Case Study: Addressing Aspiration Following a Transhiatal Esophagectomy

You’ve just met with Gary, a 78-year-old man with a history of solid food dysphagia, a 30-pound weight loss, and fatigue. His diet consistency has been changed to help facilitate safe swallowing. When an endoscopy revealed an adenocarcinoma of the esophagus, he was treated with a transhiatal esophagectomy (TH).

Seven days after surgery, Gary remains in the hospital on a nasogastric feeding tube. His doctor has ordered removal of the feeding tube and attempted to start him on clear fluids, but unfortunately, each attempt at fluids has resulted in severe coughing.

Concerned that this might indicate a leak at the anastomosis of the reconstructed esophagus to the pharyngeal remnant, Gary’s doctor is consulting with you.

Interpreting Gary’s Videofluoroscopic Swallow Study

Everything appears normal on Gary’s physical and oral peripheral examinations, including mental status and cranial nerves. While he appeared undernourished and fragile, he cooperated with the exam.

You’ve decided to order a videofluoroscopic swallow study. What does the study show? Watch the footage below to identify the problem.

The procedure was done in the lateral, oblique, and AP view with Gary standing in order to view the pharyngeal and esophageal stages of swallow. On the first swallow of 10 cc of liquid, airway penetration occurred with cough and subsequent aspiration. Aspiration occurred on subsequent swallows during and after the swallow as residue built up at the level of the UES.

Oblique views of the reconstructed esophagus showed bolus residua at the level of the anastomosis (indicating possible stricture), which was partially cleared on repeated swallow attempts. On a larger bolus in the lateral view with chin-down posture, aspiration was minimized. In the AP projection on a larger bolus, there was leakage of material—suggestive of a fistula that entered the left lung field.

After reviewing the study and consulting with Gary’s physician, you both agree that he should remain NPO for the time being, and the feeding tube was reinserted. A thoracic surgeon was called in to repair the fistula.

Before starting Gary on oral fluids, you order a repeat videofluoroscopy to check for any tracheal aspiration. No fistula was noted, and after consulting with the dietitian, Gary was safely transitioned to a modified liquid diet.

Key Takeaways

While TH may seemingly only interfere with esophageal function, there may be secondary negative effects on pharyngeal function. Gary’s videofluoroscopic examination confirmed this finding—while also detecting a fistula that required repair before further attempts could be made to continue oral feeding. Before starting attempts at oral feeding in postoperative TH patients, videofluoroscopy should be routinely used to rule out any pharyngeal or esophageal abnormality that could delay the patient’s recovery. This study is best done in the standing position.

Gary recovered well following his second surgery to repair the fistula. He remained at the hospital for a month and was then discharged home. Over the next seven months, with regular therapy and a modified diet, he was able to regain 20 pounds, helping to restore his health.