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Complications of Esophagectomy

TSRA Primer - Thoracic

TSRA Content:


Author: Saila Pillai, MD

Introduction

Esophagectomy is a complex procedure and is associated with significant morbidity and mortality even in the hands of the most experienced surgeons. Key determinants of the most likely complications include surgical approach, location of the anastomosis as well as the method of anastomosis. (1) Potential intraoperative and early postoperative complications are reviewed here.

Intraoperative Complications


Meticulous surgical technique and knowledge of potential danger areas is required to minimize intraoperative complications.

Abdominal:
Potential intraoperative complications that occur during the abdominal phase include injury to the right gastroepiploic arcade, splenic or liver lacerations/capsular tears, and gastric serosal or full-thickness tears.

Injury to the gastroepiploic arcade is perhaps the most feared of these complications, and a colonic interposition or delayed reconstruction will be needed. Keeping 1-2 cm distal to the arcade to avoids thermal injury or accidental division and grasping the arcade should be avoided when retracting the stomach. The pulse should be palpated, and the conduit observed for signs of ischemia throughout the case. Careless retraction can avulse adhesions or attachments to the liver and spleen, causing unnecessary bleeding. Packing/pressure, cauterization, or topical hemostatic agents can be used to control most injuries. Splenectomy may be needed in cases of uncontrollable hemorrhage. Trauma from careless retraction or thermal injuries to the stomach or small bowel will increase the risk of postoperative leak. The stomach should be handled gently due to its tenuous blood supply and care should be taken to minimize grasping the greater curve, which will later become the conduit. Larger bites of the stomach and small bowel help to minimize these traction injuries. Identified serosal or full thickness tears should be repaired with imbricating sutures.

Cervical:
Neck dissection is undertaken in both three-field and transhiatal esophagectomies. Potential intraoperative complications include recurrent laryngeal nerve (RLN) injury, proximal esophageal injury, and damage to the airway, particularly the posterior membranous portion.

Injury to the nerve can result from various mechanisms, direct or thermal injury, stretch injury, and vascular compromise or compression.(1) The risk of nerve injury increases with use of metal retractors in the tracheoesophageal groove and with the use of electrocautery near the nerve. Injury may result in permanent damage with resulting hoarseness and aspiration. RLN injury results in a tenfold increase in pulmonary complications and a resultant increase in hospital stay. Direct laryngoscopy should be used to diagnose an immobile vocal cord and a medialization procedure can be done to reduce aspiration risk.

The proximal esophagus and airway may be injured during cervical dissection, and risk is increased with surgeon inexperience and inpatients with a 'bull-neck' habitus. A partial sternal split can greatly aid in exposure in these cases.

Thoracic:
A number of structures can be injured during the intrathoracic portion of an esophagectomy, most commonly performed through the right chest. During anterior mobilization of the esophagus, the phrenic nerve should be identified and preserved. The vagus nerve should be divided close to the esophagus to prevent injury to the right RLN.

The posterior membranous portion of the trachea, as well as both main stem bronchi, are at risk during dissection of the anterior aspect of the esophagus. When dissecting the subcarinal lymph nodes, avoid use of excessive cautery to control bleeding, as this increases the chance of airway injury. Injuries noted intraoperatively should be dealt with immediately and can typically be repaired primarily. However, thermal injuries can present in a delayed fashion as airway-gastric fistulae and are typically associated with a high mortality rate. During posterior mobilization of the esophagus, liberal use of clips to control lymphatic and aortoesophageal arterial branches minimizes the risk of chyle leak and bleeding.

Dissection too far posteriorly puts the azygos vein, thoracic aorta, and main thoracic duct at risk. Staying close to the esophagus avoids injury to these structures. If injury to the main duct is suspected, thoracic duct ligation should be carried out at the level of the hiatus. A left-sided approach allows one to stay clear of the thoracic duct and azygos vein, but the airway and aorta are still vulnerable.

Blunt mediastinal dissection is undertaken during transhiatal esophagectomy. Bleeding from the small, periesophageal areaolar tissue branches is common and of little concern. Larger aortoesophageal branches may be avulsed and should be clipped if they can be visualized. Otherwise, packing the mediastinum will successfully control most bleeding from these branches. Of more concern is a tumor that is adherent to adjacent structures. Rather than attempting blind, blunt dissection of the tumor, it is recommended that a right thoracotomy be carried out for dissection under direct visualization. Azygous vein injury should be suspected when faced with torrential venous bleeding during dissection of the middle and upper esophagus. More than likely, a right thoracotomy is needed to control the bleeding and ligate the azygos vein.

Transient hypotension may also occur during blunt mediastinal dissection behind the heart as the surgeon's hand compresses the left atrium. Clear communication with the anesthesia team and intermittent breaks in the blunt dissection are needed to manage this typically transient hypotension.

Early Postoperative Complications


Early postoperative complications include anastomotic leaks, conduit necrosis, chylothorax, pulmonary complications, cardiac complications, and death.

Anastomotic leak rates are less with thoracic anastomosis however thoracic anastomotic leaks are more prone to unfavorable sequelae. (1) If the anastomosis is in the neck or thoracic inlet, incisional erythema and induration should raise high suspicion for a cervical anastomotic leak. Occasionally, gastric/bilious, or purulent drainage may occur, either at the incision or in a previously placed drain. Suspicion of a leak should be confirmed with endoscopy, water-soluble contrast/thin barium esophagogram, or by having the patient drink grape juice while watching for drainage. The risk of endoscopy exacerbating the leak is minimal and has been proven to be safe even with maximal insufflation. (1)

Cervical esophageal leaks typically only require the wound to be opened and loose wet-to-dry packing to allow egress of exudate until the leak is healed. However, if there is evidence of a leak draining into the chest, it should be treated like an intrathoracic leak. Intrathoracic anastomotic leaks should be suspected if gastric/bilious drainage is noted in the chest tubes, or if a patient develops an effusion on chest x-ray. At times, a low-grade fever, tachycardia, abnormal mentation, and leukocytosis may be the only signs.

The principle of management of anastomotic leaks is adequate drainage, source control and nutritional rehabilitation. An operation is indicated for patients with symptomatic, uncontained intrathoracic leaks. The pleural cavity and mediastinum should be washed out and widely drained. If possible, the leak should be repaired and reinforced with a viable tissue buttress. Well placed intraoperative drains with or without the addition of image-guided percutaneous drains can be used to control contained leaks and avoid reoperation in select cases. Simple classification systems for anatomotic leaks, such as the one described by Lerut, can be used to guide management. (2) Endoscopic strategies are also being explored for small defects in some units and include esophageal stenting, endoscopic clipping, overstitch and endoluminal vacuum therapy. Limited data is available for this treatment modality.

Airway - Gastric fistula are a rare complication and can result from direct injury to the airway, devascularization or from chronic inflammation of a staple line in close proximity. These patients present with coughing with oral intake or aspiration pneumonia and once the diagnosis is made the can be managed with stenting where technically feasible and available. (1)

Conduit Necrosis is rare but perhaps the most feared complications following esophagectomy. Risk factors include excessive traction on the conduit, damage to gastroepiploic vessels, prior radiation, narrow conduit, conduit obstruction/dilation, hypoxia, and perioperative hypotension requiring pressors. Suspect conduit necrosis when a patient has ongoing foul-smelling or copious purulent drainage from a neck wound, chest pain, or fever progressing to a septic picture. Early diagnosis is crucial to avoid this frequently fatal complication. Diagnosis is made by prompt upper endoscopy. Conduit necrosis warrants operative re-exploration and resection of devitalized tissue. Occasionally, re-anastomosis is possible if the necrotic area is small, and the patient is relatively stable. Inflamed margins are resected prior to re-anastomosis, and viable tissue buttress with pericardial fat or muscle should be undertaken. Otherwise, plan on resection of the conduit and esophageal diversion with a cervical esophagostomy and if not already in place, enteral feeding access should be established.

Interval substernal gastric pull-up or interposition grafting with jejunum or colon are then options for reconstruction once the patient has recovered and is nutritionally optimized, typically 3-6 months later.

Chylothorax can be catastrophic if characterized by high-volume output that is uncontrolled. Persistent chest tube output that increases with oral intake and changes to a milky-white appearance, with fat intake should raise the suspicion of a chyle leak. A triglyceride level of> 110 mg/ dL is strongly suggestive of the diagnosis, whereas a level <50 mg/dL makes it unlikely. If a chyle leak is confirmed, the aim of management is to drain the chyle, decrease the production of chyle and nutritional rehabilitation. Options include changing to medium chain fatty acid feeds to minimize lymph production or stopping enteral nutrition and initiating parenteral nutrition and somatostatin analogues. Output is then trended. Few (<20%) will close with conservative management alone. Continued high output (>1L/day for 5 days or > 1.5L/day) or persistent drainage warrants thoracic duct ligation, and usually a wash-out with wide drainage of the chest. Heavy cream or methylene blue may be administered via a NGT prior to surgery to help identify the site of the leak. Some institutions offer lymphangiography as a way to identify the exact site of the leak with the option of embolization.

Patients can become malnourished, experience electrolyte imbalance, and become immunocompromised due to the large volume loss of lymph, which is a particular concern in post-esophagectomy patients who are frequently malnourished and debilitated at the time of operation. Because of this fact, some prefer early surgical intervention in this patient population.

Pulmonary complications are common following esophagectomy and cause significant morbidity, an increase in post operative mortality as well as a decrease in 5-year survival. (1) Atelectasis, aspiration, pneumonia and ventilator dependence may result without aggressive pulmonary care. Predisposing factors include a history of COPD, older age, longer duration of operation, proximal tumor location, and neoadjuvant therapy. Prevention is key and consists of pre- and postoperative use of incentive spirometry, smoking cessation at least 2 weeks prior to surgery, aggressive pulmonary toilet including frequent bronchoscopy if needed, adequate pain control, intraoperative protective ventilation strategies and preoperative pulmonary rehabilitation in the highest risk patients. High risk patients are patients with FEV1 <60% of predicted normal. (1)

Atrial fibrillation is the most common cardiac complication, occurring in roughly 20% of esophagectomy patients. Arrhythmias are common in the elderly and patients with cardiac disease, as well as cases with significant blood loss or extensive thoracic dissection. Moreover, atrial fibrillation is associated with higher anastomotic leak rates, respiratory failure, sepsis, prolonged ICU stay and a higher mortality rate. Postoperative myocardial infarction is rare but can be catastrophic.

Risk factors for death after esophagectomy include age above 65 and comorbidities. Some have also suggested that low-volume centers carry a higher mortality rate than high-volume centers.

Functional Complications


Long-term, 13-50% of patients may develop dumping syndrome. 'Early' dumping syndrome is characterized by palpitations, dizziness, diaphoresis, nausea, cramping, and diarrhea. 'Late' dumping entails tremors, somnolence, and inattention, and is linked to hypoglycemia. Dumping syndrome can be managed with dietary modifications: limit simple carbohydrates, eat small frequent meals, and consume solids and liquids separately. Anti-diarrheal agents and octreotide may also provide relief. Dumping syndrome most often resolves 6 -12 months after esophagectomy.

Delayed gastric emptying affects 10-50% of patients and is a consequence of vagotomy. Although not always performed, pyloromyotomy or pyloroplasty is intended to prevent delayed gastric emptying. A trial of medical therapy should be considered, although it may not be effective. Prokinetics such as metoclopramide, cisapride, and erythromycin are commonly used. Balloon dilatation of the pylorus or botulinum toxin pyloroplasty can be used as temporizing measures if a narrow pyloric channel is noted. Most cases will resolve with time. However, it is important to act before excessive dilation of the conduit occurs, as this can lead to significant ischemia. Avoid redundant or large diameter conduits and tight reapproximation of the hiatus to minimize the risk of conduit obstruction and delayed emptying.

Reflux occurs in 30-72% of patients, with a greater incidence seen with intrathoracic anastomoses and can be exacerbated by delayed gastric emptying and gastroparesis. This is thought to be due to the pleuroperitoneal pressure gradient, and the loss of the lower esophageal sphincter. Medical management with proton pump inhibitors, anti-reflux precautions after meals, and small, frequent meals are typically effective.

Anastomotic strictures can occur as well, with the most common complaint being dysphagia. Risk factors include end-to-end and small-diameter anastomoses, leaks, and ischemia. Anastomotic strictures are treated with dilation using balloon or weighted esophageal dilators. Some strictures resolve with one treatment, while others need repeated dilations. Strictures that develop later can be associated with tumor recurrence and should be evaluated and managed accordingly.

References:

  1. I. W. Mboumi, S. Reddy and A. O. Lidor: Complications After Esophagectomy. Surgical Clinics 2019 Vol. 99 Issue 3 Pages 501-510 doi: 10.1016/j.suc.2019.02.011
  2. Lerut T, Coosemans W, Decker G, De Leyn P, Nafteux P, van Raemdonck D: Anastomotic Complications after Esophagectomy. Dig Surg 2002;19:92-98. doi: 10.1159/000052018