Chapter 70 Esophageal Surgery
OPERATIVE PROCEDURE
The technique of esophagectomy can be broken down into three parts, as summarized in Box 70-1. The first is the step of gastric mobilization; the second, esophageal dissection along with at least single-field lymphatic dissection for patients with cancer; and the third is the reconstructive esophageal anastomosis. We have advocated routine use of an adjuvant jejunostomy feeding tube.1 When used, this would be the fourth surgical step.
Box 70-1 Esophagectomy Technique: Overview
Complications
Complications are listed in the same order as they might arise during the surgery and postoperative management of a patient undergoing esophagectomy. Therefore, complications include operative complications, those that occur early and late during the initial hospital stay, and finally those encountered after discharge. The complications to be discussed are listed in Box 70-2.
Transhiatal Phase
Surgical Resection of the Esophagus
Operative Bleeding
The esophagus has a diverse and robust blood supply and lies in close proximity to many prominent vascular structures. Therefore, surgical resection of the esophagus always carries a risk of significant bleeding. The reported rate of perioperative hemorrhage complicating esophagectomy ranges from 0.3% to 4%.2–4 The risk and consequences of bleeding vary depending on the technique of esophagectomy. The risk of bleeding related to preparing the stomach for esophageal conduit is shared by all incisional techniques.
Transhiatal esophagectomy is associated with very real and significant bleeding during the intrathoracic, “blunt,” or transhiatal phase of esophageal dissection. Bleeding may result from large esophageal arteries originating from the aorta, inferior pulmonary vein, or pulmonary artery, as illustrated in Figure 70-1. Bleeding is usually immediately apparent as brisk blood flow exiting from the lower mediastinum or from the neck. However, if the mediastinal pleura has been opened during transhiatal dissection, then the bleeding event, or at least its severity, can be masked. When this happens, the first sign of trouble is an unexpected volume requirement or unstable hemodynamics. It is essential that the surgeon and anesthesiologist remain in communication during this phase of the operation.
• Consequence
• Repair
Intrathoracic bleeding during transhiatal surgery is one of the most feared complications. Bleeding from esophageal feeding arteries emanating from the aorta can lead to a sizeable blood loss before it can be visualized and controlled. If the vessel can be visualized easily in the lower mediastinum, it should be ligated, clipped, or coagulated promptly. If not, pack the mediastinum with a lap pad. This will greatly reduce the bleeding and make finding and controlling the vessel easier. Narrow hand-held malleable retractors often help greatly to see up into the mediastinum to find the bleeding vessel. Liberal use of suctioning and a surgeon’s headlight are also beneficial. Massive bleeding from the aorta, inferior pulmonary vein, or pulmonary artery is immediately life-threatening. Once bleeding is identified, it is essential that the surgeon have an idea which vessel was injured. Even without seeing into the chest, the surgeon should have an idea what was injured based on where the dissection had been just before injury. Pack the mediastinum. Notify your anesthesia colleague. Get blood into the room. Consider calling for vascular or cardiac surgery assistance. Almost invariably, another incision will be needed to get exposure for repair. A median sternotomy is not the best incision to use to fix the vessels injured during transhiatal dissection. A separate thoracotomy is most appropriate. Choose left or right based on what you think is injured. Rapidly close the abdominal incision or leave it covered, turn the patient, and get exposure. Then identify and control the bleeding using standard methods. If the inferior pulmonary vein is injured, it cannot simply be ligated because this will destroy the lower lobe. In addition, an open pulmonary vein risks serious air embolism. Position the patient’s head down until the injury site is controlled. As mentioned previously, intraoperative consultation with cardiothoracic surgery may be needed.
• Prevention
During transhiatal dissection, the surgeon must stay in the immediate paraesophageal plane, as shown in Figure 70-2. A nasogastric tube within the esophagus and downward countertraction to keep the esophagus straight are both very helpful. Alert your anesthesia colleague that you are starting the chest dissection. Begin the dissection posteriorly because this is often the easiest side of the esophagus to clear. Never persist with transhiatal dissection if the pathology forces you off the juxtaesophageal plane. If this is the case, convert to a thoracotomy approach. It will make for a longer case but will prevent disastrous consequences.
Splenic Injury
Injury to the spleen during esophagectomy requiring incidental splenectomy occurs with a reported incidence of 4.1% to 8.4%.5,6 Most commonly, the spleen is injured by traction on short gastric vessels during gastric mobilization that secondarily tear the splenic capsule. Occasionally, the spleen is directly injured by retraction. There are no data to support routine inclusion of the spleen as part of an esophageal resection for cancer. Although there are no data that splenectomy influences cancer recurrence rates,5 adverse consequences of splenectomy are well-described. It is, therefore, a complication that should be avoided.
• Consequence
• Prevention
Airway Injury
The trachea, carina, and main stem bronchi are in close proximity to the esophagus and are at risk for injury during esophageal resection (see Figs. 70-1 and 70-2). The trachea is oriented so that its weakest feature, its soft membranous wall, is immediately adjacent to the esophagus. The defenses of the membranous wall are further compromised when it is thinned and distended over an indwelling endotracheal balloon cuff. The reported rate of airway injury is unclear. Intraoperative injuries are identified and managed immediately. There is no reported series to indicate rate of injuries.
The membranous wall of the trachea is at risk for injury when encircling the esophagus in the neck during transhiatal cases (Fig. 70-3). The trachea and carina are at risk for injury while mobilizing proximal third esophageal tumors in the chest. The main stem bronchus, especially on the left side, is at risk for injury during transhiatal esophageal dissection. If the airway opening is proximal to the endotracheal tube (ETT) cuff, the surgeon will see the open airway; however, there should be no change in the patient’s cardiorespiratory status. If, however, the airway is opened distal to the ETT cuff, air escapes during positive-pressure ventilation leading to an urgently unstable situation.
![image](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/B9781416029519500876_gr3.jpg?w=960)
Figure 70-3 The membranous wall of the trachea is at risk for injury during mobilization of the cervical esophagus.
• Consequence
• Repair
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