R. EARLAM

SOUTTAR TUBES FOR OESOPHAGEAL CARCINOMA

Estratto da:

CHIRURG1A GASTROENTEROLOGICA

Vol. 13, N. 1 • January-March 1979

PICCIN E D I T O R E — P A D O V A

SOUTTAR TUBES FOR OESOPHAGEAL CARCINOMA

R. EARLAM

ABSTRACT

In 1924 Sir Henry Souttar developed a coiled wire prosthesis for inserting through anoesophageal carcinoma to maintain the lumen. From the engineering viewpoint these aresprings made of 1 mm. wire. The inside gives an appearance of a thread with 25 turns per inch.The difference between the internal and external diameter is 2 mm. The Souttar tubes have aproximal lip 2 mm larger than the body. They stay in place because the outside is rough, theyare inserted tightly into the stricture, and because of the lip. The wire is either stainless steel,German silver or gold plated. The tubes are made in various sizes; min the largest is 15.0 cmlength X 1.4 cm outside diameter X 1.2 cm inside diameter.The advantages of these tubes over Celestin or Mousseau-Barbin tubes are that they can bepulled through a laparotomy incision, reducing mortality and morbidity, avoiding anoperation and allowing the patient to leave hospital in a few days. They are flexible and for anygiven outside diameter have a larger inside diameter than other tubes.

Key words. Souttar tube; oesophageal carcinoma.Chir. Gastroent. (Surg. Gastroenr.), 13, 15, 1979

* Paper presented at 5th world congress of C.l.C.D. Sao Paulo (Brazil), September 1978.** London (England)

INTRODUCTION

There is considerable controversy overthe treatment of squamous cell car-cinoma of the body of the oesophagus.The majority of patients have unfor-tunately died by the end of the first yearand the number who survive five years is

only about 5%. In a disease with such abad prognosis it is clear that cure is a rareevent. Attempts at more major surgerywhich involves lengthier operations andremoval of more tissue in ill patients havenot improved the survival rates. Theoperative mortality for operations on themid and upper oesophagus still lies bet-ween 15 and 40% in published cases.

16 R. E A R L A M

Radiotherapy, on the other hand, hasalmost no mortality, but does not alwaysproduce permanent relief of obstructionto swallowing. The major problem thatpersists with both surgery andradiotherapy is difficulty in swallowing;if the disease process cannot becompletely eradicated the doctor shouldconcentrate of the relief of the mainsymptom, namely dysphagia. The inser-tion of palliative intubation tubes istherefore important in the treatment ofcarcinoma of the oesophagus. In generalterms the two types of tubes that are in-serted can be divided into those which arepushed through the obstruction andthose which are pulled through. The lat-ter involves making an opening either inthe oesophagus through a thoracotomyor in the stomach through a laparotomy.The hospital mortality for these proced-ures is considerable and in some cases hasreached 30%. On the other hand, if a tubecan be pushed through from above, thepatient will be able to leave hospitalwithout having had either a thoracotomyor a laparotomy and will be able toswallow. The push technique is tech-nically difficult, and requires more ex-pertise than the pull method of intu-bation.

HISTORICAL

The push type of tube is based oneither the coiled spring or a rigid plastictube. The pull type of intubation tubemost commonly used is either aMousseau-Barbin tube made of Neoplexplastic or a Cclestin tube made of latexrubber.

Historically the first successful intu-bation was reported by Sir Charles

Fig. 1 - On the left is the original type of Souttar tubemade of gold-plated German silver wire with asecondary spiral in the body. On the right is a tubemade of stainless steel 1 mm wire.

Symonds in 1885 (Symonds, 1885).Originally a boxwood funnel was usedbut later this was changed to ivory, silveror gum elastic. It was Sir Henry Souttar in1924 (Souttar. 1924) who first developeda method which was more reliable thanthose previously utilised. Souttar hadstudied engineering at Oxford before hetook up medicine at the London Hospitaland was fully aware of the properties of aspring. He developed a coiled springwhich was rigid enough to be pusheddown the oesophagus but which itselfcould bend, elongate and did not collapse(Fig. 1). His tubes were originally madeof German silver and then coated with

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SOUTTAR TUBES FOR OESOPHAGEAL CARCINOMA 17

gold to prevent them from tarnishing.The internal diameter was 10 mm or lessand there was a lip at the proximal end,which together with the rough outersurface of the spring prevented the tubefalling through. Only later did he have asecondary spiral on the shaft of the spring(Souttar, 1927).

The next major advance was the intro-duction of the Mousseau-Barbin tubemade of Neoplex plastic (Mousseau ela!.. 1956). These tubes were larger, had agreatly expanded proximal funnel andthere was a long thin introducing portion.They relied entirely on a large lip to stopthem falling through the obstruction. Theexcessive lenght was cut off once the tubehad been placed in the correct position.In 1959 Celcstin modified this tube(Celestin, 1959). Originally his was alsomade of plastic, but later he used themodern technology of enmeshing a nylonspiral into latex tubber. His tubes have aseparate detachable pilot bougie and thebody of the tube contains a radiopaquestrip. These tubes have an internaldiameter of 10 mm and a wall thicknessof 1 mm. They rely of the funnel at theproximal end for fixation since the bodyof the barrel is smooth.

Other specialists in this field havedeveloped different methods. Palmer hasused a polythene tube and shapes eachone of them individually before intro-duction (Palmer, 1973). Madder andMayer insert similar polythene tubesthrough a thoracotomy incision, havingopened the oesophagus (Mackler andMayer, 1954). The basic principle of all ofthem is similar in that they depend on thesize of the proximal lip to prevent dis-lodgement. Only the Souttar tube with itsirregular outer surface depends on aroughened barrel rather than a very largelip for fixation.

TECHNIQUE

The correct assessment of the patientby radiography is essential. Ideally a filmof the total chest during a bariumswallow should be done together withmarkers of a known size in a similarfashion to that used for radiotherapy. Ifthe patient has swallowed barium and isthen tipped into the Trendelenbergposition, both ends of the tumor will bevisible and its lenght can be assessedaccurately. It is essential to try and usethe shortest tube possible becauseswallowing will be easier than with a longtube. At oesophagoscopy, bougies arepassed until the optimum diameter isreached.

The minimal size of tube that shouldbe inserted is 10 mm in diameter, so it isalways advisable to try and enlarge theoesophagus to this size even though itmay take two or three separatedilatations. If this is impossible becauseof the danger of perforating the tumour,then a smaller size tube must be inserted.The tubes are made with 1 mm. stainlesssteel wire so any tube with an internaldiameter of 10 mm. has an outer diamet-er of 12 mm, which is equivalent to 42French gauge. French gauge is equi-valent to the circumference in mm. and itis essential to know the conversion factorfrom French gauge to the size of tubeused. Most bougies are not machinedaccurately on the basis that TT = 3.142but on the simple conversion factor of 3to give the exact diameter. Knowing thesize of the bougies and then having ex-perience as to how tight the tumour is orhow great the resistance is, the dilatation

O

should proceed. There is only one chanceof pushing in the tube and it is essential tohave dilated the stricture exactly for any

Chir. Gastroent. (Surg. Gastroent), Vol 13, No. 1, 1979

18 R. EARLAM

given sized tube. The outer lip is stan-dardised to 18 mm external diameter so alarge oesophagoscope is essential with aninternal diameter that can take at least a54 French gauge bougie. The originalNegus oesophagoscope was suitable forthis and the new oesophagoscope *developed by Erlam is slinghtly larger.

In the past there has been considerableconfusion because the metric system hasnot been adopted. If French gauge orCharricrc (which is synonymous) is usedfor the size of bougies then inches orfractions thereof must not be used fortubes. English gauge as a measure ofbougie size is incomprehensible even tothe English and few are aware of theaccurate conversion of inches tomillimetres. This in itself must have beenresponsible in the past for many pro-blems in inserting palliative intubationtubes. An additional difficulty has beenthe lack of standardisation of thematerial of the bougies. A new set ofdilators made of teflon (Fig. 2) fixed to astainless steel wire shaft and a hexagonalhandle carrying the size in French gaugeclearly marked have been developed. *Teflon is an ideal material for bougies; ithas a very slippery non-stick surface thatdoes not require lubrication, it is flexiblein its small diameters and loses none of itsproperties when heated to 260° centi-grade, so it withstands autoclaving. Hav-ing standardised the size and the materialof the bougies it is then much easier toassess the properties of each obstructivetumour.

Once the tumour has been dilated to agiven size and one has knowledge of thec c?

resistance and the lenght of the tumour,the scene is set for insertion of a tube. Theintroducer rod of 9 mm in diameter is

* Ssward Surgical, UAC House, Blackfrias Road, London SEI.

Fig. 2 - The teflon bougies are used to dilate theobstruction to a size, dependent on the resistance,suitable for a tube with a 10 mm. internal diameter.

passed well through the obstruction. Thethe correct Souttar tube is placed over itand pushed downwards. If the distal beakof the oesophagoscope rests just abovethe tumour at the site where the lip willstay in future, the introducer tube enablesit to be pushed accurately into its finalposition. Since everything is done blindlyit is essential to have markers on thistube. The first black band shows that theproximal end of the beak has beenreached (Fig. 3) and then the first of thehandle markings show the distal end(Fig. 4). If it is necessary to push Souttartube any further, the additional markingson the handle are useful in assessing howfar it should be introduced. At the end ofthe procedure the introducer rod andtube are removed. Finally, theoesophagoscope should be used to seewhether the tube is in its correct positionand is patent. It is useful to pour fluiddown to see that the lumen is open; airinsufflation can confirm this. A post-operative chest X-ray is essential to makesure that the tube is in its correct position

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SOUTTAR TUBES FOR OliSOPIIAGEAL CARCINOMA 19

rFig. 3 - The proximal end of the oesophagoscopeshowing the white handle of the introducer tube andthe black groove.

Fig. 4 - The distal end of the oesophagoscope withthe Souttar tube passing over the introducer rod andpushed by the teflon introducer tube.

and that there has been no leak (Fig. 5). Itis extremely difficult to alter the positionof a tube once it has been placed in situ.

COMPLICATIONS

One complication is that the tubepasses out through the obstruction. Themajority will stay in the stomach butsmaller ones can pass per rectum. Ana-lysis shows that the tube was in fact in-serted prior to a course of radiotherapyand in the majority, when the tumour hadshrunk, the lumen enlarged and the tubefell out. Consequently it is not theauthor's practice to use these tubes aspalliation prior to radiotherapy, sinceswallowing usually improves after one ortwo weeks. If there is complete obstruc-tion to liquids, palliative feeding withAminutrin, Vivonex or Clinifeed can bedone through a tube with a onemillimetre bore. Such small tubes do notupset the patient as much as a largernaso-gastric tube. If these Souttar tubes

Fig. 5 - A lateral chest X-Ray showing the Souttartube in its final position.

are inserted after radiotherapy orthrough an obstruction which is not goingto be treated by radiotherapy they veryrarely pass into the stomach.

Occasionally a tube may be dislodgedupwards. The author has never seen thiswith a Souttar tube and it is more likely tooccur with the pull through methodwhich relies on the lip preventing thetube passing through. Consequentlythere is nothing to prevent it working itsway upwards.

Obstruction can occur with any tube. If10 mm internal diameter is achieved thenthe patient should manage normal foodprovided he chews it well. Bolus obstruc-tion can occur and should be treated in-izially with enzymes such as chymo-trypsin orally. If this fails, a naso-gastrictube may be used to clear the obstructionand only rarely is oesophagoscopy essen-tial.

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Pressure from too large a tube mayproduce necrosis of arteries or a fistulainto the trachea or lungs. Frequently,however, these tubes can be inserted inthe presence of a pulmonary fistula,block it off and enable the patient toswallow. The danger of pressure from aSouttar tube is probably no greater thanthat from a Mousseau-Barbin or Celestintube.

One disadvantage of the Souttar tubeoccurs if it is used in obstructions of thecardia when an adenocarcinoma of thestomach extends proximally and tumourgrows up over the short lip of the spring.It is the author's practice not to useSouttar tubes in obstructive carcinoma ofthe stomach. It is much wiser to use aCelestin tube which has a larger lip sothat, during the remainder of thepatient's life, if there is longitudinalspread of the untreated tumour theproximal funnel is not obstructed. Incarcinoma of the body of the oesophagustreated by radiotherapy with a sub-sequent narrowing, the author has neverseen the lumen obstructed by furthergrowth.

SUMMARY

The Souttar tube is made of 1 mmstainless steel wire coiled as a spring and

R. EARLAM

is used for palliation in squamous cellcarcinoma of the body of the oesophagus,ideally when there is patent normaloesophagus below the tumour. Insertionof these tubes is difficult but the tech-nique is well worth learning since thepatient avoids an operation which itselfhas a mortality when the pull throughmethod of intubation is used.

Palliative intubation will enable thepatient to swallow following radio-therapy. The patients are unaware thatthe tube is in place and normal food canbe swallowed if it is chewed well.

REFERENCES

1. Celestin L. R. - Permanent intubation in inoperablecancer of the oesophagus and cardia - Ann. R. Coll.Surg. Engl.:25, 165, 1959.

2. Mackler S. A. and Mayer R. M. - Palliation ofesophageal obstruction due to carcinoma with a per-manent intraluminal tube. - J. Thorac. Cardiovasc.Surg. :2& 431. 1954.

3. Mousseau M.. Le Forcstier J., Barbin J.. Hardy M. -Place de I'intubation a demeure dans le traitementpalliatifdu cancer de I'oesophage. - Arch. Mai. Appar.Dig.: 45,208, 1956.

4. Palmer E. D. - Peroralprosthesis for the managementof incurable esophageal carcinoma - Am. J. Gas-troenterol.: 59,487, 1973.

5. Souttar H. S. - A method ofintubating the oesophagusfor malignant stricture - Brit. med. J.: 1, 782, 1924.

6. Souttar H. S. - Treatment of carcinoma of oesophagus,based on 100personal cases and eighteen postmortemreports - Brit. J. Surg.: 15, 76, 1927.

7. Symonds C. J. - A case of malignant stricture of theoesophagus illustrating the use of the new form ofoesophageal catheter - Trans. Clin. Soc. Lond.: 18.155, 1885.

Chir. Gastroent. (Surg Gastroent.), Vol. 13, No. 1.1979