Complication following esophagectomy

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Complication following esophagectomy

• Ri???
• 2008-02-04

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Esophagectomy

• Method
• Transthoracic approach
• Transhiatal approach
• Tri-incisional approach
• Left thoracoabdominal approach
• Conduit
• Stomach
• Colon
• Jejunum
• Anastomosis site
• Thorax
• Neck
• Anastomosis technique
• Hand-sewn
• Stapling device

Seminars in Thoracic and Cardiovascular Surgery,
Vol 16, No 2 (Summer), 2004 pp 124-132
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Complications

• Anastomotic leak
• Conduit necrosis
• Anastomic stricture
• Hemorrhage
• Chylothorax
• Pleural effusion
• Injury to the recurrent lanryngeal nerve
• Tracheobhronchial injury
• Cardiovascular and pulmonary complications

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215
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Anastomotic leak

• Incedence 23/307 (7.5 )
• Mortality rate 8/23 (35 )
• Death predictor
• Age (died, 72.88.3 years survived, 65.38.8
  yearsp0.063)
• Location of anastomosis (cervical, 3/9 died
  thoracic, 5/14 died p0.91)
• Leak presentation (clinical, 6/12 died contrast
  study, 2/11 died p0.11)
• Time of leak (lt7 days, 3/5 died 7 days, 5/18
  died p0.18)
• Presence of gastric necrosis (necrosis, 3/3 died
  no necrosis, 5/20 diedp0.019)
• Treatment (surgical, 4/4 died conservative, 4/19
  died p0.005)

Ann Thorac Cardiovasc Surg Vol. 10, No. 2 (2004)
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Anastomotic leak

• Incedence 19/291 (6.5 )
• Hospital mortality rate 6/19 (31.6 )

British Journal of Surgery 2001, 88, 1346-1351
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Anastomotic leak
British Journal of Surgery 2001, 88, 1346-1351
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Anastomotic leak

• Definition of Surgical Infection Study Group

Seminars in Thoracic and Cardiovascular Surgery,
Vol 16, No 2 (Summer), 2004 pp 124-132
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Anastomotic leak

• Esophageal (intrinsic) factor
• Absence of an outer serosal layer
• Longitudinal orientation of the exposed
  esophageal musculature
• Patient-related factor
• Severe malnutrition
• Not age, DM, perioprative steroid use
• Surgical/Techenical factor
• Tension
• Vessel supply
• Mucosal incorporation/apposition

Seminars in Thoracic and Cardiovascular Surgery,
Vol 16, No 2 (Summer), 2004 pp 124-132
9
Anastomotic leak

• Diagnosis
• PE
• Chest pain, dyspnea, saliva exuding, bile
  exiting, fever
• Lab
• CBC, CRP, Pleural effusion in CXR, contrast
  swallowing

Seminars in Thoracic and Cardiovascular Surgery,
Vol 16, No 2 (Summer), 2004 pp 124-132
10
Anastomotic leak

• Management

Dig Surg 2002199298
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Anastomotic leak
British Journal of Surgery 2001, 88, 1346-1351
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Conduit necrosis

• Occurs in approximately 1 of cases
• Etiologic factors
• Similar to those indicated for leaks
• Also conduit torsion, intrinsic vascular
  insufficiency due to atherosclerosis of the
  feeding vessel, technical mishaps
• S/S
• Initially subtle, progress rapidly
• Operative intervention is always necessary
• Refashioned, complete take-down with debridement
  of necrotic tissue, wide-drainage, proximal
  diversion, replacement of the remaining viable
  stomach within the abdomen.

Seminars in Thoracic and Cardiovascular Surgery,
Vol 16, No 2 (Summer), 2004 pp 124-132
13
Anastomotic stricture

• Incidence varies from 1 to 50
• Often occurs months after the procedure
• Often associated with prior occurrence of a leak
• S/S Complaint of dysphagia
• Should be carefully evaluated for recurrent
  disease with endoscopy, with or without
  endoscopic ultrasound (EUS), abdominal and chest
  CT
• Benign stricture can be treated on a symptomatic
  basis by dilation or stenting
• Proton-pump inhibitor

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215 Seminars
in Thoracic and Cardiovascular Surgery, Vol 16,
No 2 (Summer), 2004 pp 124-132
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Hemorrhage

• Incidence of 3 to 5
• Requires urgent re-exploration
• In most circumstances prevented with proper
  surgical technique
• Diagnosis usually delayed by 12 to 24 hrs
• Volume replacement
• Fairly sizable fields of dissection
• Unexpected tachycardia and decreased urine output
  are usually early clues to bleeding
• Resuscitated with blood products to correct any
  coagulopathies and then reexplored

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215
15
Chylothorax

• Incidence of 1 to 5
• Diagnosed by the presence of pleural effusion,
  consisting of a milky fluid with a high
  triglyceride and lymphocyte count
• Should be suspected when the chest tube output is
  high after postoperative day 4
• Mamagement
• Half conservatively by restricting the oral
  intake and on intravenous hyperalimentation
• Embolization of the thoracic duct using
  interventional radiology techniques
• Surgical exploration
• Perioperative prophylactic thoracic duct ligation
• Repair a thoracic duct leak during the course of
  esophagectomy

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215
16
Pleural effusion, pneumothorax

• Result from an injury to the pleura on the
  contralateral hemithorax
• Should rule out hemorrhage, chylothorax, conduit
  leak, metastatic disease, airway injury
• Managed by observation, percutaneous drainage or
  thoracostomy drainage

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215
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Injury to the recurrent laryngeal nerve

• An incidence of 10 to 20 in cervical
  anastomoses
• Diagnosis
• Video-assisted swallow studies
• Fiberoptic evaluation
• Perioperative intubation caused vocal cord edema
  can mask the injury for a few days

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215
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Tracheobronchial injury

• Neoesophageal-to-bronchial fistulas
• S/S Recurrent pneumonia or empyema
• Small injuries often heal without treatment or
  adverse sequelae
• Can lead to fistula formation involving the
  neoesophagus, requiring stenting or operative
  repair

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215
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Cardiovascular and pulmonary complications

• Esophageal ca patient
• Ederly, malnourished, smoking, alcohol abuse
• Cardiovascular complications 5 to 10
• Most common atrial fibrillation
• Management
• Intraoperative and postoperative Swan-Ganz for
  high-risk patients
• Preoperative and postoperative use of
  beta-blockade or calcium channel blockers
• Pulmonary complications 20 to 30
• Pneumonia, aspiration, respiratory failure
• Two principal reasons malnourished, smoking
• Early tracheostomy is favored in patients with
  prolonged ventilation requirements

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215
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Conclussion

• Careful preoperative evaluation of the patient
• Meticulous surgical technique
• An awareness of the potential complications
• Mortality rate of 2.5 at a high-volume center,
  in contrast to a nearly 10 mortality rate at a
  low-volume center

Seminars in Thoracic and Cardiovascular Surgery,
Vol 15, No 2 (April), 2003 pp 210-215
21
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Povidone-iodine

• Water-soluble complex of iodine with
  polyvinylpyrrolidone (PVP)
• Works through disruption of pathogen cell walls
• Bactericidal ability against a large array of
  pathogens

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Method

• Search of MEDLINE (19662006) and EMBASE
  (19802006)
• Focused on the efficacy or risks, or both, of
  povidone-iodine irrigation to prevent surgical
  site infection
• Either a randomized controlled trial (RCT) or a
  comparative study
• Exclusion
• Treatment of surgical site infection
• Used povidone-iodine topically

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Result

• 15 studies met all the inclusion criteria
• Years of publication 1977 to 2006
• General (8),cardiovascular (2), orthopedic (2),
  urologic (1)
• RCTs (11), single-blind (3)
• Level I (3), level II (12)

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Discussion

• 5/15 not find povidone-iodine superior to saline,
  water or no irrigation
• Surgery in general (1), general (3),
  cardiovascular (1)
• Effectiveness even at low concentrations,
  concentrations less than 5 would seem
  appropriate
• Whether povidone-iodine solution would show
  efficacy in conjunction with antibiotics is
  unknown
• Several recent RCTs demonstrated povidone-iodine
  irrigation further reduced surgical site
  infection rates
• The appropriateness of using povidone-iodine
  irrigation in children is unknown
• Risk
• Increased postoperative serum iodine
• Should not be used in patients with iodine
  sensitivity, burns, thryroid disease or renal
  disease
• The evidence suggests that povidone-iodine
  irrigation may be effective in preventing
  surgical site infection

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• Thank you for your attention !