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m J R oe ntge no l 129:425 431 Sep t embe r 1 9 7 7 42 5

Rad io log ic A spec ts o f B eck G as tric Tube in E sophagea l R econs tru c tionS A L E H A . F E T O U H , R IC H A R D H . D A F F N E R ,1 A . W . P O S T L E T H W A IT ,2 A N D ROGER C. M I L L A R 2

Over a 28 m on th p e rio d , 19 p a tien ts unde rw en t esophag ea lrecons truc tion us in g the B eck tu be fash io ned from th e g rea te rcu rva tu re o f the s tom ach . E ig h teen had unresec tab le ca rd -n om a o f the esophagus and one had a b en ig n s tric tu re sec -o nd a ry to re flu x esophag it is . Th e deg ree o f p a llia tio n w ascons id e red good In 13 cases . Th e surg ica l aspec ts o f th e B eckg as tr ic tu be are d esc ribed and rad lo lo g ic fea tu res in bo thuncom p lica ted and com p lica ted cases a re illu s tra ted . E a rlyexp e rience w ith th e p rocedure is encourag ing .

A s a fe m e th o d fo r sa tis fa c to ry p a llia tio n o f p a tie n ts w ithin o p e ra b le c a rc in o m a o f th e e so p h a g u s h a s n o t b e e ne s ta b lish e d , p a rtic u la rly w h e n a c o m p lic a tio n s u ch a stn a ch e o e so p h a g e a l fis tu la is p re se n t. T h e in a b ility tosw a llo w e ve n sa liva w ith o u t a sp ira tio n m a k e s th e te rm i-n a l w e e ks o f life in to le ra b le . P la s tic tu b e s , su c h a s th eC ele s tin tu b e , a t tim e s p ro v ide so m e re lie f. S u b s te rn a Ico lo n tra n sp o s itio n g iv e s e x ce lle n t p a llia tio n b u t a t theco s t o f e x ce ss ive m o rb id ity a n d m o rta lity . In s e e k in g as im p le r b yp a s s o p e ra tio n , w e a re in th e pro ce s s o f e va lu -a tin g a g a s tr ic tu b e . T h e p ro ce d u re is a lso u se fu l fo rb e n ig n c on d itio n s su ch a s s tr ic tu re s from re flu x e s op h a -g itis o r lye in g e s tio n , co n g e n ita l e s op h a g e a l a tn e s ia , a n dacha ias ia .

T h is p a p e r b r ie fly d e scr ib e s th e su rg ica l a s p e c ts o f theB e ck g a s tr ic tu b e a n d d is cu ss e s its n a d io lo g ic fe a tu re s inb o th un c o m p lic a te d a n d co m p lica te d s itu a tio n s . T h ep ro c e d u re h a s b e e n in u se a t D u ke U n ive rs ity M ed ica lC e n te r a n d th e V e te ra n s A d m in is tra tio n H o sp ita l in D u n -h a m , N o rth C a ro lin a , fo r o v e r 2 ye a rs .

C ase M ate ria lO ve n a 2 8 m o nth p e rio d , 1 9 p a tie n ts h a ve b e e n o p e n -

a te d o n u s in g th e B e ck tu b e e so p h a g e a l b y p a ss . E ig h t-e e n h a d u n n e se c ta b le ca rc in o m a o f th e e so p h a g u s, fiveo f w h o m h a d tn a ch e o e so p h a g e a l fis tu la e . O n e h a d ab e n ig n s tric tu re se c o n d ary to n e flu x e so p h a g itis . T h e rew e re tw o p o sto p e ra tive de a th s a s a re su lt o f c o ntin u e dp n e u m o n ia a n d s u b se q u e n t re s p ira to ry fa ilu re . N o n e o fth e g as tric tu b e s b e ca m e n e cro tic . L e a k s a t th e c e rv ica la n a s to m o s is o c cu rre d in s e ve n p a tie n ts ; five c lo s e dsp o n ta n e o u s ly a n d tw o re q u ire d su rg e ry .

The degree of p a llia tio n w a s co n s id e re d g o o d if th ep a tie n t w a s a b le to ta ke so lid fo o d s w ith o u t d ifficu lty . Inth is se r ie s , 13 p a tien ts ha d g o o d p a llia tio n , tw o h a d fa irp a llia tio n re q u ir in g a so ft o r b le n d e d d ie t, tw o c o u ld n otb e e va lu a te d a d e q u a te ly b e ca u se o f se ve re m e d ic a lp ro b le m s , a n d tw o d ie d p o s to p e ra tive ly . M o st o f th ep a tie n ts w e re s ta rte d o n liq u id s a fte r 7 d a ys a n d w ereta k in g so ft re g u la r fo o d a t a b o u t 1 4 d a ys .

Discuss ionIn 1 9 0 5 , B e ck a n d C a nn e ll [1 ] d e m o n stra te d o n a n e x-

p e n im e n ta l b as is th a t a g a s tn o s to m y tu b e c o u ld b eco n s tru c ted fro m a fla p fa sh io n ed fro m th e g re a te r cu r-v a tu re o f th e s to m a ch a n d b ro u g h t s u b cu ta n e o u s ly to th ea n te r io r ch e s t w a ll. In 1 9 1 2 , J ia n u [2 ] u s e d th e tu b e dg a s tric p e d ic le to b yp a s s th e e so p h a g u s in a n im a l a n dca d a v e r e xp e rim e n ts . H o w e ve r, th e se a tte m p ts w e re u n -s u cce s s fu l b e ca u se o f in a d e q u ac y o f b lo o d su p p ly a n dd ifficu lty in c re a tin g su ffic ie n t le n g th a n d m o b ility o f th eg a s tric tu be to re a ch th e ne c k . F u rth e r e x p e rim e n ta lw o rk o n d o g s w a s re p o rte d in 19 4 4 [3 ].

In th e 1 9 5 0 s th e te ch n iq u e o f th e re v e rs ed g a s tr ic tu b eo p e ra tio n w a s p e rfe c te d [4 -7 ]. M u ch o f th e p io n e e rin gw o rk w a s p erfo rm e d b y G a vn iliu a n d G e o rg e scu [5 , 6 ] o fR o m a n ia . S u b se q u e n tly , m o d ific a tio n s w e re d e ve lo p e du tiliz in g th e g a s tr ic tu b e te ch n iq u e [8 -14 ]. In th e 1 9 7 0 s ,H e im lich [1 5 , 1 6 ] re p o rte d h is 1 5 y e a r e xp e rie n c e w ithth e re ve rse d g a s tric tu b e. H e w a s a b le to o ve rco m e th ed e fic ie n c ie s o f th e B e c k-J ia n u g a s tro s to m y b y a u g m e n t-in g th e v a scu la r su p p ly to th e g re a te r c u rv a tu re o f th es to m a ch th ro u g h sp le ne c to m y w h ich d ive rte d th e e n tires p le n ic b lo o d su p p ly to th e tu b e .

In 1 9 7 5 , G av n iliu [1 7 ] p res e n te d a d e ta ile d re v ie w o f h ise xp e rie n ce w ith e so p h a g e a l re p la ce m e n t in 5 8 0 p a tien ts ,th e la rg e s t re p o rte d s e rie s . T h e e a rly re su lts o f o u r cu r-re n t e xp e rie n ce w ith th e B e ck tu b e w e re re p o rte d in 1 9 7 5[18].

S u rg ica l A sp ec tsO rig in a lly o n ly p a tie n ts w ith tra c h e o e so p h a g e a l fis tu la

w e re se le c te d fo r th is p ro c e d u re , s in c e th e y m o st u r-g e n tly n e e d e d re lie f. S u b se q u e n tly p a tien ts w ith o u t f is -tu la b u t w ith tra ch e o b ro nc h ia l in v a s io n , p a tie n ts w ithla rg e u n re s e c ta b le tu m o rs , a n d p a tie n ts w ith tu m o rs th a tre g re s se d a fte r ra d ia tio n th era p y h a ve b ee n in c lu d e d .

T h ro u g h an a b d o m in a l in c is io n , th e g re a te n c u rva tu reo f th e s to m a ch is m o b ilize d , p re s e rv in g th e rig h t g a s tro -e p ip lo ic ve s se ls . W ith th e a id o f a s ta p le r, th e g re ate ncu rva tu re o f the s to m a ch is m a de to fo rm a g as tric tub e ,b a s ed a t th e a n tru m (fig . 1 ). T h e tu b e is p la c e d su b s te r-n a lly a fte r th e n e c k d iss e c tio n is c o m p le te . T h e lo w e rpar t o f th e ce rv ic a l e so p h a g u s is d iv ide d . T h e p ro x im a le n d is a n a s to m o s e d e n d -to -s id e to th e g a s tr ic tu b e . Ins o m e p a tie n ts th e p rox im a l tip o f th e g a s tr ic tu b e isb ro u g h t o u t to th e sk in su rfa ce o f th e n e ck a s a co n -tro lle d fis tu la . T h is is e a s ily c lo se d a s a se co n d a ry p ro ce -d u re u n d e r lo ca l a n e s th e s ia .

R ec e iv ed D e cem be r 27 , 1 97 6 ; a cc ep ted a fte r rev is ion A p ril 4 , 19 77 . D ep artm e n t o f R a d io log y , D u ke U n ive rs ity M ed ica l C en te r an d V e te rans A dm in is tra tio n H o sp ita l, D u rha m , N or th C a ro lina 27 710 . A dd re ss rep rin tr e qu e st s t o R . H . D affn er.

2 D ep ar tm en t o f S ur ge ry D u k e Univers ity Me d ic a l C en te r a nd V e te rans A d m in is tra tion H o sp ita l, D u rh am , N o rth C aro lin a 27 71 0 .

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R G as tric

C 0

426 F E T O U H E T A L .

L G os troe p ip lo ic A

F ig . 1 .- An ato m y an d su rg ica l te chn iqu e o f B ec k ga str ic tu be . A, D o tted line in d ic a te s inc is io ns a lo ng grea te r cu rva tu re . B loo dsu pp ly to tub e is d e r ive d from rig h t g as troe p ip lo ic ve ss e ls . B , A ppe aran ce o f s to m ach a fte r fo rm a tion o f ga s tric tub e . N o te tha t sp leen isl ef t i nt ac t. C and 0, Completed tub e w ith co n tro lled fis tu la w h ic h is u sed in s om e p a t ien ts . N o te d ise as ed e sop ha gu s is le ft in p la ce .

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F ig . 2 .-N orm a l p la in film ap pea ra nce o f ab dom e n a fte r B e ck tub ep roc ed ure . L in e o f s tap le s id en tifies re m nan t o f g rea te r cu rva tu re ( s ma l la r r ow s ) . V er tic a l line o f s ta p le s id en tifie s po s ition o f g as tric tub e ( largea r r ow) . M u ltip le va sc u la r c lip s a re p rese n t.

F ig . 4 .-F ro n ta l ch es t f ilm a fte r B ec k tu be p roc ed ure . P a ra m e d ia s tina lga s de ns ity rep re sen tin g a ir w ith in B ec k tu be is p re se nt o n le ft arrows .This ma y a ls o b e l o c at e d o n rig h t s ide . M u lt ip le m e ta l lic c lips ide n t ify s iteo f p rio r a t tem p t a t re se c tion o f ca rc in om ato us e so ph agu s. In th is p a t ien ttrac hea d ev ia te s to righ t bec au se o f ce rv ic a l a nas to m o s is o f gas tric tub ein th is re gio n.

F ig . 3 .-N orm a l ap pe ara nc e o f la te ra l ch es t a fte r B ec k tub e proce -du re . N o te su bste rn a l lu ce nc y a nd l ine o f s ta p le s a lo n g its pos te r io raspect (ar rows) . P o s it ion o f s ta p le lin e m a y v a ry .

B E C K G A S T R IC T U B E 42 7

R ad io lo g ic A sp ec tsR a d io lo g ic e x am in a tio n a s se ss e s th e p o s to p e ra tive

m o rp h o lo g y o f the re co n s tru c tio n a n d de te c ts d e ve lo p -m e n t o f e a r ly o r la te co m p lica tio n s . O n p la in film s , th es ta p le lin e a lo n g th e g re a te r cu rva tu re o f th e s tom a c hw ill h a ve a ch a ra c te r is tic c u rv e d a p p e a ra n ce in the le ftu p p e r q u a d ra n t o f th e a b d o m e n (fig . 2 ). In th e ch e s t th es ta p le lin e a lo n g th e B e c k tu b e is re co g n iz e d in th ere tn o s te n n a l tu n n e l in th e la te ra l v ie w (fig . 3 ). A n o th e rs ta p le lin e m a y b e s ee n a t th e p ro x im a l e n d o f th e th o -ra c ic e s o p ha g u s o n th e la te ra l c h es t film . O cc a s io n a llya ir is se e n in th e tu b e b o th o n th e fro n ta l a n d la te ra l ch e s tv ie w s (fig s . 3 a n d 4 ).

T h e firs t c o n tra s t e x a m in a tio n is u s u a lly p e rfo rm e d o nth e s ix th or se ve n th p o s to p e ra tive d a y . F o r th is e xa m in a -tio n w e u se w a te r so lu b le c o n tra s t m e d iu m , lo o k in g cr iti-ca lly fo r e v id e n ce of le a ka g e a t th e ce rv ic a l a n a s to m o s is .C o n tra s t m a te ria l is e xp e c te d to e n te r th e c uta n e d tisfis tu la , e sp e c ia lly in th e re c u m b en t p o s itio n . T h is sh o u ldn o t b e co n fu se d w ith le a k ag e a t th e ce rv ica l a n a s to m o -s is . S e v e ra l s p o t film s a re ta ke n o f th e a n a s to m o s is ind iffe re n t p ro jec tio n s u n d e r flu o n o sco p ic co n tro l (fig 5 ).

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F ig . 5 .-N orm a l p os top e ra tiv e a pp ea ran ce o f u ppe r an as tom os is . A a n d B , N o rm a l an as tom os is w itho u t us e o f c u ta ne ou s fis tu la . N o te rug ae w ith ing as tric tu be . C, A na sto m os is in pa tien t w ith fis tu la . C on tras t en te rs fis tu la . Le aka ge a t a nas to m o s is pa ss es ou t th ro ug h P en ros e d ra in . E = pr ox ima leso ph ag us , T = ga stric tu be , F = cu tan eo us fis tu la , D R = dr a in .

42 8 F E T O U H E T A L .

T h e co n tra s t m a te r ia l sh o u ld p a s s re a d ily th ro u g h th eB e ck tu b e to re a ch th e re g io n o f th e g a s tr ic a n tru m a n dp y lo ru s . F ro m th e re it w ill flo w in a re tro gra d e m a n n e r tofill th e g a s tr ic re m n a nt, w ith o c ca s io na l re flu x in to th ed is ta l e s o p h a g u s, a s w e ll a s a n teg ra d e in to the du o -denum.

N o n fluo ro sc o p ic film s in c lu d e th e sa m e v ie w s o f th es tom a c h th a t w o u ld b e o b ta in e d in a re g u la r u p pe r g a s-tro in te s tin a l e xa m in a tio n (fig . 6 ). T h e o n ly v a ria tio n is ino b ta in in g e so p h a g e a l v ie w s fo r w h ich w e re co m m e n din c lu s io n o f a la te ra l c h e s t film (fig . 7 ) fo r v is u a liz a tio n o fthe B e c k tu b e in its re tro s te rna l p o s itio n .

N o e so p h a g e a l m a n o m e tn ic s tu d ie s w e re p e rfo rm e d toe v a lu a te th e m o to r fu n c tio n in th e g a s tr ic tu b e . F luo ro -s co p ic o b se rva tio n s re v e a le d n o e v id e n ce o f p e n is ta ls isin th e tu b e w h ich m e re ly a c ts a s a c o n d u it. T h is is s im ila rto p re v io u s e xp e rie n ce s w ith th e re ve rse d g a s tric tu b e[1 4 , 1 5 ].Comp l ica t ions

T he co m m o n e st a n d e a rlie s t p o s to p era tiv e co m p lic a -tio n is le a k a g e a t th e ce rv ica l a n a s to m o s is . U n le s s le a k-

a g e is s u sp e c te d c lin ica lly , b a rium is th e p re fe rre d co n -trast agent for follow up evaluation of the integrity of thetu b e . A b a se lin e b a riu m e so p h a g o g n a m is o b ta in e d b e -fo re th e p a tie n t is d isch a rg e d fro m th e h os p ita l.

In a d d itio n to le a ka g e , o th e r co m p lica tio n s w e re s e enra d io g ra p h ic a lly . O n e p a tie n t d e ve lo p e d a m ed ia s tin a lh e m a to m a (fig . 8 ). M e d ia s tin a l d ra in a g e w a s th e n in s ti-tu te d ro u tin e ly , a n d th is co m p lica tio n h a s n o t b e e n se e na g a in . O n e p a tie n t d ev e lo p e d n a rro w in g o f th e tu b e a tth e lev e l o f th e d ia p h ra g m b y a b a n d o f sca r tissu e (fig .9 ), fo r w h ich o p e ra tive d iv is io n w a s n ec e ssa ry . O th e rc o m p lica tio n s e n c ou n te re d in c lud e a sp ira tio n p n e u -m o n ia , p le u ra l e ffu s io n , a n d sh o c k lu n g .

O th er O bse rva tio ns

T h e n ee d fo r a p ro ce d u re le ss e x te n s ive an d tra u m a ticth a n co lo n in te rp o s itio n is o b v io u s . E lim in a tin g th e n e-ce ss ity fo r sp le ne c to m y o r m o b iliz a tio n o f th e ta il o f th ep a n c re a s , as su g g e s te d fo r th e re ve rse d g a s tr ic tu be[1 5 ], se e m s a d v a n ta g eo u s . B lo o d s up p ly to th e iso p e n i-

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-IFig . 7 .-La te ra l c hes t v ie w w ith ba riu m a fte r B e ck tu be p ro ced ure .S tom ac h tube is p res en t w ith in b yp as s .

s ta ltic tu b e h a d n ev e r b e e n a p ro b le m . T h o ra c o to m y an dits c o m plic a tio n s a re a vo id e d .

W ith a d e n e rv a te d tu b e a n d lim ite d life e xp e c ta n cy ,e xcre tio n a n d n e flu x o f a c id p e p s in s h o u ld n o t b e ap ro b le m . S in c e th e th o ra c ic p o rtio n o f th e e s o p ha g u s isle ft in c o n tin u ity w ith th e g a s tr ic re m n a n t to p ro v id ed ra in a g e, n e flux b a ck u p to a tra c h e o es o p h a g e a l fis tu lam a y o cc u r b u t s h o u ld b e a vo id e d b y a p p ro p r ia te p o s i-tio n in g . N o n e o f o u r p a tie n ts c o m p la in e d o f re flu xe so p h a g itis sy m pto m s.

4 3 0 F E T O U H E T A L.

ACKNOWLEDGMENTSW e e xp res s o u r a p p re c ia tio n to M rs . H a ze l U n d e rw o od a n d

M rs . F a ye B ro ck w e ll fo r the ir e ffo rts in p re p a ra tio n o f th is m a n u -scr ip t, th e s ta ff o f M e d ic a l M e d ia P ro du c tio n S e rv ic e o f th eV e te ra n s A d m in is tra tio n H o sp ita l fo r a rtw o rk a n d e xce lle n t p h o -tog ra ph ic as s is ta n ce , a n d D r. R e ed R ice fo r h e lp fu l s ug ge s tio n sa n d c ritica l re v ie w .

R E F E R E N C E S1 . B e c k C , C a rre ll A : D e m o n stra tio n o f sp e c im e n s illu s tra tin g a

m eth o d o f fo rm a tio n o f a p re -th o ra c ic es o p h a g u s. Ill M ed J7:463 1905

2. J ia nu A : G as tro ns tim e u O e s op h a go s pl a st ik . D tsch Z C h ir118:383 1912

3 . S w e n so n 0 , M a g ru d e r T V : E x p e rim e n ta l e so p h a g o s to m y .Surge ry 1 5 :9 54 -96 3 , 1 94 44 . H e im lich H J, W in fie ld J : T h e u se o f a g a s tr ic tu b e to re p la ceo r b y-p a ss th e e s o ph a g u s . Sur ge r y 3 7 :5 4 9 -5 5 9 , 1 9 5 5

5 . G a vn iliu 0 , G e o rg e sc u L : E so fa g o p la s tie d ire c ta c u m a te r ia lgastr ic . R ev S tiin te lo r M e d 3 :3 3 -3 6 , 1 9 5 1

6 . G a vril iu D , G e o rg e scu L : E so fa g o p la s tie v isc e ra la d ire c ta .Ch i r u r g ia 4 :1 0 4 -1 3 8 , 1 9 5 57 . H e im lich H J: T h e u se o f a g a s tr ic tu b e to re p la ce th e e s op h -a g u s a s p e rfo rm e d b y O r. D a n G av riliu o f B u c h are s t, A o -m a n ia . Sur ge r y 4 2 :6 9 3 -6 9 5 , 1957

I 8 . S a n d e rs G B : E s o p h a g e a l re p la ce m e n t w ith re ve rse d g a s tr icI tube.JAMA 1 8 1 :9 4 4 -9 4 7 , 1 9 6 2

{149} 9 , B u rr in g to n J D , S te p h e n s C A : E s op h a g e a l re p la ce m e n t w ith . . ga str ic tu be in in fan ts an d ch ild ren . J P ed ia tr S u rg 3 :2 4 6 -. . . 252 , 1968

10 . G lass on M J, D ey D L , C o hen D H : E s op ha ge a l a tres ia : res u ltsV o f tr ea tm e nt . M ed J A u s t 1 : 6 9 , 1 9 71 1 1 . A n d e rs o n K D , R an d o lp h JG : T h e g a str ic tu b e fo r e so p h a -

: g e a l re p la ce m en t in ch ild re n . J T h ora c C ard iova sc S u rg 66:333 -3 42 , 19 73

. 12 . C o he n 0 : E sop ha ge a l reco ns tru c tio n us ing a g astric tub e .c .,. A u st P a ed ia tr J 6 :2 2 -2 4 , 1 9 7 0- - 1 3 . M id d le to n A W : E so p h a g e a l re p la ce m e n t w ith a g a s tric tub e ,

in P roc ee d ing s o f th e P e d ia tr ic S u rg ic a l C o ng re ss , vo l 2 ,M e lb o u rn e , R o ya l C h ild re n s H o sp ita l, 1 9 7 0 , p p 4 3 0 -4 3 5

14 . C ohe n D H , M id d le to n A W , F le tche r J : G astric tub e e sop ha -gop las ty . J P ed ia tr S u rg 9 :4 5 1 -4 6 0 , 1 9 7 41 5 . H e im lic h H J: E s o p h a g o p la s ty w it h r ev er se d g a str ic tu b e .Review of f i f ty - three c a s e s . Am J S u r g 1 2 3 :8 0 -9 2 , 1 9 7 2

1 6 . H e im lic h H J: R e ve rse d g a s tric tu b e (R G T ) es o p h a g o p ia s tyfo r fa ilu re o f co lo n , je ju nu m a n d p ro s the tic in te rp os itio n .Ann Surg 182:154 160 1975

1 7 . G av n iliu 0 : R e p la c e m e n t o f th e e s o p h a g us b y a re v e rs eg as tr ic tu be . Curr P r o b S u r g 12 (1O ):3 6 -64 , 19 75

1 8 . O rn in g e r M O , S lo a n H : S u b s te rn a l g a s tr ic by p a ss o f th ee xc lu d e d th o ra c ic e so p h a g u s fo r p a llia tio n o f e so p h a g e a lc a rc in o ma . J T h orac C a rd io vas c S u rg 7 0 :8 3 6 -85 1 , 1 9 7 5

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F ig . 8 .-M e d ia s tin a l h em atom a a fte r B e ck tub e p ro ced ure . F ro n ta l A and lateral B f i lms d em on stra te a ir-f lu id lev e l w h ich w as su bs eq uen tly d ra in edw ithou t fu rth er rec u rren ce .

F ig . 9 .-N arrow ing o f g as tric tube a t d is ta l en d . B a rium s tud y sho w sta pe red narrow in g o f ga s tr ic tub e n ear its p o in t o f p as sa ge th roug hd iaph ra gm . B an d o f s ca r t iss ue w a s fo un d tha t req u ired o pera tive d iv i-s ion .