Fluoroscopic evaluation of oesophagectomy
Fluoroscopic evaluation of oesophagectomy is an important study, given the high rate of complication following oesophagectomy (~10-20% rate of leak). Although the approach will differ slightly depending on the type of oesophagectomy performed, the principles are similar.
The study should not be performed earlier than 6-7 days after the oesophagectomy.
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 water soluble contrast (Gastrografin) is contraindicated, and one should consider either oral iohexol (Omnipaque), high-density barium only, or even cancelling 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.
- water soluble contrast (e.g. Gastrografin)
- oral iohexol (Omnipaque) as an alternative
- high density barium
It is useful to think of the high-risk areas of the oesophagectomy before beginning the study, so as to target them specifically. Anastomoses are particularly high risk areas and their location depends on the type of oesophagectomy performed:
- Ivor Lewis procedure and McKeown procedure: midthoracic oesophagogastric anastomosis
- transhiatal oesophagectomy: cervical oesophagogastric 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 not be risky for aspiration, begin with water soluble contrast (Gastrografin)
- if high risk for aspiration, begin with oral iohexol (Omnipaque) or high-density barium
- evaluate the oesophagogastric 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.
If the patient aspirates high-osmolarity water soluble contrast (e.g. Gastrografin), then he or she is at risk for massive pulmonary oedema.