Carcinoma of the oesophagus is fairly common in India and much of sub-Saharan Africa, and is associated with the drinking of home-brewed spirits containing carcinogenic nitrosamines. In many parts of the developing world it is the commonest cause of dysphagia.
The patient, who is usually over 45, presents with: (1) Progressive dysphagia, first for solid food and later for thin foods and even water. If you ask him to point to the site where food sticks, it will usually correlate well with the site of the lesion. (2) Regurgitation; this is common, except in the early stages; he may describe it as vomiting. (3) Hunger, which can be very distressing. (4) Weight loss. (5) Coughing on swallowing, due either to a tracheo-bronchial fistula, or to spillage from his oesophagus, through his larynx into his trachea. This happens when the lesion is in the upper, or in the middle, third of his oesophagus. (6) Pain is a late symptom, and is due to spread into his mediastinum.
If you are going to do anything for him, you will have to oesophagoscope him (25.14), and assess his operability on the criteria below. Unfortunately, you will not find many operable cases to refer to a thoracic surgeon for resection and: (1) a gastro-oesophageal anastomosis, or (2) the transfer of a segment of his left colon to bridge the gap. Radiotherapy is a useful palliative. There is no effective chemotherapy.
Palliate a patient with an inoperable carcinoma with a Celestin or Procter[nd]Livingstone tube. It will let him swallow thin food and fluids, and relieve his distressing hunger and dehydration. It will allow him to survive some months in relative comfort, for which he will be very grateful. He may live for 18 months, and die from other complications without the tube becoming blocked. If you can refer him, palliative radiotherapy can be given with his tube in.
If possible, refer patients for the insertion of tubes, but if this is difficult, learn how to insert them yourself from an expert. If carcinoma of the oesophagus is common in your district, this is a procedure worth learning, it will save many patients much misery.
TUBES, oesophageal, Celestin, with guide, 20 assorted tubes only (optional). Alternatively, TUBES, Procter[nd]Livingstone (POR), 10 mm diameter, length 110 mm, 150 mm, and 190 mm, unflanged, 20 tubes only. A Celestin tube is inserted on a guide, and the stomach has to be opened. A Procter[nd]Livingstone (P[nd]L) tube is inserted over a bougie without opening the stomach. An expert can insert one in 5 minutes.
Fig. 32-11 INSERTING A CELESTIN TUBE. A, the tube with its guide. B, a carcinoma obstructing the oesophagus. C, the guide being passed through the tumour, and out through an opening in the stomach. D, the tube being pulled through the stricture. E, the lower end of the tube cut off and sutured to the stomach wall.
CARCINOMA OF THE OESOPHAGUS X-RAYS. See Section 34.5.
OESOPHAGOSCOPY AND BIOPSY. Do this as in Section 25.14.
THE DIFFERENTIAL DIAGNOSIS will depend on the area in which you are working.
Suggesting dysphagia due to the iron deficiency syndrome[md]the patient is a woman, uncommon in India and Africa; a post-cricoid web in a barium swallow.
Suggesting a fibrous stricture, due to regurgitation of acid from the stomach, or swallowed corrosive acids or alkalis, [md]a relevant history: the latter is not uncommon in parts of SE Asia.
Suggesting achalasia of the cardia [md]a younger age group, usually 15 to 25 years, not uncommon in India but uncommon in Africa.
SITE. Expect to find a carcinoma in the following sites in this order of frequency: (1) In the middle third (26 to 35 cm from the upper incisor teeth). (2) In the lower third (36 to 45 cm). (3) In the upper third (17 to 25 cm).
OPERABILITY AND MANAGEMENT. The few suitable cases for oesophagectomy are likely to have: (1) A lesion which is not more than 5 cm long on a barium swallow (microscopically, the tumour may extend at least as far again in each direction). (2) No mediastinal widening (no enlarged nodes). (3) A lesion which narrows the oesophagus by less than 50%. (4) No deformity of the trachea, carina, or left main bronchus on bronchoscopy. If you find such patients, refer them.
CAUTION ! Some surgeons advise that you should not be tempted to make a stoma, which will only prolong the patient's agony, and will not solve the distressing problem of his inability to swallow his saliva. If you make one, make a feeding jejunostomy, as in Section 9.7.
INSERTING A CELESTIN TUBE [s7]FOR CARCINOMA OF THE OESOPHAGUS INDICATIONS. A patient who cannot swallow solid food, and who has some difficulty with thin food, or water. Even if he cannot swallow water, you may be able to pass a tube.
CAUTION ! (1) The earlier he presents, the easier it will be to pass the tube. Don't wait until dysphagia is severe[md]you may not get it in. (2) Refer him if you can: there is no substitute for being taught this procedure by an expert.
EQUIPMENT. Oesophagoscope, oesophageal bougies. Celestin tubes and a guide. A very efficient sucker.
PREPARATION. Two operators are needed: Operator A passes the oesophagoscope, and the Celestin tube with its guide, from above. Operator B does a laparotomy, guides the tube into place through a gastrostomy, and fixes it to the stomach wall.
If the patient is dehydrated, rehydrate him intravenously for 1 or 2 days before you start, and have a drip running. Give him a general anaesthetic, or ketamine, and intubate him under relaxants (A 8.4). You will not be able to pass a naso-gastric tube because of the obstruction.
METHOD. Lay him on his back, with some rise in the table extending his spine under his upper abdomen. If your table does not open to allow this, place a thin pillow under him. Lay him with his head down a little.
OPERATOR A. Sit at the head of the table, and raise it enough to to make passing a rigid oesophagoscope convenient (this may mean that Operator B may have to use a foot stand).
Pass the largest oesophagoscope you have in the usual way (25.14). Suck out the contents of his oesophagus[md]there will be much fluid and debris. Pass the oesophagoscope further, until you see the obstruction. Clear away any more debris, and note the distance of the lesion from his upper incisor teeth. This will later help you to know if you have pulled the tube down enough[md]you won't know how far in to push it, if you don't remember the distance.
Dilate the stricture, starting with a thin, but fairly stiff bougie of 10 or 12 Ch. Dilate it up to 24 or 30 Ch if this is easy, but if it is difficult, stop, rather than make a false passage. Judging when to stop dilating, and how hard to force the tube in, are the most difficult decisions. Pass the bougie as far as possible under direct vision, so that you can manoeuvre it through the stricture. If necessary, lower his head to allow the tip of the oesophagoscope to point anteriorly. If he is very thin, you may see the tip of the bougie pressing against his stomach wall. When you remove the bougie, measure it against the oesophagoscope, and the front of his chest, to see if it has reached his stomach, or not.
If you have not previously taken a biopsy, take two pieces of tissue now from the top of the lesion.
Pass the guide through the oesophagoscope into his stomach, where Operator B will feel it, and pull on it. Sometimes, it passes behind the stomach, through a false passage, but this, fortunately, does not often cause mediastinitis. If it is not in the right place, reinsert it. If you fail 3 times, pass it by railroading (see below).
When the upper end of the guide is about 10 cm from his teeth, remove the oesophagoscope, and fix the tip of the guide to the Celestin tube using a non-absorbable suture, such as No. 1 multifilament silk, and a straight needle. Lubricate the Celestin tube with KY jelly.
When the top end of the Celestin tube is in the patient's pharynx, re-insert the oesophagoscope, and use it to help guide the Celestin tube down to Operator B, who pulls on the guide. Mostly, he pulls: but you may have to push a little with the oesophagoscope.
Check that the upper end of the tube is sitting snugly on the top of the stricture[md]don't let it go down too far; if it does, pull it up with blunt biopsy forceps.
Remove the oesophagoscope.
OPERATOR B. Meanwhile, do a laparotomy through an upper median or left paramedian incision. Feel the patient's aortic nodes and the cardia, to see if his tumour has spread.
If his stomach is shrunken and difficult to find and pull down, as it often is in a starving patient, there may not be much space on the anterior surface for making an incision. You may need to grasp it with Babcock's, or Allis' forceps, or stay sutures, to keep it in the wound.
Wait until Operator A has passed the guide. When you feel it through the stomach wall, do a longitudinal gastrotomy in the anterior wall of the stomach, about a third or halff-way distal to the cardia. Allow the tip of the guide to poke out of the gastrotomy wound. When the guide is in the stomach and Operator A has attached the Celestin tube, pull it gently down, until you feel resistance. This should be when the flange rests on the top of the growth. Co-operate with him carefully!
When the tube is in place, detach the guide and cut the tube, so that it reaches a third of the distance from the patient's cardia to his pylorus. Cut it off obliquely so as to leave a long anterior flange. Anchor the lower end of the tube with No. 2 monofilament to the anterior wall of his stomach. Make it flush with the anterior wall by passing the suture through the flange of the tube and the stomach wall, to one side of the gastrotomy, or proximal to it.
Close the gastrotomy with 2 layers of continuous sutures (the inner one of catgut). Close his abdominal wall with interrupted monofilament or steel sutures.
Fig. 32-12 INSERTING A PROCTER[nd]LIVINGSTONE TUBE. A, a bougie has been passed, and a thread attached to it has been drawn through the oesophagoscope, which is being used to insert a Procter[nd]Livingstone tube. B, a tracheal tube about to be cut, to make an improvised oesophageal tube. C, the improvised tube ready for use. D, the improvised tube in place. E, and F, anterior and lateral views of a flanged Procter[nd]Livingstone tube; some P[nd]L tubes are unflanged. Kindly contributed by Ian Kennedy.
INSERTING A PROCTER[nd]LIVINGSTONE TUBE [s7]FOR CARCINOMA OF THE OESOPHAGUS Proceed as for a Celestin tube, except that a gastrotomy and a second operator are not needed.
Dilate the stricture with bougies through the oesophagoscope as far as possible as above. Choose a P[nd]L tube of the right length (110mm, 150mm or 190mm).
Take the largest bougie that will comfortably go through your chosen P[nd]L tube, and attach a long, strong monofilament thread to its proximal end; if necessary bore a hole for this. You may need this to recover the bougie if it gets forced too far down.
With the oesophagoscope still in place, pass the bougie (with the thread attached, and well-lubricated throughout its length) through the stricture. Don't remove the oesophagoscope until after you have inserted this bougie. Now remove the oesophagoscope leaving the bougie in place. Lubricate the P[nd]L tube well inside and out, pass the thread through it, and slide it on to the bougie. Pass the thread through the oesophagoscope, and hold its end in a haemostat (A, in Fig. 32-12).
Slide the tip of the oesophagoscope over the end of the bougie, and engage it in the cupped upper end of the P[nd]L tube. Guide the P[nd]L tube into the patient's mouth and pharynx with your left hand, and then push it down the bougie with the oesophagoscope. When it reaches the tumour, you will feel resistance. Now push harder. You will feel the P[nd]L tube passing through the stricture, until you feel its cup being stopped by the upper end of the stricture.
Watch the centimetre scale on the oesophagoscope, as it passes his teeth, so that you don't push too far. Note the distance[md]it should not be more than a centimetre greater than the distance to the tumour.
Remove the bougie, twist the oesophagoscope slightly to disengage it from the cup of the P[nd]L tube. Look down the oesophagoscope to see that all is well. Suck out blood and tumour debris. Remove the oesophagoscope under direct vision, sucking out until all is clear.
POSTOPERATIVE CARE Continue intravenous fluids, until he is swallowing well, which will not be for some days.
DIFFICULTIES [s7]WITH OESOPHAGEAL TUBES If you have DIFFICULTY PASSING THE GUIDE (Celestin tube) OR THE BOUGIE (P[nd]L tube), which is not uncommon with tight strictures in the lower third of the oesophagus, ''railroading' is necessary. Ask operator B to pass a bougie up the oesophagus, and deliver its tip through the patient's mouth. Beware, you can as easily make a false passage going up, as going down! Tie the tip of the bougie side to side with the end of the guide, overlapping it for about 5 cm. Then pull the guide through the malignant stricture, detach the bougie and proceed as above.
If railroading fails (unusual), leave a large de Pezzer or Foley catheter in the stomach as a gastrostomy for feeding. Dilatation may work at a second attempt, but it is probably best to leave the Foley catheter in place. Alternatively, do nothing, you may only be prolonging his agony.
If you make a FALSE PASSAGE or tear the stricture, a rapidly (24 hours) fatal mediastinitis may follow. Life without a tube is so intolerable that you will have to take this risk.
If the BOUGIE PASSES, BUT A CELESTIN OR P[nd]L TUBE WILL NOT PASS, you may need considerable force, even after what seems like good dilatation. Only one diameter (10 mm) of P[nd]L tube is made, and it does not pass every stricture.
Either make a home made tube (B, 32-12). Take a plastic tracheal tube of suitable size, cut off the tip with half the balloon. Wind thick silk or nylon under the balloon remnant to make a bulge. Cut the tube long enough for the stricture, and bevel the other end to make it easier to pass. With the oesophagoscope in place, pass the improvised tube with long forceps under direct vision until its bulbous end is snug up to the top of the carcinoma. He will only be able to take thick liquids, but he will be able to swallow. You may be able to stretch and dilate some plastics with heat, so as to make a cup.
Or, use a wire stylet. Get a long piece of wire from the workshop which will just pass down the whole length of an 18 Ch nasogastric tube. Lubricate it well and pass it through the tube. Pass the stylet and tube through the oesophagoscope, through the stricture and into his stomach. Remove the stylet. Pass a long nasotracheal tube down his nose, recover its distal end from his throat, bring it out of his mouth, push the end of the nasogastric tube into it, and pull this back through his nose. Tape the nasogastric tube to his cheek.
CAUTION ! Don't try to pass the wire stylet down on its own.
Bandage his elbows in extension with rolled newspaper to prevent him removing the tube as he recovers from the anaesthetic. A nasogastric tube is not as satisfactory as a P[nd]L tube. A gastrostomy, which is a possible alternative, will not enable him to swallow his saliva, and is such poor palliation that it is probably never justified (see above).
If you PUSH THE TUBE PAST THE STRICTURE (unusual), you may be able to pull it back with strong forceps. If this fails, leave it.
If he REGURGITATES THE TUBE, this is a nuisance, but not a disaster. If possible, replace it by a flanged tube. The shorter the tube, the better it works, but the more easily it slips out. If it is too short, the tumour may grow over the end and obstruct it. Flanged tubes are more likely to stay in place.
If the TUBE BLOCKS, a barium swallow will show the obstruction. Oesophagoscope him.