast esophagram confirmed an increase in esoph-
ageal lumen size, primarily ventrally, at the site of the
original stricture. The horse was released with instruc-
tions to begin feeding dry hay. Twelve months after
surgery, the horse was being feed alfalfa hay and
grain, with no further episodes of esophageal obstruc-
tion.
DISCUSSION
Esophagomyotomy has been used to successfully
correct type I stricture of the equine esophagus;
however, multiple procedures may be required.9 Inter-
estingly, the need for repeated intervention in esoph-
ageal surgery has been noted across mammalian spe-
cies, with recurrence occurring commonly within 6
months after the first surgery.9-12 The modification we
describe may provide an alternative technique that
results in a successful outcome after a single proce-
dure.
In a previous report, surgical creation of a traction
diverticulum (involving all layers of the esophagus) by
ventral esophagotomy and placement of a feeding tube
was successful after two failed attempts using esoph-
agomyotomy alone to relieve a type I stricture in 1
horse.2 The technique commonly described for initial
intervention of type I stricture is to incise the muscu-
laris and separate the mucosa circumferentially from
the muscularis with or without closure of the myot-
omy. However, allowing second-intention healing of
the myotomy incision may result in secondary stricture
and surgical failure. By contrast, the 2 horses we
report had a diverticulum (involving the tunica adven-
titia and muscularis) created surgically by esoph-
agopexy (suturing the tunica muscularis to the sterno-
cephalicus muscle and dorsal fascia to increase
luminal diameter and relieve the stricture). The ster-
nocephalicus muscle also prevented further expansion
of the diverticulum until the surgical site healed.
An additional benefit of the procedure we describe
is the lack of intense feeding management reported for
esophagotomy. The electrolyte and fluid imbalances
caused by the loss of feed and water intake, as well as
the loss of saliva, have been well documented with
esophageal disease in the horse. Careful monitoring of
electrolyte and hydration status is usually required
after esophagotomy, and complications with tube
feedings have been reported.13-17
In both horses reported here, the strictures were
located near the thoracic inlet, so postoperative dis-
secting mediastinitis was a concern if esophagotomy
and tube feedings had been used for treatment. This
complication can be avoided by diligent observation of
the surgical site and adequate ventral drainage. Use of
a Penrose drain has been recommended for most
esophageal surgery.9 Drains were used in our horses
not only for passive drainage of serum, but also as an
egress for saliva had the mucosa ruptured in the early
postoperative period. Had mucosal rupture occurred,
an esophagotomy could have been performed stand-
ing, followed by tube placement and feeding.
Several factors may have contributed to success in
our horses. Creation of a diverticulum by suturing the
incised tunica muscularis to the surrounding sterno-
cephalicus musculature may have, in effect, increased
the structural diameter of the esophagus. Patching an
esophageal stricture with portions of the sternocephali-
cus muscle in the cervical region has been reported in
a horse.18 Local muscle flap techniques have been
developed to provide support to esophageal resection
and anastomosis, esophageal reconstruction from ex-
tensive defects, and for treatment of nonhealing esoph-
ageal leakage and fistula formation in humans.11 The
surrounding musculature is considered to furnish both
mesenchymal cells and a rich blood supply for esoph-
ageal healing. Whereas muscle flaps are used routinely
for reconstruction of extensive esophageal defects in
humans, complications such as postoperative stricture
formation and failure have been reported.11
Releasing the mucosa from the muscularis may
have also contributed to surgical success in our horses.
Complete circumferential separation of the mucosa
from the muscularis may reduce the need for addi-
tional myotomy incisions. In our horses, the mucosa
was separated approximately 180° at the stricture. This
degree of release combined with myotomy was asso-
ciated with success in a previous case report.7 Aggres-
sive postoperative care and feeding management may
have also contributed to a successful outcome. Mini-
mizing inflammation may have reduced fibrous scar
tissue production. An early return to mash feeding has
 LILLICH ET AL
been associated with poor results if the esophagus is
allowed to heal by second intention. Creation of the
diverticulum may have allowed esophageal motility to
have a positive influence on healing.
None of the reported complications associated with
esophageal surgery occurred in these 2 horses. These
complications include esophageal rupture, dehiscence,
repeat stricture, mediastinitis, pleuritis, laminitis, la-
ryngeal paralysis, and Horner’s syndrome.1,9 Both
horses continue to be fed normal roughage diets,
without esophageal obstruction, and they did not
require any other alterations in management. The
long-term survival for horses with chronic esophageal
strictures is reported to be 33% to 50%. Reports of
other horses treated in similar fashion are needed to
determine if long-term survival can be improved with
the technique we describe. Creation of a diverticulum
may, however, provide an alternative surgical option
for the treatment of chronic type I esophageal stric-
tures in the horse.
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