Fiberoptic endoscopic evaluation of swallowing in assessing aspiration after transhiatal esophagectomy.

Background: Pulmonary complications after transhiatal esophagectomy occur commonly and frequently cause severe morbidity and possible mortality. Aspiration, both overt and silent, can also be present with some regularity after this procedure, and it appears intuitive that identification of aspiration with the appropriate measures of avoidance of oral intake and avoidance of oral contrast studies may help reduce the consequences of aspiration pneumonia.

Study Design: In an attempt to help identify patients at risk for aspiration, we prospectively studied 73 patients who had recently undergone transhiatal esophagectomy using fiberoptic endoscopic evaluation of swallowing (FEES). Evaluation of premature spillage, pharyngeal residue, pooling, penetration, and aspiration was carried out.

Results: Twenty-one percent of patients showed evidence of aspiration and were kept npo, with deferral of oral contrast studies. Of all the potential predictors of aspiration studied, only vocal fold immobility was a notable predictor of aspiration. But 40% of patients who aspirated had normal vocal fold function. Vocal fold immobility was also identified in several patients thought to have completely normal voice quality. There were no complications of FEES. All patients who demonstrated aspiration and all those with vocal fold immobility eventually demonstrated swallowing without aspiration and recovery of cord function.

Conclusions: This study demonstrated the safety and efficacy of FEES in evaluation of laryngeal function in the postoperative setting after transhiatal esophagectomy. A FEES is recommended before the contrast study or oral feeding challenge for objective determination of aspiration risk from pharyngeal or laryngeal pathology. Early determination of aspiration status may reduce or eliminate pulmonary complications.