8
The prevention and management of perioperative complications

https://doi.org/10.1016/j.bpg.2006.05.002Get rights and content

The most important issues in perioperative complications of oesophagectomy are prevention, early detection and appropriate management. Anastomotic leakage is the most frequent technical surgical complication. Prevention comprises avoidance of tension or impaired vascularization of the conduit and meticulous suture technique. Management includes early diagnosis, conservative treatment or endoscopic stenting of contained leakage, and re-operation of non-contained insufficiency. All other surgical complications – such as bleeding, tracheobronchial lesions or chylothorax – are rare and warrant special therapeutic modalities. The main general non-surgical complication is postoperative pneumonia, which should be prevented by effective pain control (especially peridural catheter) and appropriate techniques of artificial respiration. Special attention should be offered to postoperative tachyarrhythmias and alcohol withdrawal syndrome. Prevention of complications also includes exclusion of patients with high operative risk based on scores and specific preoperative treatment of risk factors.

Section snippets

Bleeding

Intraoperatively, anatomical dissection of large and small vessels during lymphadenectomy in the thorax or abdomen is mandatory to prevent uncontrolled bleeding. Vessels should be securely closed with suture ligation or properly placed clips. Special care is necessary in T4 carcinomas or after neoadjuvant radiochemotherapy because the tissue layers can be difficult to dissect and vessel walls tend to be vulnerable.16, 17 Small branches of the aorta can cause a problem in patients with

Bleeding

Postoperative bleeding in the chest or the abdomen has to be detected as early as possible. Puncture and aspiration under ultrasonic guidance can prove bleeding as the reason for the fluid collection. In the case of continuing bleeding, the patient should undergo re-operation as soon as possible. It is more important to avoid shock and multiple transfusions than re-operation. In case of revisional surgery, blood has to be washed out completely and bleeding has to be stopped definitely. However,

Summary

Apart from oncological problems, complications after oesophagectomy are the main issues for successful treatment of oesophageal cancer. Due to the frequent presence of considerable risk factors in patients with AC and the invasiveness of the surgical procedure, perioperative complications cannot completely be avoided. Therefore all efforts must focus on exclusion of high-risk patients and prevention or early detection of complications and their consequent treatment. It has been shown that

References (88)

  • J.D. Urschel

    Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review

    Am J Surg

    (1995)
  • M.B. Orringer et al.

    Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis

    J Thorac Cardiovasc Surg

    (2000)
  • J.M. Collard et al.

    Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy

    Ann Thorac Surg

    (1998)
  • T. Kita et al.

    Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma

    J Clin Anaesthesia

    (2002)
  • H.A. Cense et al.

    Association of no epidural analgesia with postoperative morbidity and mortality after transthoracic oesophageal cancer resection

    J Am Coll Surg

    (2006)
  • P. Michelet et al.

    Perioperative risk factors for anastomotic leakage after esophagectomy: influence of thoracic epidural analgesia

    Chest

    (2005)
  • R.J. Korst et al.

    Intrathoracic manifestations of cervical anastomotic leaks after transthoracic esophagectomy for carcinoma

    Ann Thorac Surg

    (2005)
  • B.P. Whooley et al.

    Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer

    Am J Surg

    (2001)
  • V.A. Anikin et al.

    Total thoracic esophagectomy for oesophageal cancer

    J Am Coll Surg

    (1997)
  • J.A. Crestanello et al.

    Selective management of intrathoracic anastomotic leak after esophagectomy

    J Thorac Cardiovasc Surg

    (2005)
  • D. Schubert et al.

    Endoscopic treatment of thoracic oesophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents

    Gastroint Endosc

    (2005)
  • S. Merigliano et al.

    Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation

    J Thorac Cardiovasc Surg

    (2000)
  • E. Bollschweiler et al.

    Preoperative risk analysis in patients with adenocarcinoma or squamous cell carcinoma of the oesophagus

    Br J Surg

    (2000)
  • E. Bollschweiler et al.

    Demographic variations in the rising incidence of oesophageal adenocarcinoma in white males

    Cancer

    (2001)
  • F. Fiorica et al.

    Preoperative chemoradiotherapy for ooesophageal cancer: a systemic review and meta-analysis

    Gut

    (2004)
  • I. Kaklamanos et al.

    Neoadjuvant treatment for resectable cancer of the esophagus and the gastrooesophageal junction: a meta-analysis of randomized clinical trials

    Ann Surg Oncol

    (2003)
  • B.P. Whooley et al.

    Analysis of reduced death and complication rates after oesophageal resection

    Ann Surg

    (2001)
  • P. McCulloch et al.

    Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicenter prospective cohort study

    BMJ

    (2003)
  • N. Ando et al.

    Improvement in the results of surgical treatment of advanced squamous oesophageal carcinoma during 15 consecutive years

    Ann Surg

    (2000)
  • S.F. Khuri et al.

    Determinants of long-term survival after major surgery and the adverse effect of postoperative complications

    Ann Surg

    (2005)
  • H. Bartels et al.

    Preoperative risk analysis and postoperative mortality of oesophagectomy for respectable oesophageal cancer

    Br J Surg

    (1998)
  • A.H. Hölscher

    Clinical management of oesophageal cancer in 2005

    Chinese-German J Clin Oncol

    (2005)
  • P.M. Schneider et al.

    Histomorphologic tumour regression and lymph node metastases determine prognosis following neoadjuvant radiochemotherapy for oesophageal cancer. Implications for response classification

    Ann Surg

    (2005)
  • A.H. Hölscher et al.

    How safe is high intrathoracic esophagogastrostomy?

    Chirurg

    (2003)
  • I. Gockel et al.

    Influence of splenectomy on perioperative morbidity and long-term survival after esophagectomy in patients with oesophageal carcinoma

    Dis Esophagus

    (2005)
  • J.B.F. Hulscher et al.

    Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus

    New Engl J Med

    (2002)
  • N. Altorki et al.

    Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus

    Ann Surg

    (2002)
  • T. Lerut et al.

    Three-field lymphadenectomy for carcinoma of the esophagus and gastrooesophageal junction in 174 R0 resections: Impact on staging, disease-free survival and outcome

    Ann Surg

    (2004)
  • Siewert JR & Hölscher AH. Eingriffe beim Ösophaguskarzinom und Eingriffe beim Adenokarzinom des gastroösophagealen...
  • J.D. Luketich et al.

    Minimally invasive esophagectomy. Outcomes in 222 patients

    Ann Surg

    (2003)
  • L.L. Swanstrom et al.

    Laparoscopic total esophagectomy

    Arch Surg

    (1997)
  • W. Schröder et al.

    Postoperative recovery of microcirculation after gastric tube formation

    Langenbecks Arch Surg

    (2004)
  • N.H. Boyle et al.

    Scanning laser Doppler flowmetry and intraluminal recirculating gas tonometry in the assessment of gastric and jejunal perfusion during oesophageal resection

    Br J Surg

    (1998)
  • J.P. Pierie et al.

    Impaired healing of cervical esophagogastrostomies can be predicted by estimation of gastric serosal blood perfusion by laser Doppler flowmetry

    Eur J Surg

    (1994)
  • Cited by (41)

    • Endoscopic vacuum therapy for anastomotic leakage after esophagectomy: a retrospective analysis at a tertiary university center

      2023, Surgery Open Science
      Citation Excerpt :

      The incidence of AL varies highly and is reported to up to 60%, however, the Esophagus Complications Consensus Group (ECCG) reported an incidence of 19% across 14 high-volume centres [4]. Consequences of AL are high morbidity and morality rates, a prolonged intensive care unit (ICU) and hospital stay, increased hospital costs and negative long-term outcomes such as long-time survival and quality of life [5–7]. Over the last two decades treatment of AL after esophagectomy has undergone an evolution.

    • Developing a toolbox for identifying when to engage senior surgeons in emergency general surgery: A multicenter cohort study

      2021, International Journal of Surgery
      Citation Excerpt :

      This may help explain why success with process-based interventions in elective surgery cannot simply be repeated in emergency surgery, a phenomenon seen in our patient safety program and others [6,23] A key difference between elective and emergency surgery is the time available for a thorough evaluation of patients for risk of possible adverse outcomes [24]. The preoperative stage is compressed in emergency general surgery, and the clinical judgment of an experienced surgeon is of great importance in making the treatment plan and detecting the patient's functional defects to minimize risk of operation-related and medical complications [25,26]. Therefore establishing a “green” pathway to have experienced surgeons handle the most life-threatening conditions would be important to drive improvement in emergency general surgery.

    • Systematic review of nasogastric or nasojejunal decompression after gastrectomy for gastric cancer

      2014, European Journal of Surgical Oncology
      Citation Excerpt :

      Some studies showed that risk factors for developing anastomotic leakage were ischemia, neoadjuvant therapy, comorbid conditions, splenectomy and pancreatectomy.32,33 It is also well established that inadequate vascularization and tension are major issues for leading to anastomotic leakage.34 Pulmonary complications are common after gastrectomy.

    • Omentoplasty in the prevention of anastomotic leakage after oesophagectomy: A meta-analysis

      2014, European Journal of Surgical Oncology
      Citation Excerpt :

      With only a minor modification of surgical technique, omentoplasty may pose a cost-effective and pragmatic solution to the problem of anastomotic leakage post-oesophagogastomy. It is regarded that a cervical anastomosis of stomach to oesophagus is placed under greater tension and imparts greater risk of ischaemia to the gastric conduit than thoracic anastomosis.12 This may go some way to account for previous reports of higher leakage rates in cervical anastomoses.13,14

    View all citing articles on Scopus
    View full text