ajr.129.3.425

Am J Roentgenol 129:425-431, September 1977 425
Radiologic Aspects of Beck Gastric Tube in Esophageal Reconstruction
SALEH A. FETOUH,’ RICHARD H. DAFFNER,1 A. W . POSTLETHW AIT,2 AND ROGER C. MILLAR2
Over a 28 month period, 19 patients underwent esophageal
reconstruction using the Beck tube fashioned from the greater
curvature of the stomach. Eighteen had unresectable card-
noma of the esophagus and one had a benign stricture sec-
ondary to reflux esophagitis. The degree of palliation was
considered good In 13 cases. The surgical aspects of the Beck
gastric tube are described and radlologic features in both
uncomplicated and complicated cases are illustrated. Early
experience with the procedure is encouraging.
A safe method for satisfactory palliation of patients with
inoperable carcinoma of the esophagus has not been
established, particularly when a complication such as
tnacheoesophageal fistula is present. The inability to
swallow even saliva without aspiration makes the termi-
nal weeks of life intolerable. Plastic tubes, such as the
Celestin tube, at times provide some relief. SubsternaI
colon transposition gives excellent palliation but at the
cost of excessive morbidity and mortality. In seeking a
simpler bypass operation, we are in the process of evalu-
ating a gastric tube. The procedure is also useful for
benign conditions such as strictures from reflux esopha-
gitis or lye ingestion, congenital esophageal atnesia, and
achaiasia.
This paper briefly describes the surgical aspects of the
Beck gastric tube and discusses its nadiologic features in
both uncomplicated and complicated situations. The
procedure has been in use at Duke University Medical
Center and the Veterans Administration Hospital in Dun-
ham, North Carolina, for over 2 years.
Case Material
Oven a 28 month period, 19 patients have been open-
ated on using the Beck tube esophageal bypass. Eight-
een had unnesectable carcinoma of the esophagus, five
of whom had tnacheoesophageal fistulae. One had a
benign stricture secondary to neflux esophagitis. There
were two postoperative deaths as a result of continued
pneumonia and subsequent respiratory failure. None of
the gastric tubes became necrotic. Leaks at the cervical
anastomosis occurred in seven patients; five closed
spontaneously and two required surgery.
The degree of palliation was considered good if the
patient was able to take solid foods without difficulty. In
this series, 13 patients had good palliation, two had fair
palliation requiring a soft or blended diet, two could not
be evaluated adequately because of severe medical
problems, and two died postoperatively. Most of the
patients were started on liquids after 7 days and were
taking soft regular food at about 14 days.
Discussion
In 1905, Beck and Cannell [1] demonstrated on an ex-
penimental basis that a gastnostomy tube could be
constructed from a flap fashioned from the greater cur-
vature of the stomach and brought subcutaneously to the
anterior chest wall. In 1912, Jianu [2] used the tubed
gastric pedicle to bypass the esophagus in animal and
cadaver experiments. However, these attempts were un-
successful because of inadequacy of blood supply and
difficulty in creating sufficient length and mobility of the
gastric tube to reach the neck. Further experimental
work on dogs was reported in 1944 [3].
In the 1950s the technique of the reversed gastric tube
operation was perfected [4-7]. Much of the pioneering
work was performed by Gavniliu and Georgescu [5, 6] of
Romania. Subsequently, modifications were developed
utilizing the gastric tube technique [8-14]. In the 1970s,
Heimlich [15, 16] reported his 15 year experience with
the reversed gastric tube. He was able to overcome the
deficiencies of the Beck-Jianu gastrostomy by augment-
ing the vascular supply to the greater curvature of the
stomach through splenectomy which diverted the entire
splenic blood supply to the tube.
In 1975, Gavniliu [17] presented a detailed review of his
experience with esophageal replacement in 580 patients,
the largest reported series. The early results of our cur-
rent experience with the Beck tube were reported in 1975
[18].
Surgical Aspects
Originally only patients with tracheoesophageal fistula
were selected for this procedure, since they most ur-
gently needed relief. Subsequently patients without f is-
tula but with tracheobronchial invasion, patients with
large unresectable tumors, and patients with tumors that
regressed after radiation therapy have been included.
Through an abdominal incision, the greaten curvature
of the stomach is mobilized, preserving the right gastro-
epiploic vessels. W ith the aid of a stapler, the greaten
curvature of the stomach is made to form a gastric tube,
based at the antrum (fig. 1). The tube is placed subster-
nally after the neck dissection is complete. The lower
part of the cervical esophagus is divided. The proximal
end is anastomosed end-to-side to the gastric tube. In
some patients the proximal tip of the gastric tube is
brought out to the skin surface of the neck as a con-
trolled fistula. This is easily closed as a secondary proce-
dure under local anesthesia.
Received December 27, 1976; accepted after revision April 4, 1977.
Department of Radiology, Duke University Medical Center and Veterans Administration Hospital, Durham, North Carolina 27710. Address reprint
requests to R. H. Daffner.
2 Department of Surgery, Duke University Medical Center and Veterans Administration Hospital, Durham, North Carolina 27710.
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R Gastric
C 0
426 FETOUH ET AL.
L Gostroepiploic A
Fig. 1.-Anatomy and surgical technique of Beck gastric tube. A, Dotted line indicates incisions along greater curvature. Blood
supply to tube is derived from right gastroepiploic vessels. B, Appearance of stomach after formation of gastric tube. Note that spleen is
left intact. C and 0, Completed tube with controlled fistula which is used in some patients. Note diseased esophagus is left in place.
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Fig. 2.-Normal plain film appearance of abdomen after Beck tube
procedure. Line of staples identifies remnant of greater curvature (small
arrows). Vertical line of staples identifies position of gastric tube (large
arrow). Multiple vascular clips are present.
Fig. 4.-Frontal chest film after Beck tube procedure. Paramediastinal
gas density representing air within Beck tube is present on left (arrows).
This may also be located on right side. Multiple metallic clips identify site
of prior attempt at resection of carcinomatous esophagus. In this patient
trachea deviates to right because of cervical anastomosis of gastric tube
in this region.
Fig. 3.-Normal appearance of lateral chest after Beck tube proce-
dure. Note substernal lucency and line of staples along its posterior
aspect (arrows). Position of staple line may vary.
BECK GASTRIC TUBE
427
Radiologic Aspects
Radiologic examination assesses the postoperative
morphology of the reconstruction and detects develop-
ment of early or late complications. On plain films, the
staple line along the greater curvature of the stomach
will have a characteristic curved appearance in the left
upper quadrant of the abdomen (fig. 2). In the chest the
staple line along the Beck tube is recognized in the
retnostennal tunnel in the lateral view (fig. 3). Another
staple line may be seen at the proximal end of the tho-
racic esophagus on the lateral chest film. Occasionally
air is seen in the tube both on the frontal and lateral chest
views (figs. 3 and 4).
The first contrast examination is usually performed on
the sixth or seventh postoperative day. For this examina-
tion we use water soluble contrast medium, looking criti-
cally for evidence of leakage at the cervical anastomosis.
Contrast material is expected to enter the cutanedtis
fistula, especially in the recumbent position. This should
not be confused with leakage at the cervical anastomo-
sis. Several spot films are taken of the anastomosis in
different projections under fluonoscopic control (fig 5).
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Fig. 5.-Normal postoperative appearance of upper anastomosis. A and B, Normal anastomosis without use of cutaneous fistula. Note rugae within
gastric tube. C, Anastomosis in patient with fistula. Contrast enters fistula. Leakage at anastomosis passes out through Penrose drain. E = proximal
esophagus, T = gastric tube, F = cutaneous fistula, DR = drain.
428
FETOUH ET AL.
The contrast material should pass readily through the
Beck tube to reach the region of the gastric antrum and
pylorus. From there it will flow in a retrograde manner to
fill the gastric remnant, with occasional reflux into the
distal esophagus, as well as antegrade into the duo-
denum.
Nonfluoroscopic films include the same views of the
stomach that would be obtained in a regular upper gas-
trointestinal examination (fig. 6). The only variation is in
obtaining “esophageal” views for which we recommend
inclusion of a lateral chest film (fig. 7) for visualization of
the Beck tube in its retrosternal position.
No esophageal manometnic studies were performed to
evaluate the motor function in the gastric tube. Fluoro-
scopic observations revealed no evidence of penistalsis
in the tube which merely acts as a conduit. This is similar
to previous experiences with the reversed gastric tube
[14, 15].
Complications
The commonest and earliest postoperative complica-
tion is leakage at the cervical anastomosis. Unless leak-
age is suspected clinically, barium is the preferred con-
trast agent for follow-up evaluation of the integrity of the
tube. A baseline barium ‘ ‘esophagognam” is obtained be-
fore the patient is discharged from the hospital.
In addition to leakage, other complications were seen
radiographically. One patient developed a mediastinal
hematoma (fig. 8). Mediastinal drainage was then insti-
tuted routinely, and this complication has not been seen
again. One patient developed narrowing of the tube at
the level of the diaphragm by a band of scar tissue (fig.
9), for which operative division was necessary. Other
complications encountered include aspiration pneu-
monia, pleural effusion, and shock lung.
Other Observations
The need for a procedure less extensive and traumatic
than colon interposition is obvious. Eliminating the ne-
cessity for splenectomy or mobilization of the tail of the
pancreas, as suggested for the reversed gastric tube
[15], seems advantageous. Blood supply to the isopeni-
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“V’.
4. h .4
.t. ..
-4
1T
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o*.
.9
‘V
-I
Fig. 7.-Lateral chest view with barium after Beck tube procedure.
Stomach tube is present within bypass.
staltic tube had never been a problem. Thoracotomy and
its complications are avoided.
W ith a denervated tube and limited life expectancy,
excretion and neflux of acid pepsin should not be a
problem. Since the thoracic portion of the esophagus is
left in continuity with the gastric remnant to provide
drainage, neflux back up to a tracheoesophageal fistula
may occur but should be avoided by appropriate posi-
tioning. None of our patients complained of reflux
esophagitis symptoms.
430 FETOUH ET AL.
ACKNOWLEDGMENTS
W e express our appreciation to Mrs. Hazel Underwood and
Mrs. Faye Brockwell for their efforts in preparation of this manu-
script, the staff of Medical Media Production Service of the
Veterans Administration Hospital for artwork and excellent pho-
tographic assistance, and Dr. Reed Rice for helpful suggestions
and critical review.
REFERENCES
1 . Beck C, Carrell A: Demonstration of specimens illustrating a
method of formation of a pre-thoracic esophagus. Ill Med J
7:463, 1905
2. Jianu A: Gastronstime u Oesophagosplastik. Dtsch Z Chir
118:383, 1912
3. Swenson 0, Magruder TV: Experimental esophagostomy.
Surgery 15:954-963, 1944
4. Heimlich HJ, W infield J: The use of a gastric tube to replace
or by-pass the esophagus. Surgery 37:549-559, 1955
5. Gavniliu 0, Georgescu L: Esofagoplastie directa cu material
gastric. Rev Stiintelor Med 3:33-36, 1951
6. Gavriliu D, Georgescu L: Esofagoplastie viscerala directa.
Chirurgia 4:104-138, 1955
7. Heimlich HJ: The use of a gastric tube to replace the esoph-
agus as performed by Or. Dan Gavriliu of Bucharest, Ao-
mania. Surgery 42:693-695, 1957
I 8. Sanders GB: Esophageal replacement with reversed gastric
I tube.JAMA 181:944-947, 1962
; #{149} ‘ 9, Burrington JD, Stephens CA: Esophageal replacement with
‘ . . . gastric tube in infants and children. J Pediatr Surg 3:246-
. . . 252, 1968
‘ 10. Glasson MJ, Dey DL, Cohen DH: Esophageal atresia: results
‘V of treatment. Med J Aust 1 :69, 1971
1 1 . Anderson KD, Randolph JG: The gastric tube for esopha-
: geal replacement in children. J Thorac Cardiovasc Surg
66:333-342, 1973
. : . ! 12. Cohen 0: Esophageal reconstruction using a gastric tube.
c.,. Aust Paediatr J 6:22-24, 1970
- - 13. Middleton AW : Esophageal replacement with a gastric tube,
in Proceedings of the Pediatric Surgical Congress, vol 2,
Melbourne, Royal Children’s Hospital, 1970, pp 430-435
14. Cohen DH, Middleton AW , Fletcher J: Gastric tube esopha-
goplasty. J Pediatr Surg 9:451-460, 1974
15. Heimlich HJ: Esophagoplasty with reversed gastric tube.
Review of fifty-three cases. Am J Surg 123:80-92, 1972
16. Heimlich HJ: Reversed gastric tube (RGT) esophagopiasty
for failure of colon, jejunum and prosthetic interposition.
Ann Surg 182:154-160, 1975
17. Gavniliu 0: Replacement of the esophagus by a reverse
gastric tube. Curr Prob! Surg 12(1O):36-64, 1975
18. Orninger MO, Sloan H: Substernal gastric bypass of the
excluded thoracic esophagus for palliation of esophageal
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Fig. 8.-Mediastinal hematoma after Beck tube procedure. Frontal (A) and lateral (B) films demonstrate air-fluid level which was subsequently drained
without further recurrence.
Fig. 9.-Narrowing of gastric tube at distal end. Barium study shows
tapered narrowing of gastric tube near its point of passage through
diaphragm. Band of scar tissue was found that required operative divi-
sion.
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