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A Simple Technique for Intubation of the Esophagus for Fistulae and Obstructions
346-352, 1956 3 Doan AE, Peterson DR, Blackmon JR, et al: Myocardial ischemia after maximal exercise in healthy men. A method for detecting potential coronary heart disease? Am Heart J 69:11-21, 1965 4 Leaf A: Everyday is a gift when you are over 100. Nat Geographic 143:93-118, 1973 5 Mellerowicz H: Vergleichende Untersuchunger iiber das Oknomierprinvip in Arbeit und Leistung des trainierten Kreislaufs und seine Bedeutung fur die preventive und rehabilitiv medizin. Arch Kreislaufforsch 24:70, 1956 6 Groom D: Cardiovascular observations on Tarahumara Indian runners—the modern Spartans. Am Heart T 81:304314, 1971 7 Pollock M, Miller H: Younger than their years. Runner's World 8:15-17, 1973
#28F Tapered Bougie
FICUHE 1. A no. 28 tapered bougie is inserted through the Celestin tube, then the Celestin tube containing the bougie is guided into position in the distal esophagus.
MATERIALS AND METHODS
A Simple T e c h n i q u e for I n t u b a t i o n of t h e Esophagus for Fistulae a n d Obstructions* Morton Heafitz, M.D., F.C.C.P.; Manuel Irarrazaval, Hubert Huebl, M.D., F.C.C.P.; and Harris Gibson, F.C.C.P.
M.D.; M.D.,
We have used a new technique for palliation of tracheoesophageal fistulae and esophageal obstruction in five patients. In all cases, swallowing was satisfactory the day following intubation, with the elimination of aspiration. Moreover, we have no instance of obstruction or dislodgement of the prosthesis. In one case, a benign esophagobronchial fistula from a caseating node was healed using a Celestin tube. This technique has eliminated major surgery in debilitated patients, allowing them to eat the day following peroral intubation.
After an esophagogram has documented the level of fistula or obstruction, we perform esophagoscopy and bronchoscopy on these patients under anesthesia to further determine the level and nature of the disorder. Using tapered Maloney dilators, we dilate the esophagus to about a 36 French. The tip of the Celestin tube is beveled where it joins the guide stylet; the stylet is then removed and replaced by a no .28 tapered bougie which is inserted through the Celestin tube, then the Celestin tube containing the bougie is guided into position in the distal esophagus (Fig 1 ) . The guide bougie is then removed and the polyethylene cuff is manipulated into position with a no. 50 tapered Maloney dilator, placing it comfortably just below the cricopharyngeus. Esophagoscopy is now carried out to ascertain that the opening of the Celestin tube does not "buckle" and obstruct the esophagus. Further manipulation can be carried out using both a foreign body forceps and a no. 50 dilator. The patient is then started on a fluid diet, progressing to soft solid food the following day. We have performed intubation on five patients using this technique, with immediate success in all. CASE REPORTS CASE 1
I tracheoesophageal fistulae and obstructions of the esophagus often lead to pneumonia and death through inanition. Consequently, many ways of dealing with this situation have been proposed, among them: exclusion of the fistula by a cervical esophagostomy, and obliteration and oversewing of the esophagus distally; radiation and surgical excision in rare instances; and palliative intubation. W e describe a simple technique for palliative intubation by means of a Celestin tube. There are two main types of palliative intubation. One method consists of pushing the tubes into position, such as described by Souttar or Mackler, through an esophagoscope. The other common method utilizes the more recent "pull through" methods with Mousseau Rarbin or Celestin tubes. These methods necessitate a double team effort during esophagoscopy and introduction of the endoesophageal prosthesis, while concurrently performing a gastrostomy. W e have combined the better features of both methods by abandoning gastrostomy and using a Celestin tube for "push through" intubation. R
1
2
3
4
5
A 47-year-old woman had an exploratory thoracotomy in June, 1972 after failure to establish a cause for a tracheoesophageal fistula endoscopically. At operation she was found to have a large caseating lymph node in the mediastinum, secondary to inflammatory disease. The esophagus and bronchus were oversewn with reinforcing pleura, but the fistula persisted, requiring esophageal intubation with a Celestin tube. After eight weeks the Celestin tube was removed, and the communication healed. Barium swallow afterward revealed resolution of the fistulous tract and the disappearance of her symptoms. CASE 2
A 63-year-old man had exploratory operation for esophageal cancer. The lesion was found to be nonresectable. A Celestin tube was inserted after operation, which was palliative for 11 weeks when the patient died of metastases. CASE 3
'From the Department of Thoracic Surgery, Maiden Hospital, Maiden, Mass.
A 52-year-old patient had inoperable cancer of the lung with dysphagia secondary to esophageal involvement, requiring dilatation. An endoesophageal tube was inserted, with palliation for only two weeks. He died shortly of extensive metastases.
CHEST, 65: 3, MARCH, 1974
SIMPLE TECHNIQUE FOR INTUBATION OF ESOPHAGUS 359
Systemic Nocardia caviae Infection
CASE 4
This 62-year-old man had bronchogenic carcinoma on the left side involving the mediastinum, aorta and esophagus. He was treated with cyclophosphamide and had a bronchoesophageal fistula. A Celestin tube was placed one week before he died of continued spread of his disease. CASE 5
This patient had an esophageal lesion eroding into a bronchus, with continuous aspiration. A Celestin tube was placed, with remarkable palliation for a short time. There was mediastinal extravasation of barium in this patient, with the Celestin tube allowing continuous passage of ingested materials into the surrounding tissues without contamination.
W. A. Causey, M.D.t
M.D.," P. Amell,
M.D.,°"
and J.
Bunker,
Nocardia caviae has been implicated as a cause of actinomycotic mycetoma in man. To date, this is the only form of nocardiosis with which this species has been associated. The two fatal infections described in this report are the first known cases of systemic nocardiosis in man caused by N caviae.
ocardia caviae was first isolated from an infected ear of a Sumatran guinea pig by Snijders in 1924. This species occurs in soil as a s a p r o p h y t e and has been isolated from cases of human mycetoma in Tunisia, Japan, India, and Mexico. N caviae has also been associated with naturally occurring infections in animals. There have been reports of bovine mastitis in the United States, and fatal infections have occurred in a dog in E n g l a n d , a bottle-nosed dolphin in Hawaii, and a domestic goat in Malawi, T o our knowledge, N caviae has not previously been reported as a cause of systemic human disease. 1
DISCUSSION
Communications between the tracheobronchial tree or obstruction of the esophagus, whether due to benign or malignant lesions, are difficult to palliate. These patients usually die in a short time from aspiration pneumonitis, starvation or even the palliative procedure. Many approaches have been used to treat these lesions including exclusion of a segment of esophagus, resection of the communicating areas, along with irradiation, or bypass procedures, all of which are extensive procedures with poor surgical expectations. Similarly, some of the earlier esophageal prosthetic devices were attempted in intubating beyond the cricoid, with poor results because of dislodgement and obstruction, or erosion from a short, stiff and narrow tube. Therefore, the pull-through Mousseau Barbin and Celestin tube are now most commonly used. However, their disadvantage is that they require gastrostomy, often in poor risk patients. This is associated with a high mortality from laparotomy or a substantial morbidity from ileus wound infection, dehiscence and peritonitis, often aggravated by the preterminal state of these patients. By the use of simple endoesophageal placement of a Celestin tube over a mercury weighted bougie, in turn manipulated into place by a larger bougie and finally inspected via an esophagoscope, we have eliminated the morbidity and mortality of the procedure in desperately ill patients.
REFERENCES
1 Papaioannou AN: A simple operation for the palliative treatment of tracheoesophageal fistula due to cancer. J Thorac Cardiovasc Surg 49:881, 1965 2 Ammann J F , Collis L: Palliative intubation of the esophagus. J Thorac Cardiovasc Surg 61:863, 1971 3 Celestin LR: Permanent intubation in inoperable cancer of the esophagus and cardia. Ann R Coll Surg Engl 25:165, 1959 4 Souttar HS: Treatment of carcinoma of the esophagus: Based on 100 personal cases and 18 postmortem reports. Br J Surg 15:76, 1927 5 Mackler SA, Mayer RM: Palliation of esophageal obstruction due to carcinoma with a permanent intraluminal tube. J Thorac Cardiovasc Surg 28:431, 1952
360
CAUSEY, ARNELL, BRINKER
20
6
1
8
9
2
30
11
12
CASE REPORTS CASE 1
This 54-year-old Illinois housewife was well until a month before her admission to the hospital when she began to have intermittent bouts of fever, sweats, and dyspnea accompanied by pain under the left breast and severe generalized weakness. Two weeks before her admission she was found to have bilateral anterior pulmonary infiltrates, although her chest roentgenogram had been normal six months previously. She was given oral tetracycline, but failed to improve and was hospitalized. A review of her past history was not significant except for occasional episodes of "pleurisy and bronchitis" that extended back at least four years. She had no family history of diabetes and had taken no medicines before the onset of her illness. On physical examination the patient seemed to be acutely ill and had a temperature of 39°C and a blood pressure of 120/58. A 12 to 15 mm Hg pulsus paradoxus was noted, and there was a grossly irregular heartbeat at 100 per minute. The heart was enlarged toward the left, her neck veins were distended, and her heart tones were muffled. The suspicion of a pericardial effusion was supported by the appearance of massive cardiomegaly on chest radiograph. Bilateral pleural effusions were also noted. An electrocardiogram showed low voltage and nonspecific ST and T wave abnormalities. Pertinent laboratory abnormalities included a mild normocytic anemia, moderate leukocytosis with a slight shift to the left, and a markedly accelerated erythrocyte sedimentation rate. A nose and throat culture grew out Proteus mirabilis. Tetracycline was continued, and rapid digitalization was accomplished. Nonetheless, the patient continued to be febrile and *From the Mycology Branch, Center for Disease Control, Public Health Service, US Department of Health, Education, and Welfare, Atlanta. * "Lutheran Hospital, Moline, Illinois. tVeterans Administration Hospital, Tucson. Reprint requests: Dr. Causey, Center for Disease Control, Atlanta 30333
CHEST, 65: 3, MARCH, 1974
#28F Tapered Bougie
FICUHE 1. A no. 28 tapered bougie is inserted through the Celestin tube, then the Celestin tube containing the bougie is guided into position in the distal esophagus.
MATERIALS AND METHODS
A Simple T e c h n i q u e for I n t u b a t i o n of t h e Esophagus for Fistulae a n d Obstructions* Morton Heafitz, M.D., F.C.C.P.; Manuel Irarrazaval, Hubert Huebl, M.D., F.C.C.P.; and Harris Gibson, F.C.C.P.
M.D.; M.D.,
We have used a new technique for palliation of tracheoesophageal fistulae and esophageal obstruction in five patients. In all cases, swallowing was satisfactory the day following intubation, with the elimination of aspiration. Moreover, we have no instance of obstruction or dislodgement of the prosthesis. In one case, a benign esophagobronchial fistula from a caseating node was healed using a Celestin tube. This technique has eliminated major surgery in debilitated patients, allowing them to eat the day following peroral intubation.
After an esophagogram has documented the level of fistula or obstruction, we perform esophagoscopy and bronchoscopy on these patients under anesthesia to further determine the level and nature of the disorder. Using tapered Maloney dilators, we dilate the esophagus to about a 36 French. The tip of the Celestin tube is beveled where it joins the guide stylet; the stylet is then removed and replaced by a no .28 tapered bougie which is inserted through the Celestin tube, then the Celestin tube containing the bougie is guided into position in the distal esophagus (Fig 1 ) . The guide bougie is then removed and the polyethylene cuff is manipulated into position with a no. 50 tapered Maloney dilator, placing it comfortably just below the cricopharyngeus. Esophagoscopy is now carried out to ascertain that the opening of the Celestin tube does not "buckle" and obstruct the esophagus. Further manipulation can be carried out using both a foreign body forceps and a no. 50 dilator. The patient is then started on a fluid diet, progressing to soft solid food the following day. We have performed intubation on five patients using this technique, with immediate success in all. CASE REPORTS CASE 1
I tracheoesophageal fistulae and obstructions of the esophagus often lead to pneumonia and death through inanition. Consequently, many ways of dealing with this situation have been proposed, among them: exclusion of the fistula by a cervical esophagostomy, and obliteration and oversewing of the esophagus distally; radiation and surgical excision in rare instances; and palliative intubation. W e describe a simple technique for palliative intubation by means of a Celestin tube. There are two main types of palliative intubation. One method consists of pushing the tubes into position, such as described by Souttar or Mackler, through an esophagoscope. The other common method utilizes the more recent "pull through" methods with Mousseau Rarbin or Celestin tubes. These methods necessitate a double team effort during esophagoscopy and introduction of the endoesophageal prosthesis, while concurrently performing a gastrostomy. W e have combined the better features of both methods by abandoning gastrostomy and using a Celestin tube for "push through" intubation. R
1
2
3
4
5
A 47-year-old woman had an exploratory thoracotomy in June, 1972 after failure to establish a cause for a tracheoesophageal fistula endoscopically. At operation she was found to have a large caseating lymph node in the mediastinum, secondary to inflammatory disease. The esophagus and bronchus were oversewn with reinforcing pleura, but the fistula persisted, requiring esophageal intubation with a Celestin tube. After eight weeks the Celestin tube was removed, and the communication healed. Barium swallow afterward revealed resolution of the fistulous tract and the disappearance of her symptoms. CASE 2
A 63-year-old man had exploratory operation for esophageal cancer. The lesion was found to be nonresectable. A Celestin tube was inserted after operation, which was palliative for 11 weeks when the patient died of metastases. CASE 3
'From the Department of Thoracic Surgery, Maiden Hospital, Maiden, Mass.
A 52-year-old patient had inoperable cancer of the lung with dysphagia secondary to esophageal involvement, requiring dilatation. An endoesophageal tube was inserted, with palliation for only two weeks. He died shortly of extensive metastases.
CHEST, 65: 3, MARCH, 1974
SIMPLE TECHNIQUE FOR INTUBATION OF ESOPHAGUS 359
Systemic Nocardia caviae Infection
CASE 4
This 62-year-old man had bronchogenic carcinoma on the left side involving the mediastinum, aorta and esophagus. He was treated with cyclophosphamide and had a bronchoesophageal fistula. A Celestin tube was placed one week before he died of continued spread of his disease. CASE 5
This patient had an esophageal lesion eroding into a bronchus, with continuous aspiration. A Celestin tube was placed, with remarkable palliation for a short time. There was mediastinal extravasation of barium in this patient, with the Celestin tube allowing continuous passage of ingested materials into the surrounding tissues without contamination.
W. A. Causey, M.D.t
M.D.," P. Amell,
M.D.,°"
and J.
Bunker,
Nocardia caviae has been implicated as a cause of actinomycotic mycetoma in man. To date, this is the only form of nocardiosis with which this species has been associated. The two fatal infections described in this report are the first known cases of systemic nocardiosis in man caused by N caviae.
ocardia caviae was first isolated from an infected ear of a Sumatran guinea pig by Snijders in 1924. This species occurs in soil as a s a p r o p h y t e and has been isolated from cases of human mycetoma in Tunisia, Japan, India, and Mexico. N caviae has also been associated with naturally occurring infections in animals. There have been reports of bovine mastitis in the United States, and fatal infections have occurred in a dog in E n g l a n d , a bottle-nosed dolphin in Hawaii, and a domestic goat in Malawi, T o our knowledge, N caviae has not previously been reported as a cause of systemic human disease. 1
DISCUSSION
Communications between the tracheobronchial tree or obstruction of the esophagus, whether due to benign or malignant lesions, are difficult to palliate. These patients usually die in a short time from aspiration pneumonitis, starvation or even the palliative procedure. Many approaches have been used to treat these lesions including exclusion of a segment of esophagus, resection of the communicating areas, along with irradiation, or bypass procedures, all of which are extensive procedures with poor surgical expectations. Similarly, some of the earlier esophageal prosthetic devices were attempted in intubating beyond the cricoid, with poor results because of dislodgement and obstruction, or erosion from a short, stiff and narrow tube. Therefore, the pull-through Mousseau Barbin and Celestin tube are now most commonly used. However, their disadvantage is that they require gastrostomy, often in poor risk patients. This is associated with a high mortality from laparotomy or a substantial morbidity from ileus wound infection, dehiscence and peritonitis, often aggravated by the preterminal state of these patients. By the use of simple endoesophageal placement of a Celestin tube over a mercury weighted bougie, in turn manipulated into place by a larger bougie and finally inspected via an esophagoscope, we have eliminated the morbidity and mortality of the procedure in desperately ill patients.
REFERENCES
1 Papaioannou AN: A simple operation for the palliative treatment of tracheoesophageal fistula due to cancer. J Thorac Cardiovasc Surg 49:881, 1965 2 Ammann J F , Collis L: Palliative intubation of the esophagus. J Thorac Cardiovasc Surg 61:863, 1971 3 Celestin LR: Permanent intubation in inoperable cancer of the esophagus and cardia. Ann R Coll Surg Engl 25:165, 1959 4 Souttar HS: Treatment of carcinoma of the esophagus: Based on 100 personal cases and 18 postmortem reports. Br J Surg 15:76, 1927 5 Mackler SA, Mayer RM: Palliation of esophageal obstruction due to carcinoma with a permanent intraluminal tube. J Thorac Cardiovasc Surg 28:431, 1952
360
CAUSEY, ARNELL, BRINKER
20
6
1
8
9
2
30
11
12
CASE REPORTS CASE 1
This 54-year-old Illinois housewife was well until a month before her admission to the hospital when she began to have intermittent bouts of fever, sweats, and dyspnea accompanied by pain under the left breast and severe generalized weakness. Two weeks before her admission she was found to have bilateral anterior pulmonary infiltrates, although her chest roentgenogram had been normal six months previously. She was given oral tetracycline, but failed to improve and was hospitalized. A review of her past history was not significant except for occasional episodes of "pleurisy and bronchitis" that extended back at least four years. She had no family history of diabetes and had taken no medicines before the onset of her illness. On physical examination the patient seemed to be acutely ill and had a temperature of 39°C and a blood pressure of 120/58. A 12 to 15 mm Hg pulsus paradoxus was noted, and there was a grossly irregular heartbeat at 100 per minute. The heart was enlarged toward the left, her neck veins were distended, and her heart tones were muffled. The suspicion of a pericardial effusion was supported by the appearance of massive cardiomegaly on chest radiograph. Bilateral pleural effusions were also noted. An electrocardiogram showed low voltage and nonspecific ST and T wave abnormalities. Pertinent laboratory abnormalities included a mild normocytic anemia, moderate leukocytosis with a slight shift to the left, and a markedly accelerated erythrocyte sedimentation rate. A nose and throat culture grew out Proteus mirabilis. Tetracycline was continued, and rapid digitalization was accomplished. Nonetheless, the patient continued to be febrile and *From the Mycology Branch, Center for Disease Control, Public Health Service, US Department of Health, Education, and Welfare, Atlanta. * "Lutheran Hospital, Moline, Illinois. tVeterans Administration Hospital, Tucson. Reprint requests: Dr. Causey, Center for Disease Control, Atlanta 30333
CHEST, 65: 3, MARCH, 1974