Fluoroscopic evaluation of esophagectomy

Fluoroscopic evaluation of esophagectomy is an important study, given the high rate of complication following esophagectomy (~10-20% rate of leak). Although the approach will differ slightly depending on the type of esophagectomy performed, the principles are similar.

Procedure

Preprocedural evaluation

The study should not be performed earlier than 6-7 days after the esophagectomy.

The most important thing to establish initially is the patient's risk for aspiration. Patients are often very debilitated after the surgery and the risk for aspiration is high. A cup of water can be given for them to sip, and if they aspirate on this, then high osmolar water soluble contrast diatrizoate (Gastrografin) is contraindicated, and one should use water soluble contrast of low osmolarity such as iohexol (Omnipaque) and iopamidol (Gastromiro). High-density barium should be avoided in this situation, and it may be even necessary to cancel the study.

Positioning / room set-up

Normal fluoroscopic suite; a tilting table is often helpful to bring patients from reverse Trendelenburg position (head up) to a recumbent position and back again.

Equipment

• water soluble contrast e.g. diatrizoate (Gastrografin)
  • alternatively iohexol (Omnipaque) or iopamidol (Gastromiro)

Technique

It is useful to think of the high-risk areas of the esophagectomy before beginning the study, so as to target them specifically. Anastomoses are particularly high risk areas and their location depends on the type of esophagectomy performed:

• Ivor Lewis procedure and McKeown procedure: midthoracic esophagogastric anastomosis
• transhiatal esophagectomy: cervical esophagogastric anastomosis

If you do not know the surgical history, you can try to make a reasonable guess by looking at the types of cervical, thoracic, and abdominal incisions the patient has.

After considering your approach:

• take scout/control radiographs of the neck, chest, and abdomen
  • take additional coned-in images of the anastomoses
• if the patient does not appear to be at risk for aspiration, begin with water soluble contrast diatrizoate (Gastrografin)
  • if high risk for aspiration, begin with low osmolar water soluble contrast, e.g. iohexol (Omnipaque) or iopamidol (Gastromiro)
• evaluate the esophagogastric anastomosis (LPO, erect or semi-erect)
• continue the study in recumbent LPO and RPO positions to coat the proximal portion of the gastric pull-through

If having trouble timing spot radiographs with patient's swallowing, consider rapid-sequence imaging

• continue the study through the pylorus and into the proximal small bowel

If there is no leak initially with water-soluble contrast, repeat the study with high density barium. High density barium can often identify small subtle leaks that are nearly-invisible with water-soluble contrast.

Complications

If the patient aspirates high-osmolarity water soluble contrast (e.g. Gastrografin), then he or she is at risk for massive pulmonary edema.