Question 17

a) Outline the surgical differences between the following operations for carcinoma of the oesophagus:

b) List the complications of the above procedures that are of relevance to the ICU management.
(60% marks)

c) Outline specific post-operative management strategies of an oesophagectomy patient that reduce mortality and morbidity. (25% marks)

College answer

Not available.

a) Surgical differences between the following operations, for 15% of the marks, would have to be relatively brief:

3 Stage (modified McKeown) oesophagectomy
- Right thoracotomy
- Midline laparotomy
- Left neck incision
Ivor Lewis oesophagectomy:
- Right thoracotomy
- Midline laparotomy
Transhiatal oesophagectomy
- Midline laparotomy only

b) Complications:

Pain
Recurrent laryngeal nerve injury
Respiratory complications:
- Surgical complications:
  - Tracheobronchial tree injury
  - Thoracic duct injury, leading to chylothorax (1-5% risk)
- Early post-operative complications:
  - Atelectasis
  - Pneumothorax
- Delayed post-operative complications
  - Hospital-acquired pneumonia
  - Pleural effusion
  - airway-gastric fistulae
Anastomotic leak
Circulatory complications
- Immediate:
  - Haemorrhage due to retraction or dissection
  - Traction injuries to the heart or pericardium
  - Atrial fibrillation (very common - up to 40%)
- Delayed:
  - Herniation of abdominal contents into the chest, via a loosened diaphragmatic hiatus
  - Sepsis and septic shock
Gastrointestinal complications
- Early:
  - Ileus
  - Delayed gastric emptying and gastric outlet obstruction (due to vagotomy and "anatomic rearrangement", to borrow a turn of phrase from Flanagan et al, 2016).
- Late:
  - "Dumping syndrome": where hyperosmolar gastric contents is propelled abruptly into the small bowel, causing sudden bursts of insulin release, diarrhoea, nausea, and haemodynamic compromise (tachycardia and hypotension).
  - Decreased peristalsis due to vagotomy
  - Gastric reflux (this is an expected complication, in the sense that everybody gets it)
  - Oesophageal stricture

c) Post-operative strategies that reduce morbidity and mortality:

Early extubation
Prevention of AF: early use of enteral beta-blockers
Strategies to prevent morbidity from anastomotic leak, from Vetter & Gutschow (2020):
- Gastric decompression by NG tube
- Intravenous proton pump inhibitors (eg. pantoprazole)
- Early nutrition
- Early detection of leak (vigilant monitoring +/- radiological swallow studies)
- Avoidance of hypotension
- Avoidance of CPAP
Strategies to prevent pneumonia:
- Multimodal analgesia: epidural, regional block, plus systemic opioids via PCA, plus potentially a co-analgesic like ketamine
- Early mobility and chest physiotherapy
- Early swallowing assessment: aspiration pneumonia is a major contributor to morbidity, so to identify at-risk patients early would be beneficial. Ideally, this should incorporate nasendoscopy and evaluation of vocal cord function, as laryngeal nerve palsy is very common.

Paul, Subroto, and Raphael Bueno. "Section VI: complications following esophagectomy: early detection, treatment, and prevention." Seminars in thoracic and cardiovascular surgery. Vol. 15. No. 2. WB Saunders, 2003.

Grimminger, Peter, et al. "Diagnosis, assessment, and management of surgical complications following esophagectomy." Annals of the New York Academy of Sciences 1434.1 (2018): 254-273.

Mboumi, Igor Wanko, Sushanth Reddy, and Anne O. Lidor. "Complications after esophagectomy." Surgical Clinics 99.3 (2019): 501-510.

Oxenberg, Jacqueline. "Prevention and management of complications from esophagectomy." Esophageal cancer and beyond. London: IntechOpen (2018): 29-47.