Malignant oesophageal strictures: a review of

Br. J. Surg. Vol. 69 (1982) 61-68
Printed in Great Britain
Proffered review
Malignant oesophageal strictures:
a review of techniques for
palliative intubation
RICHARD EARLAM AND
J. R.CUNHA-MELO
The London Hospital, Whitechapel, London
El IBB.
A review of the different designs for palliative oesophageal intubation
tubes confirms Souttar's original suggestion that they should be
flexible, incompressible, non-traumatic, compact, have an adequate
lumen and stay in place. The internal diameter should be at least
10mm. The thickness of the wall should be about 1 mm. The length
will vary according to the stricture and should be as short as possible,
provided that the proximal rim prevents future longitudinal growth
occluding the lumen. Various methods of achieving the ability to stay
in place are described, which comprise either a large proximal rim or
a roughened barrel. No details about results are given because the
original patient populations vary so much. Success probably depends
more on the technical expertise and experience of the surgeon than
specific variations in design.
Dysphagia is the leading symptom in oesophageal cancer and
its relief must be the main aim of treatment. Approximately 60
per cent of all patients with squamous cell carcinoma of the
oesophagus have extensive tumours that cannot be resected
(1,2). In one large series, 45 per cent had intubation because
they were unsuitable for surgery (3), but even after surgical
resection about 20 per cent will have further dysphagia either
due to recurrence or a stricture at the site of the anastomosis
(4, 5). Similarly, radiotherapy is followed by dysphagia in over
25 per cent, usually caused by a fibrotic cicatricial narrowing
rather than local recurrence (6). The treatment of dysphagia by
oesophageal dilatation is essentially similar to that for a benign
stricture but with additional complications due to the nature of
the malignant process. The minimal requirement is for the
patient to swallow his own saliva and since this is often thick he
will easily swallow clear liquids through such a lumen. Patients
can survive on modern clear fluids such as Vivonex,
Amicalorin, Aminutrin or Clinifeed for months. Any large
lumen will enable more solid food to be taken. There is a
mistaken idea that normality is the perfection that should
always be achieved. The average length of time with symptoms
prior to diagnosis is over 6 months (1,7) and perhaps some
patients are not really worried by some trouble swallowing
food. Each patient has his threshold for what suits him and
many are happy if they can settle down with their spouse to the
same food, provided it is minced or mashed and they can eat
slowly in their own time.
A recent study has confirmed that over 50 per cent of patients
with oesophageal cancer die in hospital (8). If treatment cannot
achieve a radical cure then surely it should enable the patient to
die at home if he and the relatives so wish under the care of his
family doctor who can treat all his other difficulties
symptomatically but relies on the surgeon to deal with the
mechanical problems of stenosis or fistula.
In the past 25 years there has been more interest in the
subject of palliative intubation. Numerous tubes have been
described and their sizes, materials and special properties are
listed in Table I. Presently available ones may be suitable or
new tubes require invention, but what may be lacking is the
experience in using them. This paper is concerned primarily
with the technology of intubation. Indications for palliation,
which are closely connected with non-resectability, are not
discussed; nor are the results included, because they vary so
much with the patient population and details are given in the
individual papers ciled in Ihe text.
Optimal diameter of the oesophageal lumen
Every individual has a different optimal diameter for an
oesophageal stricture because it depends on the actual nature
of the obstruction, its degree of elasticity, length, the power of
the muscle pushing the bolus through as well as the patient's
threshold for tolerating discomfort on swallowing. It is not
possible to be dogmatic, therefore, about the minimal diameter
to be achieved by dilatation, but it is the authors' aim with
malignant strictures to achieve dilatation to at least 10mm
diameter or 30 FG. Using modern techniques, this can almost
always be achieved with repeated dilatations so there is no
reason to accept a smaller diameter. The internal diameter of
most palliative tubes lies between 10 and 12mm, with only a
few being 14 or 15mm. Larger tubes are not used because a
stricture which can be dilated to more than 15 mm diameter or
45 FG does not need an indwelling tube. The only justification
for inserting a tube with a large lumen is to block off a fistula
unaccompanied by narrowing of the oesophagus.
A tube will maintain a given lumen but there are several
methods other than simple dilatation to achieve this. They are
all based on the fact that most oesophageal tumours are
proliferative and the tumour itself encroaches on the lumen to
narrow it, frequently leaving the muscle walls themselves
widely separated. Radiotherapy gradually causes necrosis of
the tumour and then the act of swallowing removes the dead
tissue. Occasionally, radiotherapy gives no relief because
patients have had a complete oesophageal block prior to the
start of the course. In such a case, dilatation or reaming out the
lumen will enable the scouring process to begin. Barlow's borer
(9) or reamer (see Fig. 1) is the only instrument specially
designed for this. Heat provided by diathermy (10) and extreme
cold from cryosurgical probes have also been used (11). None
of these particular methods changes the natural history of the
disease but does achieve symptomatic relief.
Historical aspects
The great advances of the past century in palliative intubation
were made in the 1880s. There were several case reports of
catheters being passed enabling a patient to obtain nutrition
and survive for a few months (12-16). Sir Charles Symonds is
usually cited as the first to use an indwelling tube rather than a
catheter in 1885 (17,18). This relied for its fixation on strings
emerging through the nostrils and tied behind the ears but in
another method it was attached to the moustache, if available.
In 1845 a French surgeon Leroy d'Etoilles had used a short
R. Earlam and J. R. Cunha-Melo
62
ATKINSON Keymed
MOUSSEAU-BARBIN
CELESTIN simple
PALMER
CELESTIN flange
COLLIS
PROCTER-LIVINGSTONE
COYAS
SACHS
DIDCOTT
SOUTTAR
STIRNEMANN
HOLINGER
MACKLER
TYTGAT (a)
TYTGAT (b)
Malignant oesophageal strictures
63
BARLOW'S BORER
GUISEZ
GOTTSTEIN
NOTTINGHAM INTRODUCER
Fig. 1. Various designs for palliative oesophageal intubation tubes.
tube of decalcified ivory (19). Symond's tube was made of
boxwood and ivory. Although oesophagoscopy had already
been developed, by Kussmaul (20) and Mikulicz (21), tubes
were placed blindly at this time. In 1901 Gottstein (22)
developed a short rubber tube with an inverted funnel top and a
rim distally which did not require strings for fixation (see Fig.
1). This was developed later by Guisez (22,23), who used a tube
with a de Pezzer catheter type of end (see Fig. 1). In his article
there is an illustration of a small tube of earlier design held in
place by strings. The Mosher plug was another method (24).
The honour for developing an indwelling palliative tube with
no external fixation must go to Gottstein in 1901; previous
attempts had succeeded in isolated cases but his tubes were of
more practical use.
In 1924 the next progress was made by Sir Henry Souttar
who developed a tube based on the design of a spring and held
in place by the roughness of its exterior and a proximal lip (25).
Souttar was an engineering student at Oxford before becoming
a surgeon at the London Hospital so his knowledge of the
accurate measurement needed helped him in producing this
tube. It was originally made of German silver covered with gold
plating. The secondary spiral in the spring appeared later
(26,27) and, in the Souttar tube modified by Professor Leigh
Collis, was lost (28). These tubes were all smaller than the
lumen of the rigid oesophagascopes available and were inserted
under direct vision through the oesophagoscope and not
blindly.
For the next 30 years there was no great interest in palliative
intubation. It was, however, apparent that there was a demand
for a tube that could be pulled downwards through an
obstruction in the oesophagus, cardia or upper stomach,
whereas the Souttar tube was only suitable for pushing from
above. The Mousseau-Barbin tube was the first of this type to
be designed in 1956 with a long leading catheter end (29). In
1959 this was developed by Celestin and later manufactured in
latex rubber rather than plastic (30-32). In an article dated
1974 (33), detailing the methods and attempting to assess the
best tube available, there were only 2459 patients described in
the literature between 1960 and 1971, which is not many
considering that the need for palliation is so high. Exceptions to
this were two large series described by O'Connor (34) and
Mounler-Kuhn (35). Recently, there has been a change of
emphasis and Procter has described his own personal
experience in over 2000 patients (36).
Although most tubes can be divided into either push or pull
types, there has recently been a solution to the problem of how
to 'push a piece of string'. The Celestin tube, which was
originally designed for the pull method, was first actually
pushed in 1974 (37) and now a commercially available method
has been developed by Atkinson (38-40) and called the
Nottingham introducer (see Fig. 1).
Throughout the years, attempts have been made to excise a
portion of the oesophagus and bridge the gap with a prosthesis.
Experimentally, this was achieved in dogs (41) and then the
same technique was applied to one patient (42). Replacement of
a segment of the thoracic oesophagus has been attempted but is
not accepted as a practical procedure because of the danger of
mediastinal leaks (43). Replacement of portions of the cervical
oesophagus, after pharyngolaryngectomy, is more successful
(44-46).
The majority of indwelling tubes that had an opening to the
exterior were brought out through the nostril but attempts have
been made to ease the patient's discomfort by bringing them
out through the cervical oesophagus below the cricopharyngeal
sphincter (47-51) or above through the pyriform fossa (52).
Technical aspects
Material: The different materials and their properties are
summarized in Table II. The majority of the new tubes are
plastic. The essential properties of flexibility and
incompressibility which can be provided by the old materials of
reinforced rubber or a stainless steel spring have not been
improved by the modern ones. Even with plastic there is a
certain thickness below which the tube is too easily compressed.
Internal diameter: The majority of the tubes have an internal
diameter between 10 and 12 mm. Those with the figure 12-5 mm
merely reflect a conversion of the imperial measurement of half
an inch to metric size. American plastic tubing comes in such
measurements (53,54). Historically, Chevalier Jackson
considered that half an inch (12-5 mm or 39 FG) was sufficient
diameter for dilatation of a stricture to enable swallowing to be
improved.
Wall: The thickness depends on the material used. Technically,
it is difficult to obtain a thickness ofless than 1 mm. The thicker
the wall, the greater the outside diameter becomes and
obviously this should be minimized.
Outside diameter: From Table I it will be seen that the majority
have an external diameter of between 14 and 17 mm. Some have
a measurement of 18mm, which is 54 FG. This is probably an
unacceptably large size because dilatation to such a diameter
relieves dysphagia in the majority of patients. A size of 15mm
or 45 FG seems to be the maximum acceptable. For any given
outside diameter the largest lumen is provided by those with the
thinnest walls such as the Goni, Mousseau-Barbin, Sachs and
Souttar tubes.
Proximal end: The majority of tubes depend on the size of the
proximal end (Fig. 2) to prevent them slipping downwards into
the stomach. Some have a thin collar, 1-2 mm wider in
diameter than the barrel, but this is too small a limit for safety
because it loosens due to movement and pressure necrosis. A
proximal end that is much wider serves the two purposes of (a)
preventing distal displacement and (h) directing the bolus into a
narrowing. The shapes can be subdivided as follows: collar
(Souttar), funnel (Palmer), cup (Mousseau-Barbin and Palmer)
and tulip (Celestin).
The tulip shape was developed to prevent the rim
intussuscepting if floppy or causing pressure necrosis if it were
more firm. If the soft end, when compressed, is still too rigid,
R. Earlam and J. R. Cunha-Melo
Table I: PALLIATIVE
TUBES
Year
Reference
Atkinson
1978
(38-40)
Push
Celestin
1959
(30-32)
Laparotomy
Pull
Push
Author
Method
ID
(mm)
OD
(mm)
Silastic rubber
11
15
2
14
12
15
1-5
34
11
13
1
7
2
13
Material
Wall
(mm)
Length
(cm)
Collis
1971
(28)
Push
Originally
polyethylene
then latex
rubber with
nylon
reinforced
spiral
Stainless steel
Coyas
1955
(61,84)
Push
Polyvinyl
10
14
Didcott
1973
(82-84)
Push
Stainless steel
wire embedded
in rubber
1 6
? ?
Polyvinyl
Polyethylene
10
15
14
17
2
1
40
40
Fell
Goni
1966
1964
(85)
(86, 87)
Pull
Pull
9
11
15
19
Gourevitch
1959
(88)
Pull
Armoured latex
rubber
?
?
?
16
Haring
1964
(58, 89)
Pull
13
17
2
9,12,18
Holinger
1955
(59)
Push
Latex rubber
reinforced
with stainless
steel
Polyvinyl
7-10
?
?
7-12
Mackler
1954
(90)
Thoracotomy Polyvinyl
?
9-12
?
?
MousseauBarbin
1956
(29,91)
Pull
Neoplex
10
14
12
16
1
30 + 70
Palmer
1970
(53,55,
92-94)
Push
Tygon
R8420
12-5
15-7
1-6
Any
Latex rubber
armoured with
monofilament
nylon
Nylon
12
18
3
10,15,19
8
10
1
?
Gold plated
German silver
A 8
BIO
10
12
1
5-20
C12
14
1968
Sachs
1959
Souttar
1924
(36,95-98) Push
(66)
Push
(7,25-27) Push
Funnel top (29 mm) with
non-return flange
Proximal end tulipshaped (28 mm) distal
end tapered but can
be cut or trimmed,
later distal flange
}
^
ProcterLivingstone
Comments
Stirnemann
1965
(99,100)
Pull
Porflex
11
14
1-5
?
Tytgat
1976
(54,65)
Push
Tygon R3693
Tygon R8420
12-5
15-7
1-6
8-35
Weisel
1959
(101,102)
Push
Polyethylene
10
13
1-5
10-25
Similar to Souttar
but stainless steel
and no spiral in the
body
Proximal collar
projecting 1-5 mm
with metallic ring
for radiology, body
has multiple rings
Self expanding, when
compressed it
elongates and
narrows for ease of
insertion
Proximal end 3 mm
rim (23mmOD),
distal end duckbilled
Proximal end funnelshaped distal end
bevelled
Proximal end soft funnel
Both ends mushroomshaped de Pezzer catheter
shape
Proximal end funnelshaped, inserted after
opening oesophagus
through a thoracotomy
Proximal end floppy
funnel (24mm OD),
distal end can be
trimmed
Heated plastic
moulded to funnel
shape
Proximal end fishmouthed 3-0x2-5 cm,
distal end also fishmouthed
Format of a hollow screw
that is actually
screwed into place,
proximal end two notches
Held in place by
proximal lip, rough
exterior and spiral
body
Proximal end funnelshaped and distal end
reversed funnel
Transparent plastic
with two radio
opaque rings, can be
pushed in place over
flexible fibrescope
proximal end diameter
25 mm. One type has
a spiral ring barrel.
Flanged proximal end
with bevelled distal
end
-
65
Malignant oesophageal strictures
DISTAL ENDS
PROXIMAL ENDS
collar
funnel
cup
tulip
Fig. 2. Proximal ends of tubes.
the rim will form angles at both sides which may perforate the
oesophageal wall. For this reason Procter (36) developed the
fish-mouthed end to avoid this (see Fig. 1). When a
tube is made of polyethylene or polyvinyl chloride the end. can
be heated and formed as a funnel, or indeed any shape which is
then maintained at body temperature (55,56). A floppy
proximal end such as the Celestin tube can be compressed to a
smaller size during insertion. The cricopharyngeal sphincter
limits the size of the proximal end. Although it presents as a
transverse slit, it can be dilated up to 75 FG, but it will not
usually take instruments of one inch diameter (23-9 mm
diameter is equivalent to 75 FG). One inch diameter is
equivalent to 24-5 mm or 78 FG, if the conversion uses n as
3-142 rather than 3-0. At smaller diameters this difference for
the value of re does not matter for all practical purposes, but it
is essential for a surgeon to know whether his tubes and dilators
are measured accurately and with what conversion factor. In
the past much trouble occurred because dilatation was
measured in inches and their fractions but tubes were inserted
in metric sizes or vice versa.
Too large a proximal end is cumbersome during insertion
and may cause pressure necrosis in situ. It must be remembered
that the oesophagus is normally collapsed with a negative
intraluminal pressure. These problems are exacerbated with
intubation of the cervical oesophagus. Here, there is very little
space between vertebrae and the trachea and it is essential also
for the length of the proximal end to be so short that it does not
impinge on the cricopharyngeal sphincter. Tubes of a smaller
Table II:
MATERIALS
Material
Boxwood and ivory
German silver, an
alloy of brass and
nickel
Ivory
Latex rubber
Ncoplcx
Nylon
Polyethylene PE 410
Polyvinyl chloride
(PVC)
Portex
Resinyl
Silicon rubber
Solid silver
Stainless steel
Tygon R8420
3693
Author
Symonds (17,18)
Souttar (25-27)
Etoilles(19)
Celestin (32)
Procter-Livingstone
(36,95)
Mousseau (29)
Sachs (66)
Carter (56)
Clauss (103)
Coyas (81)
Dubois(104)
Fell (85)
Greening (105)
Grewe (106)
Heimlich (50)
Holinger (59)
Mackler (90)
O'Connor (34)
Weisel (101)
Zaslavsky (107)
Hayes (108)
Stirnemann (100)
Kropff(109)
Atkinson (40)
Brown (110)
Amman and Collis (28)
Farlam (7)
Palmer (53)
Jager(65)
Tytgat (54)
flush
bevel
fishmouth
flap
valve
Fig. 3. Distal ends of tubes.
size with a narrow collar are to be preferred in this anatomical
situation.
Distal end: Most tubes have the distal end cut off at right angles
to the long axis (Fig. 3). Some have suggested an oblique end to
enlarge the lumen at the exit. Another advantage proposed for
this is that compression of the end will not occur. The former
idea ignores the fact that the internal diameter of the barrel will
limit the flow and the latter the fact that the barrel should be
non-compressible anyway.
Proximal dislodgement is a problem with some tubes. Distal
collars have been provided as with the original Guisez tube (see
Fig. 1) (22) and others have an additional flange or end (57)
some of which can be screwed on through the laparotomy
incision (50, 58). A de Pezzer or mushroom-shaped end has also
been used (22, 59,60). Three designs presently available, by
Celestin, Atkinson and Procter, have a distal flange or collar to
prevent proximal movement.
Reflux back through the tube can be a problem if it traverses
the gastro-oesophageal junction. Flap valves (61), similar to
those provided in the Aldon bag (62), can prevent reflux (Fig. 3).
Most surgeons will deal with this particular problem by advice
to go to bed with an empty stomach and to sleep propped up,
similar to that given patients after an oesophagogastrectomy.
Oesophagitis, due to gastric reflux proximal to the tube, does
occur, is infrequent and rarely causes complications.
Barrel: The majority are smooth. None is made of Teflon
which has the lowest possible surface tension, but on the
contrary many rely on a rough external surface for fixation
such as the Souttar tube, which is a spiral screw with 10 turns
per cm, pushed in rather than screwed in. The Souttar tube has
been modified by coating it with plastic to prevent tumour
infiltration (63), but this modification eliminates the roughness
which prevents the normal Souttar tube moving. The tube
designed by Coyas (64) has multiple rings to prevent dislodgement, as does one described by Tytgat (54, 65). Two designs
have a spiral superimposed upon the barrel, which is made of
plastic (65,66). The only tube with a deliberate continuous
spiral specifically made for screwing into place is the one Sachs
described (see Fig. 1) (66).
Complications (36, 67)
Bolus obstruction
This is often cited as the main contraindication to intubation
but it is rare. Some patients can swallow normal food without
observers being aware that they have a tube in situ. The patient
should aim to take the same diet as is cooked for other
members of the household. Specifically, steaks and fresh bread
may cause trouble and should be avoided. Minced meat and
toast are less likely to stick. All patients should have their teeth
properly looked after so that they can chew well. Bolus
obstruction in the majority of instances will relieve itself by
autodigestion and softening but if there is still total blockage
after 12-24 hours the patient should go to hospital. Meat
tenderizer or fresh pineapple juice have been suggested as
methods for the patient to clear the block himself. All the
authors' patients are given a letter describing the size and site of
the tube inserted in case they attend a strange hospital or their
notes cannot be found on admission. The first procedure is to
pass a large nasogastric tube to try and push the bolus through.
If this fails, endoscopy is necessary. It is doubtful whether a
preliminary Gastrografin radiological examination is helpful.
66
Perforation
The most dangerous complication is perforation. This may
be caused by making a false passage through the tumour or
below, early during the process of dilatation, later as the
palliative tube is inserted or delayed due to pressure necrosis.
The use of guide wires can help to reduce the incidence of
making a hole through the oesophageal wall and careful
attention to- the size of the lumen in relation to the outside
diameter of the tube reduces the risk of splitting the muscle.
Most tubes arc inserted over a guide rod as described with
the original Souttar tube (25). The modern ones can be guided
over a flexible fibrescope. If a Souttar tube is passed blindly it is
helpful to block the open distal end with a soluble device, either
a glycerine suppository acting like an obturator, as first
described by Souttar, or a moulded toffee.
Tumours at the gastro-oesophageal junction are more
difficult to intubate because of the change in axis. Previously
the pullthrough technique was used exclusively but it is possible
to push either a Celestin (38), a Souttar (68) or a Tytgat tube
(65) from above provided that there is a guide wire or a bougie
in place. Pulling a tube through a tumour via a gastrostomy
does not completely avoid perforation or a false passage. It
may help to have a nasogastric tube, guide wire or thread (69)
in situ first. Hegar's dilators are usually the most suitable for
retrograde dilatation. Another technique of use with a
gastrostomy is gradual dilatation from above downwards using
the 'endless-string' technique and passing increasing sized
bougies through the narrowing (70).
The earliest signs of perforation are pain, rising pulse rate
and temperature, but exploration is not necessarily essential as
'small leaks can be treated conservatively. The procedure
should be covered with preoperative antibiotics. Local pressure
may lead to perforation as a delayed phenomenon (71).
Tracheal compression may be caused by a tube with a very
large lip (72) but perforations caused apparently by pressure
may be part of the natural process of the disease and not due to
the inert material penetrating through local structures. Fistulas
due to necrosis may enter the trachea, bronchi or the lungs (73),
aorta, other mediastinal vessels or the pericardium. If fluid
enters the lung through a fistula, a palliative tube can be
inserted to block off the hole and provide a preferentially large
lumen for the bolus passing down the oesophagus. Coughing
immediately after swallowing, worse with liquids than solids,
should be interpreted as a tracheo-oesophageal fistula and
treated as an emergency by intubation. If acute haemorrhage
occurs due to erosion of a large vessel it is doubtful whether
anything can or should be done. When air is seen in the
pericardium, intubation is not helpful but it can persist for
weeks before death.
Proximal displacement
Proximal displacement can occur with any palliative tube as a
result of too loose a tube being inserted or it not being jammed
tightly enough against the upper edge of the tumour. It is a
simple matter to re-insert a correct size of tube. Early diagnosis
of this complication can be made by a comparison of the
postoperative X-ray with a preoperative film. It is essential to
have films of the tumour in relation to the whole chest or upper
abdomen. These are obtained by radiotherapists so that the size
and position of the growth can be measured for subsequent
irradiation. They are also essential before inserting a tube so
that its appropriate length can be assessed, any curves or axis
deviation can be recognized and the correct position be easily
seen on a straight film after insertion. If this latter film is correct
and the patient is swallowing normally there would appear to
be no advantage in postoperative barium or Gastrografin
swallows.
Different designs have been developed to prevent tubes
moving upwards, which are either in the form of a de Pezzer
catheter, a collar or a flange (Fig. 4). The tubes are designed to
prevent proximal dislodgement; consequently, if they are
pushed too far originally or slip down, it is almost impossible to
withdraw them through the mouth and they have to be
removed through a gastrostomy. It is suggested that this is an
unnecessary complication which can easily be avoided by not
using this type of design. If a tube dislodges proximally it can
R. Earlam and J. R. Cunha-Melo
PREVENTION OF PROXIMAL DISPLACEMENT
\
collar
de Pezzer
flange
Fig. 4. Prevention of proximal displacement.
easily be pushed back or changed. The complications of the
distal collar or flange far outweigh the risk of either having to
push the tube back down again or change it.
Distal displacement
Distal displacement with the tube passing into the stomach can
occur with any of the tubes and it is more likely to occur in
those with a relatively small proximal lip. Careful attention to
the accurate measurement of diameters is the most essential
factor in prevention. The new stainless steel Souttar tubes have
a wider rim than the older type and are less likely to pass into
the stomach. Short small tubes have been known to pass
throughout the bowel but some may remain for ever in the
stomach causing no symptoms. The Souttar, Procter Livingstone, Celestin and Mousseau-Barbin types have been
known to pass per rectum. If a tube passes into the stomach at
least adequate dilatation of the stricture has occurred.
Reflux
Reflux occurs when a tube is inserted in the lower one-third of
the oesophagus bridging the gastro-oesophageal junction.
Macroscopic oesophagitis is usually unaccompanied by
symptoms whether due to reflux or stasis above an obstruction
and should not necessarily be treated per se. Heartburn or
reflux up through the cricopharyngeal sphincter should be
treated symptomatically by antacids, posture and the
avoidance of large meals before going to bed.
Wound infection
Wound infection occurs in almost half the patients when a
thoracotomy or a laparotomy is necessary to insert a tube
directly or to pull one down through a gastrostomy. It is
probably always wise to drain the laparotomy incision. The
reasons lie in the poor general condition of the patient, the
absence of high acidity in the stomach to sterilize its contents
and the unavoidable contamination of pulling the tube through
the mouth and oesophagus. Wound infection must be accepted
as one of the complications to be assessed when deciding
whether to push or pull a tube through an oesophageal
obstruction.
Guide wire complications
These can occur during the course of dilatation. A guide wire
provides safety for the inexperienced but there are a few specific
complications which should be avoided. The wire must be
carefully looked after since once it has been kinked it is
damaged for ever and should be replaced. The guide wire
springs are delicate and can break if pushed too hard (73).
Loops and knots can also cause obstruction and this can be
avoided by not passing too much wire into the stomach.
Complications related to tube material
Specific complications of the Celestin tube include rubber
destruction or decomposition (74). This can be avoided by
replacement of the tubes at 6-monthly intervals but there is no
advantage in regular endoscopic inspection even if Celestin
tubes are used for benign strictures (75) because this
complication is rare. In the latest tubes the nylon spiral is in
short lengths. Originally the nylon spiral was continuous and
when the latex decomposed the distal part attached by the
nylon passed down the bowel and perforation was caused by
the bowstring sawing effect (76). Any tube with the old-
Malignant oesophageal strictures
fashioned design should be discarded because the rubber does
not have an indefinite shelf life.
The other types of tube have not been in use long enough for
specific complications to be described or were discarded early
because too many complications occurred. Polyethylene does
not have an indefinite life in the body and becomes brittle
and fractures with time. Each material has its own specific
complications but they can be avoided by replacement. If this is
done together with further dilatation, a larger tube can be
pushed in. If the tube was originally one of the pullthrough
type, further laparotomy is unjustified. The problems of
material decomposition in the majority of instances are of no
practical importance because the natural history of the disease
at this stage is so short.
Others
Proximal prolapse of the rim has been described (77) but the
tulip shape was designed to avoid this. Prolapse of the
oesophageal mucosa has been described once, but only with a
Mousseau-Barbin tube (78).
Assessment of results
. Very few papers have been concerned with measurement of the
quality of life after intubation, in spite of this being the main
factor in palliation (79). Apart from the ability to swallow, it is
essential to assess such items as sleeping at night without
coughing or choking (80). The ability to enjoy leisure and be
able to work are rarely measured but are actually extremely
important.
The ideal palliative tube
Sir Henry Souttar originally proposed that an ideal tube should
be (27): flexible, incompressible, non-traumatic and compact,
should have an adequate lumen and remain in place. Nothing
more can be said except perhaps to add the questions: what is
the name of this ideal tube and from where can it be obtained?
The authors consider that the basic tube types, Celestin (with or
without flange, Medoc (Glos.) Ltd, Tetbury, Gloucestershire)
or Atkinson (with flange, Ke'ymed, Southend-on-Sea) and
Souttar (stainless steel, Seward's, Blackfriars, London), are-as
near to ideal as can be obtained. They are available in different
sizes, and can be pushed or pulled according to the particular
tumour. The Didcott dilator and the Procter-Livingstone tubes
can also be obtained in this country (Staniforth Limited,
Penarth, South Glamorgan). It is essential that tubes are
stocked in every operating theatre because suitable patients are
admitted frequently as emergencies.
Acknowledgement
Dr Cunha-Melo would like to thank the Brazilian National Council of
Scientific and Technological Development (CNPq) for a grant.
References
1. Earlam R. J. and Cunha-Melo J. R.: Oesophageal squamous cell
carcinoma: I. A critical review of surgery. Br. J. Sure. 1980; 67:
381-90.
2. Saunders N.- R.: The Celestin tube in the palliation of carcinoma .
of the oesophagus and cardia. Br. J. Surg. 1979; 66: 419-21.
3. Angorn I. B. and Hegarty M. M.: Palliative pulsion intubation in
oesophageal carcinoma. Ann. R. Coll. Surf. Engl. 1979; 61212-4.
4. Sanfelippo P. M. and Bernatz P. E.: Celestin-tubc palliation for
malignant esophageal obstruction. Surg. Clin. North Am. 1973;
53: 921-6.
5. Jackson J. W., Cooper D. K. C., Guvendik L. et al.: The surgical
management of malignant tumours of the oesophagus and cardia;
a review of the results in 292 patients treated over a 15-year period
(1961-75). Br. J. Surg. 1979; 66: 98-104.
6. Earlam R. J. and Cunha-Melo J. R.: Oesophageal squamous cell
carcinoma; II. A critical review of radiotherapy. Br. J. Surg. 198067: 457-61.
7. Earlam R. J.: Souttar tube for oesophageal carcinoma. Chir.
Caxlroenterol. 1979; 13: 15-20.
8. Earlam R. J., Cunha-Melo J. R., Donnan S. P. B. et al.: The
epidemiology of oesophageal cancer. 1982. (In the press.)
9. Barlow D.: Alternative methods of oesophageal replacement and
reconstruction. In: Rob C. and Smith R. (ed.): Operative SurgeryService. London: Butterworths. 1965; 5: 23.
67
10. Schomacher P. H.: Treatment of inoperable oesophageal malignancies with a thermal probe. Dtsch. Med. Wochenschr. 1977; 102:
647-9.
11. Wittrin G.: Die palliative Behandlung tumorbedingter
inoperabler Oesophagusstenosen mil der Thermosonde. Chirurg
1973; 44: 285-7.
12. Krishaber A.: De la sonde oesophagienne a demeure. Trans. Int.
Med. Congress 1882; 2: 393-6.
13. Durham. A.: Gastrostomy and oesophagostomy in cancer of the
oesophagus. Lancet 1881; 2: 872-5.
14. Croft J.: Treatment of cancerous obstruction of the oesophagus
by permanent catheterism. St Thomas' Hospital Reports 1882; 12:
45-53.
15. Bird G.: Gastrostomy and oesophagostomy in cancer of the
oesophagus. Lancet 1881; 2: 872-975.
16. Mackenzie M.: A Manual of Diseases of the Throat and Nose
including the Pharynx, Larynx, Trachea, Oesophagus, Nose and
Naso-pharynx. London: J. A. Churchill, 1884.
17. Symonds C. J.: A case of malignant stricture of the oesophagus
illustrating the use of the new form of oesophageal catheter.
Trans. Chir. Soc. Land. 1885; 18: 155-8.
18. Symonds C. J.: The treatment of malignant stricture of the
oesophagus by tubage or oral catheterism. Br. Med. J. 1887; 1:
870-4.
19. d'Etoilles L.: In de Lanacherie de I'Oesophagotomie. Brussels.
1845.
20. Kelly H. D. B.: Origins of oesophagology. Proc. R. Soc. Med.
1969; 62: 781-6.
21. Mikulicz J.: Ueber Gastroskopie und Oesophagoskopie. Zentralbl. Chir. 1881:8: 43.
22. Guisez J.: De 1'intubation caoutchoutee oesophagienne. Presse
Med. 1914; 22: 85-7.
23. Guisez J.: Traite des Maladies de I'Oesophage. Paris. Libraire J. B.
Bailliere et fils, 1911.
24. Mosher H. P.: Some observations on esophageal cases and the
presentation of two new instruments. Laryngoscope 1909; 19:
401-27.
25. Souttar H. S.: Method of intubating the oesophagus for malignant stricture. Br. Med. J. 1924; 1: 782-3.
26. Souttar H. S.: Treatment of carcinoma of the oesophagus based
on 100 personal cases and 18 post-mortem reports. Br. J. Surg.
1927; 15: 76-94.
27. Souttar H. S.: Cancer of the oesophagus. Br. Med. J. 1934; 2:
797-800.
28. Amman J. R. and Collis J. L.: Palliative intubation of the
oesophagus. Analysis of 59 cases. /. Thorac. Cardio vase. Surg.
1971; 61: 863-9. '
29. Mousseau M., Le Forestier J., Barbin J. et al.: Place de
1'intubation a demeure dans le traitement palliative du cancer de
1'oesophage. Arch. Mai. Appar. Digest. 1956; 45: 208-16.
30. Celestin L. R.: Permanent intubation in inoperable cancer of the
oesophagus and cardia. A new tube. Ann. R. Coll. Surg. Engl.
1959; 25: 165-70.
31. Celestin L. R.: Intubation in carcinoma of the esophagus and
cardia. Armamentarium 1965; 4: 8.
32. Celestin L. R.: Improvements in the Celestin tube for endooesophageal intubation in carcinoma and strictures. Armamentarium 1969; 5: 10.
33. Giradet R. E., Ransdell H. T. jun., Wheat M. W. jun. et al.:
Palliative intubation in the management of esophageal carcinoma. Ann. Thorac. Surg. 1974; 18: 417-30.
34. O'Connor T., Watson R., Lepley D. jun. et al.: Esophageal
prosthesis for palliative intubation. Further evaluation of 378
patients. Arch. Surg. 1963; 87: 275-9.
35. Mounier-Kuhn P., Gaillard J., Haguenauer J. P. et al.: Les
indications de Fintubation par voie haute des cancers de
1'oesophage. J. Fr. Olorhinolaryngol. 1968; 17: 491-5.
36. Procter D. S. C.: Esophageal intubation for carcinoma of the
esophagus. World J. Surg. 1980; 4: 451-61.
37. Heafitz M., Irarrazvavai M., Huebl H. et al.: A simple technique
for intubation of the oesophagus for fistulae and obstructions.
Chest 1974; 65: 359-60.
38. Atkinson M. and Ferguson R.: Fibreoptic cndoscopic palliative
intubation of inoperable oesophagogastric neoplasms. Br. Med. J.
1977; 1: 266-7.
39. Atkinson M., Ferguson R. and Parker G. C.: Tube introducer
and modified Celestin tube for use in palliative intubation of
oesophagogastric neoplasms of fibreoptic endoscopy. Gut 1978;
19:669-71.
40. Atkinson M., Ferguson R. and Ogilvie A. L.: Management of
malignant dysphagia by intubation at endoscopy. J. R. Soc. Med.
1979; 72: 894-7.
41. Berman E. F.: The experimental replacement of the esophagus by
a plastic tube. Ann. Surg. 1951; 135: 337-43.
42. Berman E. F.: A plastic prosthesis for resected esophagus. Arch.
Surg. 1952; 65: 916-9.
43. Watanabe K. and Mark J. B. D.: Segmental replacement of the
thoracic esophagus with a silastic prosthesis. Am. J. Surg. 1971;
121: 238-40.
68
44. Chu W., Rics G., Jaurigue V. G. et al.: Restoration of pharyngocsophaeeal continuity with a replaceable prosthetic conduit: a
new method. Am. ./. Surg. 1978: 135: 269-71.
45. Skerik P. and Tichy S.: Neue Indicationen fur Endoprothesen der
Speisewege bei Stenosen im Bereiche des Speiserohremundes
Monatsschr. Ohrenheilkd. Laryngorhinol. 1971; 105: 38-42.
46. Stuart D. W.: Surgery of cancer of the cervical oesophagus with
plastic tube replacement. /. Laryngol. 1966: 80: 382-6.
47. Shilling B. B.: Hypopharyngostomy. Laryngoscope 1971: 81:
1119-25.
48. Klopp C. T.: Cervical csophagostomy. J. Thorac. Surg. 1951; 21:
490-1.
49. Davidson J. S.: Puncture of the cervical esophagus in the
palliative treatment of carcinoma of the esophagus. J. Thorac.
Surg. 1955; 30: 348-55.
50. Heimlich H. J.. Greenless T. W. and Winfield J. M.: Carcinoma of
the esophagus. A palliative procedure with use of a plastic tube
introduced through a cervical incision. JAMA 1956; 101: 192-5.
51. Heimlich H. J.: Two palliative operations for cancer of the
esophagus using plastic prostheses. Am. J. Surg. 1962; 103:
376-82.
52. Ritter J. A.: Pyriform sinusostomy. JAMA 1969; 207: 365-8.
53. Palmer E. D.: Peroral prosthesis for the management of incurable
esophageal carcinoma. Am. J. Gastroenterol. 1973; 59: 487-98.
54. Tytgat G. N., Hartog-Jagcr F. C. A. and Hauerkamp H. J.:
Positioning of a plastic prosthesis under fibre endoscopic control
in the palliative treatment of cardio-esophageal cancer. Endoscopy 1976; 8: 180-5.
55. Boyce H. W. and Palmer E. D.: Techniques of Clinical Gastroenterology. Springfield, 111., Charles C. Thomas, 1975.
56. Carter M. G.: Endoscopic intubation and dilatation in the
management of esophageal carcinoma. Am. J. Surg. 1957; 93:
266-70.
57. de Souza L. J.: Palliative intra-oesophageal intubation in advanced cancer of the oesophagus. Ind. J. Cancer 1971; 8:
116 22.
58. Haring R.: Eine neue Oesophagusendoprothese als Palliativmassnahme beim inoperablen Oesophagus- und Kardiacarcinom.
Chirurg 1964; 35: 549-51.
59. Holinger P. H.: Self retaining esophageal intubation tube. Ann.
Owl. Rhinol. Otolaryngol. 1955; 64: 921.
60. Lcvine S.: Palliative treatment of carcinoma of the esophagus.
Rocky Mt. Med. J. 1959; 56: 39-41.
61. Davidenko N., Chifflct J., Fossati C. G. et al.: Intubation of
neoplaslic esophageal stenoses. A new prosthesis with an antireflux device. Nvuv. Presse Med. 1975; 4: 2396-8.
62. Beaugie J. M. and Earlam R. J.: The Aldon bag flutter valve. Br.
J. Urol. 1971; 43: 608-10.
63. Leonard J. R., Rossi N. P. and Blaedel M.: Esophageal carcinoma. Palliation by indwelling tubes. Ann. Otol. Rhinol.
Laryngol 1969; 78: 1169-78.
64. Coyas A. and Triboulet-Piton J.: Resultats obtenus par un
nouveau procede d'intubation palliative du cancer inoperable de
Foesophage. Ann. Otolarvngol. 1955; 72: 143-7.
65. Jager F. C. A. H., Bartefsman J. F. W. M. and Tytgat G. N. J.:
Palliative treatment of obstructing csophagogastric malignancy
by endoscopic positioning of a plastic prostheses. Gaslroenterology 1979; 77: 1008-14.
66. Sachs L.: A plastic prosthesis for palliating carcinoma of the
esophagus. Surgery 1959; 45: 377-88.
67. Adams C. L.: The complications of endoesophageal tubes.
J. Thorac. Cardiovasc. Surg. 1966; 51: 685-93.
68. Kaloor, G. H. and Collis J. L.: Palliative push-through intubation
for malignant stricture of the esophagus. Lancet 1960; 1: 923.
69. Anscombe A. R., Pearson K. and Taylor T. V.: A simple method
for the introduction of an oesophageal tube in advanced carcinoma of the oesophagus. Br. J. Surg. 1976; 63: 944-8.
70. Crossing F. T.: A set of guide and bougies to facilitate insertion
of Mousseau-Barbin lubes. Br. Med. J. 1961; 1: 1032.
71. Jamieson R. A., Cameron E. and Clark R. G.: Palliation in
malignant stricture of the esophagus. Lancet 1960; 1: 923.
72. Holden M. P., Wooler G. H. and lonescu M. I.:
Mousseau-Barbin tubes for the treatment of carcinoma of the
lower two-thirds of the oesophagus. Results and operative techniques. Br. J. Surg. 1973; 60: 401-2.
73. Bancewicz J.: A hazard of the Eder-Puestow system for oesophageal dilatation. Br. J. Surg. 1979; 66: 66.
74. Ranson M. B. and John H. T.: Complications associated with the
use of the Celestin tube for benign oesophageal obstruction. Br. J.
Surg. 1979; 66: 110 2.
75. Wilson M. G., Bristol J. B., Mortcnsen N. J. et al.: The Celestin
tube in the treatment of benign oesophageal strictures. Br. J.
Surg. 1980; 67: 506 8.
76. Shaw J. F. L. and Coombes G. B.: Multiple intestinal perforation
due to Celestin tube. Br. J. Surg. 1979; 66: 807-8.
77. Mackenzie I., Whyte A. S. and Tankel H. I.: Structural deterioration in Celestin tubes. Br. J. Surg. 1976; 63: 851-2.
R. Earlam and J. R. Cunha-Melo
78. Adams C. L. and Emerson D. M.: Obstruction of a
Mousseau-Barbin tube from prolapsed esophageal mucosa.
J. Thorac. Cardiovasc. Surg. 1965; 49: 259-63.
79. Das S. K. and John H. T.: Oesophageal intubation in obstructive
lesions of the-oesophagus. Br. J. Surg. 1973; 60: 403-6.
80. Stoller J. L., Toppin D. I. and Flores A. D.: Carcinoma of the
esophagus; a new proposal for the evaluation of treatment. Can.
J. Surg. 1977; 20: 454-9.
81. Coyas A.: Palliative intubation in carcinoma of the oesophagus.
Lancet 1955; 2: 647-9.
82. Didcott C. C.: Oesophageal strictures. Treatment by slow continuous dilatation. Ann. R. Coll. Surg. Engl. 1973; 53: 112-26.
83. Didcott C. C.: Simplified oesophageal intubation for cancer
palliation. 5. Afr. J. Surg. 1974; 12: 173-5.
84. Didcott C. C.: Simplified oesophageal intubation for carcinoma.
In: Silber W. (ed.): Carcinoma of the Oesophagus. Rotterdam:
Balkema, 1978: 352-7.
85. Fell S. C., Grunwald R. P. and Hurwitt E. S.: Palliation of
esophageal carcinoma by prosthetic intubation. J. Thorac.
Cardiovasc. Surg. 1966; 51: 272-8.
86. Goni-Moreno I.: Cirurgia del Esofago y Hernias par el Hiatoesofagico. Buenos Aires: Editorial Universitaria, 1964.
87. Segura J., Martinez A. and Olarter H.: Palliative treatment of
esophageal obstruction with Goni's plastic tube. Surg. Gvnecol.
Obstet. 1966; 122: 1021-4.
88. Gourevitch A.: Intubation of the cardia for inoperable carcinoma. Lancet 1959; 2: 258-60.
89. Fornaro M., Sauerberli H. and Baumgartner D.: The Haring
tubes for palliative surgery of inoperable esophageal cancer. An
improvement of the quality of life. Helv. Chir. Acta 1976; 43:
533-6.
90. Mackler S. A. and Mayer R. M.: Palliation of esophageal
obstruction due to carcinoma with a permanent intraluminal
tube. /. Thorac. Surg. 1954; 28: 431-45.
91. Moghissi K.: Palliation in malignant stricture of the oesophagus.
Lancet 1960; 1: 679-80.
92. Palmer E. D.: Experiences with management of malignant oesophagorespiratory fistula by peroral esophageal prosthesis. Gastrointest. Endosc. 1970; 17: 12-16.
93. Boyce W. H.: Peroral prosthesis for palliating malignant
esophageal and gastric obstruction. Gastroenterology 1979; 77;
1141-1153.
94. Boyce H. W. jun.: Non-surgical measures to relieve distresses of
late oesophageal carcinoma. Geriatrics 1973; 28: 97-102.
95. Procter D. S. C.: Carcinoma of the oesophagus. A review of 523
cases. S. Afr. J. Surg. 1968; 6: 137-59.
96. Haffejee A. A. and Angorn I. B.: Oral alimentation following
intubation for esophageal carcinoma. Ann. Surg. 1977; 186:
759-61.
97. Hegarty M. M., Angorn I. B., Bryer J. V. et al.: Palliation of
malignant esophago-respiratory fistulae by permanent indwelling
prosthetic tube. Ann. Surg. 1977: 185: 88-91.
98. Hegarty M. M., Angorn I. B., Bryer J. V. et al.: Pulsion
intubation for palliation of carcinoma of the oesophagus. Br. J.
Surg. 1977; 64: 160-5.
99. Stirnemann H. and Kammer B.: Zur palliativen Behandlung des
Oesophaguscarcinoms: Weitere Erfahrung mit dem Doppcltrichterschlauch. Chirurg 1971; 42: 130-3.
100. Stirnemann H. and Roth F.: Erfahrungen mit Plastikrorohen bei
der palliativen Behandlung des Oesophagus Kardiacarcinoms.
Helv. Chirurg. Acta 1965; 32: 139-43.
101. Weisel W., Raine F., Watson R. R. et al.: Palliative treatment of
esophageal carcinoma. A method and its evaluation. Am. Surg.
1959; 149: 207-16.
102. Weisel W.: Palliation of advanced carcinoma of the esophagus by
intubation. In: Ellison E. H. and Freisen S. R. (ed.): Current
Surgical Management III. Philadelphia: Saunders, 1965; 23-9.
103. Clauss D. and Baudisch J.: Der Wert der Endoprothesen bei der
palliativen, Behandlung inoperable Oesophagus und Kardiacarcinom. Zentralbl. Chir. 1971; 96: 602-607.
104. Dubois J., Michel A., Naudin E. et al.: Valeur de Fappareillagc
plastique dans le traitment palliatif des cancers de Focsophage et
du cardia. Arch. Fr. Mai. App. Dig. 1962; 51: 920-5.
105. Greening W. P. and Ramsay G. S.: Cancer of the oesophagus
palliation by intubation. Lancet 1960: 2: 1122 3.
106. Grewe H. E. and Bircks W.: Palliative Behandlung durch Endoprosthese beim inoperable Oesophagus; kardia-karcmom. Thoraxchirurgie 1964; 11: 328-38.
107. Zaslavsky U. K.: Rehabilitation of esophageal permeability in
inoperable patients. Acta Union Int. Cancer 1963; 19: 1025-6.
108. Hayes A. V.: Observations on a new method of canalizing
strictures of the oesophagus. S. Afr. Med. J. 1959; 33: 1071 -6.
109. Kropff G.: Intubation oesophagienne par tube en matiere plastique suivie de radiumtherapie dans le traitmcnt du cancer de
Foesophage. Mem. Acad. Chir. (Paris) 1954; 80: 628-34.
110. Brown A. L.: Carcinoma of the esophagus. Use of rigid indwelling esophagcal tube. J. Thorac. Surg. 1949; 18: 493-5.
Paper accepted 16 June 1981.