Complications
Complications are numerous post eosphagectomy,
however they can be broadly classified as early, intermediate, late and
Early
complications ( days 0 to 5) include
Poor urine output and low blood
pressure
This tends to be due to hypovolaemia.
Concealed bleeding should always be thought of, a CXR could be helpful. A CVP
line may be necessary. An adequate blood pressure is necessary, which may
require inotropic support, dopamine is a good first line therapy. Gross
vasodilation secondary to an inflammatory reaction or the effects of the
epidural may require noradrenaline.
Bleeding
This can be difficult to manage post
operatively, obvious heavy bleeding requires re-exploration. Clotting should be
corrected if grossly abnormal INR>1.8 and platelets <100.
Respiratory complications
These are common secondary to the
thoracotomy, pain, lung being collapsed for a long time, and underlying
pulmonary pathology. Nebulisers of salbutamol, atrovent, and saline, combined
with adequate analgesia and physiotherapy and in cases with secretions an a poor
cough the use of a nasopharyngeal airway or a minitrach. Persistent collapse may
require a bronchoscopy. Pleural effusions of moderate or larger size should be
drained with a large chest drain.
Medical comorbidity
These can obviously cause problems at
any time and include myocardial events, renal failure, neurological events,
respiratory distress, infection and bleeding problems with haematological
conditions and gastro intestinal problems
Intermediate
complications ( days 3 to 10) include
The septic patient
Obviously any cause is possible, but
check for lines, anastomotic leak, chest, wound and urine infection.
Pancreatitis should always be excluded.
DVT and PE
Obviously these are always possible and
should be always considered especially in a breathless patient of sudden onset
without an obvious cause. LMW heparin remains a good half way house as treatment
/ prophylaxis.
Medical comorbidity
See above
Late
complications ( days 5 to 10) include
Anastomotic leaks and new onset
atrial fibrillation
Anastomotic leaks are a constant
concern, and any suspicion should prompt the institution of nil by mouth and a
barium contrast study.
Atrial fibrillation occurs in between
10 and 20 % of cases. The possibility of a leak should always be investigated in
new onset atrial fibrillation.
Aspiration
This tends to occur just before the
patient is ready for discharge, they have started to eat larger amounts, in
common with a smaller gastric reservoir and delayed emptying aspiration is not
uncommon. Except in the most minor cases, urgent bronchoscopy is essential to
clean out the lungs before a chemical pneumonitis develops. The classical case
is to be called in the middle of the night to a confused hypoxic patient with no
history and an infiltrate on the CXR.
Chyle leaks
These usually occur within 1 to 2 day
of the resumption of oral feeding. They usually present with the onset of a new
pleural effusion. They can result in an enormous loss of protein and Ig G loss.
Fluid (normal saline or Hartmans) and protein ( human albumin) replacement are
essential as up to 3 to 4 litres can be lost in a day. A drain is needed to
reexpand the lung and prevent an empyema forming.
The decision on management depends on
the volume of drainage and its rate of reduction with conservative measures.
Conservative measures include Nil by
mouth, TPN, octreotide, and short chain fatty acid diet.
Operative measures include thoracotomy
or thoroascopic clipping of the thoracic duct. The side to operate on is usually
the side that the chylothorax has developed on. The preoperative administration
of cream may help in the peri operative identification of the site of chyle
leak.
The septic patient
See above
DVT and PE
See above
Medical comorbidity
See above
Post
discharge complications include
Benign stricture
Only diagnosed after an OGD has
eliminated recurrence with biopsy if necessary.
Recurrence
This can occur locally at the
anastomosis ( OGD best for diagnosis), in the mediastinum or abdominal cavity
(CT or PET best for diagnosis), or as metastasis (CT or PET for soft tissue and
bone scan for skeletal).
Dumping syndrome early and late
Early dumping syndrome is due to the
osmotic load of the food in the GIT causing relative hypovolaemia.
Late dumping is due to reactive
hypoglycaemia secondary to rapid absorption of small sugars from the GIT and a
relative excess of circulatory insulin.