Esophageal obstruction: probang technique

• Esophageal obstruction in cattle is most commonly related to ingestion of feedstuffs.
• Commonly occurs when feedstuffs such as fruit (apples and especially unripe kiwifruits), onions, root crops (turnips, beets, potatoes, and swedes) and ears of corn are ingested rapidly without mastication.
• The esophageal foreign body my lodge the cervical region, thoracic inlet, base of the heart and the cardia of the rumen.
• The obstruction may be partial or complete.
  • Complete: secondary free gas rumen tympany with an inability to drink, eat or swallow saliva -> can become an emergency condition.
  • Partial: mild signs or rumen tympany.
• The condition is often referred to as ‘choke’ or esophageal foreign body.
• This article with focus on the non-surgical management of esophageal obstruction.

• Outside the esophageal lumen:
  • Compression of the esophagus due to abscess or hematoma along the neck.
  • Compression due to neoplasia (especially lymphosarcoma of the thymus or mediastinal lymph nodes).
• Oral cavity:
  • Stomatitis (BVDV, calf diphtheria, vesicular stomatitis). Stomatitis
  • Pharyngeal trauma (balling gun injury).

Technical problems

• Overzealous attempts to dislodge the esophageal foreign body can lead to lacerations which can result in strictures of the lumen of the esophagus Esophagus: diseases and disorders.
• Overzealous attempts to dislodge the esophageal foreign body can also lead to perforations of the esophagus.
• Pressure necrosis may occur to the mucosa of the esophagus due to the presence of the foreign body which can lead to stricture of the esophageal lumen.

Alternative techniques

Medical management

• Medical management, as outlined below should be carried out before any attempt to remove the esophageal foreign body:
  • Smooth muscle relaxant (to aid in relaxing the esophageal smooth muscle)- Hyoscine-n-butylbromide (as per manufacturer’s recommendations).
  • Small volumes of a lubricant per os – paraffin oil.

• External palpation and manipulation:
  • Milking the foreign body upwards towards to oral cavity to be retrieved (only if the obstruction is in the cervical region).
  • Usually requires two people- one person manipulating the foreign body and the second person tries to retrieve the foreign body from the oral cavity.
• Endoscopy with the use of a probang:
  • Concurrent use of a two-tube flushing system will allow water to be passed into the esophagus and aid in breaking up and floating the foreign body.
    • Generally carried out in anesthetized animals.

Alternative surgical options

• Cervical esophagostomy:
  • Procedure performed in an animal that is under a general anesthetic.
  • The animal is placed in right lateral recumbency.
  • A stomach tube is placed orally to the level of the esophageal obstruction.
  • Surgical incision is made through the skin and underlying tissues over the area of esophageal obstruction.
  • Balfour retractor may be used to aid in exposing the esophagus.
  • The esophagus is incised (the incision should be made through healthy tissue) and the foreign body is removed.
  • Closure of the esophagus is carried out in two layers:
    • Mucosa and submucosa together – using  simple interrupted or a continuous suture pattern Surgery: suture patterns: overview.
    • Muscular layer – using simple interrupted or a mattress suture pattern.
  • The subcutaneous and skin layer are then surgically closed.
  • If excessive dead space is present a  closed suction drain should be considered.
  • Food and water are withheld for the next 48 hours and hydration is maintained through intravenous fluids.

• Transthoracic esophagostomy:
  • Procedure performed in an animal that is under a general anesthetic.
  • Positive pressure ventilation is required.
  • The animal is placed in right lateral recumbency.
  • A 35 to 45cm incision is made through the skin over the 7th or 8th rib.
  • Partial rib resection may be required from the level of the costochondral junction and the distal portion of the rib is removed.
  •  All soft tissues are packed off and lavaged to keep moist.
  • The esophagus is located and grasped using a penrose drain or umbilical tape.
  • The esophagus is incised (the incision should be made through healthy tissue) and the foreign body is removed.
  • Closure of the esophagus is carried out in two layers:
    • Mucosa and submucosa together – using  simple interrupted or a continuous suture pattern Surgery: suture patterns - overview.
    • Muscular layer –using simple interrupted or a mattress suture pattern.
  • A chest drain is put in place prior to closure of the thoracic cavity.
  • Firstly the parietal pleura is closed, followed by the musculature, subcutaneous tissue and the skin.
  • Food and water are withheld for the next 48 hours and hydration is maintained through intravenous fluids.
• Rumenotomy (reserved for cardia esophageal obstructions that do not have sharp edges) Rumenotomy and ruminal fistulation:
  • Procedure performed in the standing animal  (the animal may be sedated) Sedation: overview.
  • The procedure is carried out through the left paralumbar fossa.
  • A surgical incision is made through the body wall into the rumen (care is needed, not contaminate the abdomen with rumen liquor or feed material).
  • The esophageal foreign body is grasped and removed via the rumen.
  • The rumen wall is then surgically closed.
  • The abdominal wall is then surgically closed.

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