A 62-year-old male is admitted to the ICU post-operatively having undergone a transthoracic oesophagectomy for squamous cell carcinoma of the oesophagus. The patient was extubated at the end of the operation but requires re-intubation two days post-surgery due to respiratory failure.

a) List the likely underlying causes of respiratory failure specific to this clinical situation.

b) List the pros and cons of non-invasive ventilation in this clinical situation.

c) Briefly outline the principles of management of an anastomotic leak in this patient.

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College Answer

a)
 Pre-existing COAD.
 Diminished airway protection /Altered mental status.
 Chronic aspiration due to impaired preoperative oesophageal function.
 Postoperative aspiration due to recurrent laryngeal nerve compromise and/or inability to swallow.
 Surgical complication including anastomotic breakdown or conduit ischaemia.
 Postoperative pain.
 Pleural effusion.
 Chylothorax.
 Myocardial ischaemia.
 Cardiac failure.
 Weakness due to pre-existing malnutrition.

b)
Pros
 May reduce need for invasive ventilation
 Decreased need for sedation as opposed to invasive ventilation
 Many of the these patient have COAD – reduces work of breathing
 May decrease risk of VAP

Cons
 Oesophageal anastomosis might be compromised and oesophageal leak is a devastating complication
 Many of these patients are at high risk of aspiration

c)
 Assurance of adequate perfusion – maintain good MAP, maintain euvolemia, (avoid vasopressors if possible).
 Adequate source control- all leaks must be adequately drained by re-operation or percutaneous drainage.
 Cessation of contamination – Nil by mouth and well positioned NG tube with free drainage.
 Appropriate nutritional support e.g. enteral feed via jejunostomy
 Endoscopy to assess graft viability if concerned.
 Consider oesophageal stent
 Broad-spectrum antibiotics such as Tazocin and consider anti-fungals – Fluconazole after culture of blood and other secretions.
 In general, cervical leaks can be managed with drainage of neck wound at the bedside, while thoracic leaks are likely to need open re-exploration and drainage