Care for the patient following oesophagectomy

The routine post-oesophagectomy patient is such a common ICU presentation that it is remarkable it has not appeared more often in the CICM exams. The only appearance of a question specifically examining this area was Question 17 from the second paper of 2021. Specific knowledge was required of surgical approaches, potential complications, and specific strategies that could add value to their stay in ICU.

Surgical approaches for oesophagectomy

Apart from intensivists and surgeons, another group that need to have a solid understanding of the surgical approach and complications are radiologists. It is not surprising that one of the better articles describing different kinds of oesophagectomy is from a radiology journal (Flanagan et al, 2016). To illustrate the differences in surgical technique, these three Apollo marbles were defaced:

3 Stage (modified McKeown) oesophagectomy

  • Right thoracotomy 
  • Midline laparotomy
  • Left neck incision

Ivor Lewis oesophagectomy: 

  • Right thoracotomy 
  • Midline laparotomy

Transhiatal oesophagectomy

  • Midline laparotomy only

These are the major external differences. Practically,

  • The McKeown method allows the resection of more proximal oesophageal masses, all the way up to the level of the clavicles. 
  • The advantage of the Ivor Lewis method is that the laparotomy is early in the procedure, which allows the surgeon to explore the peritoneum. If there are plentiful metastatic deposits there, the procedure can be called to a close early, so as to spare the patient all the unnecessary morbidity of oesophagectomy.
  • The transhiatal oesophagectomy has the least respiratory complications, and is most suited to patients with poor lung function. Unfortunately, it also affords the least exposure for the surgeon, and is suitable only for masses in the lower third of the oesophagus

Complications of oesophagectomy

The best resource for this would have to be Subroto & Bueno (2003) or Mboumi et al (2019), which are unfortunately paywalled.  If you are not able to get a hold of these papers, Oxenberg (2018) would be a valid alternative, and it also covers the preventative steps required. In any case, most trainees at the latter stages of CICM training will surely be able to produce enough of a list of complications to pass a written question about oesophagectomy, mainly because oesophagectomy has so many possible complications. The real skill would actually be in the classification system one decides to use.

  • Airway complications:
    • The recurrent laryngeal nerve can be damaged, leading to hoarseness of voice or even post-extubation stridor. The risk of this with a neck incision is about 10-20%
  • 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:
    • Seems sensible to put this between circulatory and respiratory complications, as an anastomotic leak following oesophagectomy will usually produce both.
    • It usually occurs within the first 10 days following surgery 
    • A pleural effusion will usually form
    • This will usually be purulent, and will often require drainage
    • Respiratory compromise from the effusion, and circulatory compromise from the sepsis, will usually result
  • 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
  • Pain
    • Especially with thoracotomy, pain can be a major barrier to progress from ICU
    • With thoracotomy, it may have a neuropathic component
  • 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

Prevention of complications from oesophagectomy

It would be good at this stage to discuss some preoperative steps, such as:

  • Attendance of the patient to a multidisciplinary high risk surgery clinic, to identify the malnourished chainsmoking alcoholics who are likely to have complications, and to refer them to appropriate services
  • Consultative case review of high-risk patients, involving ICU, oncology, surgery, anaesthetics and palliative medicine (as some patients may simply be too frail to undergo this high-morbidity procedure)
  • Planning of the surgical approach which is based on patient comorbidities (eg. patients with poor baseline lung function may be better off with a transhiatal approach)
  • Planning of the anaesthetic approach which incorporates regional techniques and multimodal analgesia
  • Conditioning the patient to perform well preoperatively by (for example) optimising their cardiovascular risks and improving their nutrition through supplements. The literature tends to refer to this as "prehabilitation".

But realistically the first time the intensivist will meet these patients will often be in ICU, right after their procedure. So: what specific strategies can be employed at that late stage to reduce mortality and morbidity from oesophagectomy?

  • Airway management: extubate them early. This seems to reduce their ICU length of stay (Imai et al, 2018)
  • Avoidance of CPAP probably needs to be mentioned somewhere in a discussion of oesophagectomy, as there is a perception that it is associated with an increased risk of anastomotic breakdown. 
  • Prevention of AF: early use of enteral beta-blockers to prevent AF seems to have some evidence behind it, whereas prophylactic amiodarone does not (Smith et al, 2018)
  • 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
  • Strategies to prevent pneumonia: pneumonia is a major cause of death following oesophagectomy, and prevention of pneumonia should take priority. The steps which could help consist of:
    • Multimodal analgesia: good epidural coverage is usually impossible for cervical and thoracic wounds, as the level would have to be too high; however regional infusions and nerve blocks are still possible, and often highly effective.
    • Early mobility: these people are often not able to have HFNP, which means good positioning and physiotherapy are essential to prevent atelectasis
    • 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. 

References

Flanagan, Jennifer C., et al. "Esophagectomy and gastric pull-through procedures: surgical techniques, imaging features, and potential complications." Radiographics 36.1 (2016): 107-121.

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.

Imai, Takeharu, et al. "Immediate extubation after esophagectomy with three-field lymphadenectomy enables early ambulation in patients with thoracic esophageal cancer." Esophagus 15.3 (2018): 165-172.

Smith, Heather, et al. "A review and analysis of strategies for prediction, prevention and management of post-operative atrial fibrillation after non-cardiac thoracic surgery." Journal of thoracic disease 10.Suppl 32 (2018): S3799.

Vetter, Diana, and Christian A. Gutschow. "Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction." Langenbeck's Archives of Surgery (2020): 1-9.