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Rigid esophagoscopy
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MICHAEL T. MARRINAN FRCS(ED)
Consultant Cardiothoracic Surgeon, King’s College Hospital, London, UK
CLAUDE DESCHAMPS MD
Professor of Surgery, Mayo College of Medicine, Rochester, Minnesota, USA
32
PRINCIPLES AND JUSTIFICATION
Rigid esophagoscopy is a useful and safe procedure in the
evaluation of esophageal disorders. In recent years flexible
fiberoptic esophagoscopy has enjoyed widespread use, mainly
because general anesthesia is not required, the stomach and
duodenum can be examined, and the risk of perforation is
lower. Nevertheless, the specific situations outlined later
show that a need for rigid esophagoscopy persists, and the
technique should remain part of the armamentarium of all
esophageal surgeons.
In some circumstances, the relatively cheap cost of a rigid
esophagoscope, combined with its greater durability, may
make the rigid instrument preferable to the fiberoptic instrument. The greater ease of sterilization of the rigid instrument
may also be a factor, particularly where human immunodeficiency virus infection is endemic.
Indications
Removal of ingested foreign bodies is greatly facilitated by the
large-bore rigid open tube with appropriately proportioned
grasping forceps. When severe esophageal bleeding is
encountered, suctioning is far more efficient. To decrease the
risk of aspiration, impacted megaesophagus should be treated
using the rigid endoscope. This allows for liberal irrigation
and more efficient evacuation of debris. This technique also
facilitates the evaluation of high lesions at or just beyond the
cricopharyngeus, an area poorly examined with the flexible
endoscope. Whenever the need dictates, larger biopsy specimens can be obtained through the rigid endoscope.
When an endoesophageal prosthesis is being considered to
palliate intrinsic and extrinsic compression of the esophagus
or malignant esophagorespiratory fistula, rigid endoscopy is
of particular help intraoperatively in dilatation, guide wire
positioning, and verification of the position of the prosthesis
after insertion.
Although injection sclerotherapy of esophageal varices is
preferably performed under sedation using a flexible
esophagoscope, it is possible and safe to perform chronic sclerotherapy using a rigid esophagoscope.
Contraindications
Contraindications to the procedure are few, but it should not
be performed if the cervical spine is unstable and it may be
impossible to perform if severe kyphoscoliosis or restricted
jaw opening is present. Great care should be exercised if large
cervical osteophytes are seen on radiographs of the cervical
spine, if a large thoracic aortic aneurysm is present, or if a
pharyngoesophageal or epiphrenic diverticulum is present. A
chest radiograph and barium swallow results should be
reviewed, and radiographs of the cervical spine may be
required if symptoms are present.
PREOPERATIVE ASSESSMENT AND
PREPARATION
Patient preparation
The patient should have taken nothing by mouth overnight
or for a minimum of 8 hours. This precaution is specifically to
decrease the risk of aspiration during the procedure.
Dentures should be removed. The esophagus should be
empty, which may require consumption of a clear liquid diet
for 24 hours before the procedure and aspiration of the
esophagus immediately before performing the endoscopy.
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Equipment
Chevalier Jackson, Negus, or Moersch-type esophago-
1
scopes may be used. At the Mayo Clinic, the preference is
for the Moersch esophagoscope modified to carry a fiberoptic
light source. This modification uses a fiberoptic light rod to
provide illumination directly at the level of the object being
examined.
A full range of sizes, up to 20 mm for a man and 16 mm for
a woman, should be on hand. An endoscope with magnification is advisable for use in children to compensate for the loss
of visual acuity associated with the use of a small-bore open
esophagoscope.
Large-bore and small-bore suction devices longer than the
overall length of the esophagoscope should be available, as
well as a variety of long biopsy forceps and a full range of
esophageal dilators and guidewires.
Anesthesia
Premedication consisting of pethidine hydrochloride,
1 mg/kg, and atropine sulphate, 0.4 mg, may be given intramuscularly before the procedure.
1
General anesthesia is delivered via a cuffed endotracheal
tube. Muscle relaxation is helpful for the safe performance of
rigid esophagoscopy, as this reduces the risk of perforation.
Rigid esophagoscopy can also be performed under neuroleptanalgesia, although the benefits of complete muscle relaxation are lost. Throughout the procedure the patient’s eyes
are kept covered for protection.
During passage of the rigid esophagoscope through the
cricopharyngeal sphincter, the anesthetist may assist by deflating the cuff on the endotracheal tube and/or pulling forward
on the larynx. When insertion of an endoesophageal prosthesis is being considered, a smaller endotracheal tube should be
used to ease passage of the prosthesis and its introducer.
2a
2b
OPERATION
Position of patient
The patient is positioned supine on an operat-
2a, b
lowered easily, with the head stabilized on a foam ring.
Alternatively, the head and neck may be entirely supported by
an assistant. The surgeon stands during insertion of the
esophagoscope, then sits during the examination.
ing table, the head of which can be raised or
Operation 337
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Tooth protection
The lubricated esophagoscope is introduced at the base
3
of the tongue with the head in the ‘sniffing’ position.
Throughout the procedure, the upper teeth and gums are
protected by a guard, and a gauze swab is positioned over the
upper lip. The tongue is gently pushed to the left, and the
instrument is held at all times between the operator’s thumb
and fingers, so that the lips and teeth are protected.
3
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Passage of the esophagoscope
The epiglottis is visualized and pushed out of
4a–c
scope is then advanced to the posterior pharynx, and the neck
is extended by approximately 15 degrees. The cricopharyngeal sphincter is identified as a horizontal groove halfway
between the posterior larynx and the posterior pharyngeal
wall. The esophagus is entered at this point.
No force should be used as this is an area of high risk for
perforation. If resistance is met, the balloon on the endotracheal tube should be deflated, and the anesthetist can assist by
gently drawing forward on the larynx. If difficulty is still
encountered, a small bougie can be threaded through the
endoscope into the esophagus to lead the endoscope through.
As the esophagus is gently entered, the head must be lowered to allow a decrease in the angulation of the instrument to
bring it into alignment with the long axis of the esophagus.
view by the beak of the endoscope. The endo-
4b
4a
4c
Examination
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The esophagus is examined
5a, b
areas of natural constriction of the esophagus should be borne in mind, as well as the
deviation anteriorly and to the left in the
lower third of the esophagus. The position
of the gastroesophageal junction is of particular importance and should be noted
with reference to its distance from the incisor teeth.
The esophagus should also be examined
as the endoscope is being withdrawn,
particularly in the area just below the
cricopharyngeus, which is poorly seen by
other methods. The same care should be
taken when withdrawing the esophagoscope as during its introduction, as the
esophagus can also be injured during this
phase of the examination. Those maneuvers performed on introduction should be
replicated in reverse during withdrawal of
the instrument.
The opportunity should be taken to palpate the abdomen while the patient is
anesthetized and relaxed.
under direct vision. The
0 cm
18-20 cm
15 cm
Operation 339
40 cm30 cm20 cm10 cm0 cm
5a
40 cm
22 mm19 mm
14 mm
16-19 mm15-17 mm
5b
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POSTOPERATIVE CARE
Apart from aspiration, perforation is the most common
major complication after esophagoscopy, and symptoms and
signs of this should be sought in all patients in the early postoperative period. The cardinal features of esophageal perforation are the following:
1 Severe localized pain
2 Subcutaneous emphysema
3 Pneumothorax
4 Pleural effusion
5 Fever
Even in the absence of any of these features, oral intake should
be withheld until the patient is fully recovered from the general anesthetic. When an endoesophageal prosthesis has been
inserted, a chest radiograph should be obtained to rule out a
pneumothorax and verify the position of the prosthesis. If perforation is suspected, an immediate study using water-soluble
contrast (meglumine diatrizoate) should be performed.
OUTCOME
Rigid esophagoscopy is mainly a diagnostic procedure but
when used for therapeutical dilatation of a stricture is associated with an 80–90% success rate and a less than 5% risk of
perforation.
FURTHER READING
Fontana RS, Higgins JA. Endoscopic techniques. In: Payne WS, Olsen AM
eds. The esophagus. Philadelphia: Lea & Febiger, 1974; 30–8.
Gaer JA, Blauth C, Townsend ER, Fountain SW. Method of endoscopic
esophageal intubation using a rigid esophagoscope. Annals of
Thoracic Surgery 1990; 49: 152–3.
Orringer MB. Complications of esophageal surgery and trauma. In:
Greenfield LJ ed. The complications in surgery and trauma. 2nd ed.
Philadelphia: JB Lippincott, 1990; 302–25.
Wilson RH, Campbell WJ, Spencer A, Johnston GW. Rigid endoscopy
under general anaesthesia is safe for chronic injection sclerotherapy.
British Journal of Surgery 1989; 76: 719–21.
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Sutured anastomoses
JAMIE KELLY BM, BSC, MRCS, FRCS(GEN SURG)
Upper Gastro Intestinal Fellow, University of Adelaide, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
GLYN G JAMIESON MD, MS, FRACS, FACS, FRCS(GLASGOW)
Dorothy Mortlock Professor and Chairman, Department of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia,
Australia
PRINCIPLES AND JUSTIFICATION
Better staging of esophageal cancer has led to better case
selection for esophagectomy, and this has contributed to
improved survival figures. As curative resections increase,
operative morbidity and mortality becomes even more
important. The penalty of an anastomotic leak can be severe,
accounting for around 40 per cent of perioperative deaths.
Even subsequent survival has considerable morbidity due to a
high incidence of anastomotic stricturing, often requiring
repeated dilatations
In an effort to reduce complications the surgeon has been
left with several decisions to make – the site of the anastomosis, hand sewn Vs stapled anastomosis, and whether or not to
combine the anastomosis with an antireflux procedure.
Site – cervical/thoracic
There are two reasons for undertaking a cervical anastomosis.
The first is oncological necessity, to provide adequate clearance for an upper third esophageal tumor. The second reason
is surgical preference, often dependent on the preferred surgical approach, as with a transhiatal esophagectomy. However,
the additional 3–5 cm clearance provided by a cervical over a
thoracic anastomosis has shown no survival advantage for
middle or lower third tumors.
Traditionally cervical anastomoses have been thought to
be associated with a lesser mortality if a leak occurs, since it
can be managed by simply opening the cervical wound, for
drainage. This has been regarded as less severe than the
mediastinal contamination and resultant sepsis from an
intrathoracic leak. Nevertheless, cervical anastomoses have
higher rates of leakage, stenosis, and recurrent laryngeal
nerve injury than thoracic anastomoses. The modified sideto-side stapled techniques described by Collard and Orringer
may reduce the morbidity from a cervical anastomosis, and
indeed in large centers this has been the case. Nevertheless
many surgeons, ourselves included, prefer intrathoracic
anastomoses for resectable tumors of the lower two thirds of
the esophagus. This preference is influenced by advantages
such as avoiding a third incision, better access to nodal disease if node resections are undertaken, lower leakage rates,
and the fact that leaks today can often be managed conservatively.
Hand sewn versus stapled
There are a number of variables that make it difficult to compare anastomotic trials. The anastomosis can be located in the
thorax or cervical regions; the use of circular or linear stapling
devices; and the hand sewn group can be continuous, interrupted, single, or multi layered. These variables, along with
the different conduits used, make it difficult to show a significant difference in anastomotic outcomes. Urschel’s 2001
meta-analysis confirms that a stapled anastomosis is quicker
but suggests it may be associated with a higher mortality.
There is no ready explanation for this finding and it is not
supported by more recent studies.
OPERATION
Preparation is the key to any gastrointestinal anastomosis and
meticulous attention to technical details applies particularly
to the easily compromised esophagus and newly formed conduit.
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Technique
DOUBLE LAYER – INTRATHORACIC ANASTOMOSIS
The anastomosis is undertaken above the level of the
1
azygos vein in the apex of the thoracic cavity.
1
Following the construction of a gastric conduit, viability
2
in terms of length and vascularity are checked. The oxygen tension of the gastric conduit is lowest at its most proximal point, where an end-to-end esophagogastrostomy would
be constructed. To avoid this potential ischemia we favor an
anastomosis placed more distally on the gastric conduit. Not
only does this give a better vascularized end-to-side anastomosis but it also has the advantage of facilitating the addition
of a “fundoplication.” The gastrotomy is made on the anterior stomach wall, a minimum of 2 cm away from the newly
sutured or stapled margin of the gastric conduit.
2
As the anastomosis is high in the apex of the chest the
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3
specimen is first resected and four full thickness stay
sutures are placed at the 3, 6, 9, and 12 o’clock positions in the
esophagus. The stays help with esophageal manipulation and
prevent retraction of the esophageal muscle.
Operation 343
3
The esophagus is lifted cranially while the conduit is
4
brought up near to the apex of the thoracic cavity, to lie
behind the esophageal remnant. Two nonabsorbable sutures
are used to anchor the apex of the conduit to the muscle of
the esophagus, as high as is practicable. This allows the esophagus to lie on the anterior stomach wall in preparation for the
anastomosis, which begins on the posterior aspect of the
esophagus.
4
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