| BACKGROUND:Esophageal resection is a demanding and complex procedure due to the massive bloodloss, with high rate of intraoperative and postoperative complications, including majorcomplications like pulmonary complications, anastomotic leakage, chylothorax,anastomosis stricture, laryngeal nerve palsy, delayed gastric emptying etc. Surgicalresection is the only effective approach for esophageal carcinoma and esophagogastricjunction. Esophageal resection and reconstruction still remains an inevitable challenge.Challenges of removing esophagus traversing3distinct anatomic zones in the body(neck, chest and abdomen) and reconstruction of the gastrointestinal tract has led to aconsiderable variation in technique. Although various kinds of instruments can be usedduring surgical procedure but there are many well-known risk factors for morbidity andmortality during esophageal resection, with poor long-term outcomes and adverse effectin the patient quality of life. Numerous variables including etiology of the disease,patients demographics, comorbidities, disease state, treatment variables, age criteria,gender, surgeons experience, preoperative variables and the surgical proceduresshould be considered when discussing operative complications.Aim:The aim of this clinical analysis was to clinically analyze the postoperativecomplications in radical resection of the esophageal carcinoma. To analyze andunderstand the main causes for the major postoperative complications and to study theeffective methods to minimize the postoperative complications.Objectives:To evaluate the complications after esophagectomy, to investigate the causes andreasonable methods to help prevent the complications to possible extent. Thisretrospective clinical analysis was done to conduct and evaluate the postoperative complications, factors effecting the complications, surgical approach, blood loss, totalhospital stay, duration of ICU stay and many other factors.Methods:From the period of December2009to December2012, total of211clinical patientsunderwent the procedure of radical esophagectomy: transthoracic esophagectomy(TTE-involving a thoracotomy) or transhiatal esophagectomy (THE-not involvingthoracotomy), with lymphadenectomy. The detailed necessary medical information forall the patients undergoing esophagectomy was noted. The median age was61.95years(range61.95±7.56yrs). In accordance with the histology, squamous cell carcinoma(SCC) in202cases (95.73%), adenocarcinoma (AC) in8cases (3.79%) and othercarcinoma in1case (0.47%) were noted. The clinical TNM staging, according to theUICC[6],were as following: Stage0-I15cases (7.1%), Stage IIa39cases (18.4%),Stage IIb46cases (21.8%), Stage IIIa87cases (41.2%), IIIb18cases (8.5%) and StageIIIc5(2.3%) cases. ASA class was assigned by the anesthesiologist after completing astructured review of physical status just before the surgery, and3cases of ASA1,123cases of ASA2,84cases of ASA3, and1case of ASA4were noted respectively. Theesophageal reconstruction was performed by the gastric tube in all the211patients, outof which patients undergoing Traditional Open Thoracotomy (TOT)(n=122) and VATS(Video Assisted Thoracic Surgery)(n=89) were noted. After the esophageal resectionwith the reconstruction of the stomach, the fundus of the stomach was then anastomosedwith the remaining normal esophagus stump, making a complete conduit allowing thelater delivery from the stomach to the thoracic cavity of the neck. In the211clinicalpatients, the esophagogastric anastomosis done by stapling technique is183cases, themanual suturing technique28cases. Out of which, the intrathoracic anastomosis bystapling technique were performed in183cases, cervical anastomosis by manualsuturing technique in28cases, and cervical anastomosis by stapling technique in47cases. Result:The median duration of the operations was307.53±79.59minutes (120to615min).Also the overall mean surgery duration for patients undergoing TOT was relativelyshorter than patients undergoing VATS(282.85±78.77min vs341.36±67.71min;p=0.036).The mean volume of blood loss was284.36±197.43ml (range40to1500ml),with mean volume of blood transfusion: RBC54.98±132.42ml and Plasma42.18±113.69ml. Patients undergoing VATS, the mean volumes of bleeding(207.19±143.85ml vs340.66±212.19ml, p=0.018) and blood transfusion (RBC29.21±106.82ml vs73.77±145.91ml, p<0.001; Plasma43.48±58.76ml vs63.11±137.99ml, p<0.001) respectively, were markedly less then patients undergoingTOT. The total number of patients who received blood transfusion were noted40cases(18.9%) and number of patients without blood transfusion were171cases (81.1%). Themetastases to lymph nodes were noted in84cases (39.8%). The median numbers ofresected lymph nodes were6-8(range12±2). Postoperative complications were seen in113cases (53.5%), with different complications. Two or more than two complicationsin48cases (22.7%). Out of the211clinical patients, pulmonary complications occurredin78cases (36.96%). Among which ARDS in4cases(1.8%), respiratory failure notedin5cases(2.3%), pulmonary lung infection in78cases(53.55%), pulmonary embolismin1case(0.4%), pulmonary edema in3cases (1.4%) and atelectasis in4cases(1.8%)respectively. Pulmonary complications were closely related with factors like elderly,gender, history of active smoking, chronic lung disease and operation durationexceeding5hours (all p<0.05). Also the postoperative pulmonary complications wasassociated with tumor occurrence site, with upper and mid-esophageal tumor beinghigher than the lower esophageal tumor site (p<0.001). Anastomotic leakage werenoted in18cases (8.5%), which was closely associated with the anastomosis site, withthe upper-aortic and post-aortic anastomosis site leakage rate higher than thelower-aortic anastomosis site leakage (p=0.02). Also the hand sewen or manualanastomotic leakage rate was seen to be higher than patients with mechanical staplingtechnique (p=0.001). Anastomosis Stricture was noted in7cases (0.3%), which was significantly associated with anastomotic leakage site (p<0.001). Chylothorax in7cases(0.3%) were noted, and occurrence of chylothorax after esophagectomy was seen to berelated with the site of tumor and the site of anastomosis (p=0.03; p=0.04) respectively.Recurrent Laryngeal Nerve injury occurrence rate was significantly associated withlymph node metastases (p=0.038) and TNM staging with mid-stage and late stagecarcinoma were relatively higher than early stage carcinoma (p=0.02), but had nosignificant association with the tumor occurrence site (p=0.26). The wound infectionwas noted in22cases (10.4%). The median postoperative hospital stays for all patientswere21.93days (range21.93±7.48d). Also the hospital stay for patients undergoingVATS was comparatively less then patients undergoing Open Thoracotomy (21.5±7.7dvs22.6±7.1d, p=0.02). The mean duration of the ICU stay was4.4±3.1d with rangefrom1d to19d. Also the duration of ICU stay in patients undergoing VATS wascomparatively less than patients undergoing TOT (4.6±3.4d vs4.3±2.8d; p=0.047).Themortality rate in the hospital was1.8%.Conclusion:Esophagectomy is a very complicated surgical procedure with a high rate of morbidityand postoperative complications, which could affect the surgical outcome and affect thepatients’ quality of life, but still is the main treatment for esophageal cancer. Thepostoperative complications are curable and preventable to certain extent withimprovement in anesthesia, strict and proper innovated surgical technique withenhanced and proper perioperative management. |
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