Hi, my name is Jules Lin. I'm one of the thoracic surgeons, and welcome to today's lecture on short-term complications after esophagectomy. The objective of today's talk is to review the common complications after esophagectomy. I want to illustrate typical imaging and diagnostic findings, and discuss prevention and treatment options for complications. After today's talk, we hope that you can answer this question on which of the following has been associated with anastomotic leaks after esophagectomy? A, previous hiatal hernia repair. B, epidural. C, stapled anastomosis. And D, atrial fibrillation. So over 3,000 transhiatal esophagectomies have been performed at the University of Michigan. And in a study from 2007, comparing esophagectomies performed between 1976, and 1998 versus 1998 to 2006. The hospital mortality decreased from 4% to 1%. And discharge within 10 days increased from 52% to 78%. So despite improvements in technique and post operative care, esophagectomy is still a major operation. We're dissecting several areas of the body, including the neck, the chest, and the abdomen. Patients are often older and have many comorbidities. They can be malnourished and dehydrated due to dysphagia, chemoradiaton, and bowel prep. So it's important to select these patients carefully. You have to consider whether they have any cardiac disease. How's their pulmonary function? What is their activity level and how is their nutrition especially if they're older. And to consider all these risk factors together and determine whether patients are candidates for an esophagectomy. The preoperative preparation is essential. So these patients we tell them to ambulate, we want them to walk one to three miles a day. It's important for them to be using an incentive spirometer to practice exercising their lungs which they'll be doing postoperatively. Nutritional supplements are important, especially, if they've lost a significant amount of weight. And we have esophagectomy support group, where these patients can talk to patients who've undergone esophagectomy before, as part of their preparation for surgery. And for neoadjuvant therapy, it's important that we wait until patients have returned to their baseline function before undergoing esophagectomy. So pneumonia is an important complication to avoid, and these patients sometimes will have recurrent nerve injuries. This happens in 1 to 2% of patients, and when that occurs, it's important to watch for aspiration. These patients have increased pain, especially after thoracotomy. And when they do swallow, sometimes we'll recommend that they tuck their chin, to help prevent aspiration. When they sleep at night, we tell these patients to sit in a semi-upright position, greater than 30 degrees, again to decrease aspiration. And if they're nauseated or they needed a procedure that requires general anesthesia, we're sure to replace our NG tube. We avoid BIPAP, and positive pressure to avoid distending their stomach of air, which would increase the risk of aspiration and pneumonia. And good pain control is essential, and we found that an epidural is very useful for this post op as well. Atrial fibrillation is also common during the first four postoperative days. Some of this is due to hypervolemia, mediastinal inflammation, and increased sympathetic tone. There are a lot of fluid and electrolyte shifts, and atrial fibrillation is associated with pulmonary complications as well anastomotic leak. And when atrial fibrillation occurs, we treat it initially with beta blockers or calcium channel blockers. And if that's not successful, then we use amiodarone to chemically cardiovert them. Chylothorax is suspected when there's high chest tube output in the first 72 hours. Here, you can see on the X-ray that there is a right effusion. And that combined with a high chest tube output would make us suspicious for chylothorax. The fluid can be sent for triglycerides to confirm this. It's important to recognize this complication because of the loss of albumin, protein, and lymphocytes in the fluid. This needs to be recognized early, these patients often nutritionally depleted, and this needs to be aggressively treated. One thing we do is we administer cream through the jejunostomy tube for 6 hours. This helps us to see the leak, so you can see the cream coming out of the thoracic duct intraoperatively, and then you can ligate the duct. There's also some newer techniques that are being undertaken by interventional radiology to actually embolize the duct. And this can be done non operatively with a percutaneous access to the thoracic duct. Anastomatic leak occurs on average on postoperative day 7. And a routine barium swallow is usually performed on postoperative day 7, unless there's a reason to do it earlier. So we suspect a leak if patients are having fevers, if there's redness around their incision, they have crepitus, bad breath, or drainage from the incision. If there's signs of sepsis, then we consider doing an esophagoscopy early to evaluate the stomach for any necrosis. And here you can see, here is a barium swallow, and the arrow points out an anastomotic leak. And on the endoscopy, you can see their sloughing of the anastomosis, sloughing. We found over time that a side-to-side stapled anastomosis decreases in anastomotic leaks, and it's very important to minimize trauma to the gastric conduit. So pink in the abdomen, pink in the neck. It's also important to have an adequate mediastinal tunnel. So when you bring the stomach up through the chest, you want to make sure there's adequate space that the stomach isn't being constricted with venous congestion, which increases the chance of a leak. An epidural may increase blood flow to the stomach, but again it's important to avoid hypertension. And if the patients are hypertension post op, we'll legal hold the epidural until we can improve their blood pressure. We found that a previous hiatal hernia or previous antireflux surgery does not increase the risk of an anastomotic leak. For an astomonic leak, 94% of these patients can be treated by wound packing alone. And during their dressing change, we usually have them drink water to help irrigate the wound. And we recommend early dilation, so we dilate them with bedside dilaters, usually within 7 to 10 days. And this helps to improved wound healing, and what you swallow tends to go down the path of least resistance, that's why we dilate early. A third of patents will develop a stricture, after having an anastomotic leak. These can be potentially life threatening, and mortality with complete necrosis of the gastric conduit, can be as high as 50 to 90%. So again a leak must be recognized early and drained. If not treated aggressively, there's a risk of ongoing sepsis, and even a broken gastric or aortoenteric fistula, and death. Here, you see on the barium swallow again, there's a leak here at the anastomosis. And again, important to avoid hypotension. Hold epidural if needed to keep the mean pressure greater than 60. Bleeding can lead to hypotension, and important to prevent or treat atrial fibrillation. Initially in post op, we do have a NG tube in to avoid gastric distension. And again, if the NG tube falls out and the patient is nauseated. Important to replace that NG tube which also helps prevent aspiration. Anastomotic stricture, we have a low threshold to dilate patients. 50% of our patients were dilated at least once, and this can be performed at the bedside or in the procedure unit. And patients with recurring dysphagia and we'll teach them in clinic how to perform a self dilation, so they can do this at home. In the last follow-up, 76% of the patients had no dysphagia. And this usually gets better over time as the stricture stabilizes. Here you can see on barium swallow, there is an anastomotic stricture. And this is a picture of one of the bedside dilators. And it's just a long rubber tube that we have the patients swallow to help dilate their anastomosis. It's important to prevent complications, and we can talk about treating them, but prevention is key. And as we talked about patient selection is important, preoperative preparation, interoperative management, and postoperative management. Early to recognize and treat these complications, and this goes to the concept of failure to rescue. And often times when you think of hospitals, you think of the decreases in complications. But actually, it's probably more important to recognize these complications and treat them early. So as we asked before which of the following has been associated with anastomotic leak after esophagectomy? Is it A, previous hiatal hernia repair. B, epidural. C, stapled anastomosis. Or D, atrial fibrillation. Well the answer is atrial fibrillation. Atrial fibrillation has been associated with anastomotic leaks. And again it's important to recognize atrial fibrillation and treat it early. Take home points from this talk, esophagectomy is a major operation. Patients can be elderly, malnourished, and dehydrated. Preoperative preparation is essential with ambulation, incentive spirometer use, and nutritional supplements. And all of these are important for preventing these complications. Again, important to recognize and treat these complications early. Thank you very much for listening to this talk today, and I hope you learned something about short-term complications after an esophagectomy.
