Editing Oesophagectomy (section)

== '''Complications''' ==

* Death
** 30-day mortality 3.4%
** Overall 5-year survival      35-45%
* Major morbidity 33%
** RTT 15%
* Sepsis
** Could reflect ischaemia of      conduit if presents within first 2-3 days, and consider gastroscopy
*** This would dictate taking       down the conduit and doing a staged reconstruction
* Pneumonia 12%
* Chyle leak (check for     chylomicrons and triglycerides)
** Discontinue enteral feeds,      provide TPN
** If high outputs      (>2-4L/day), intervention may be indicated
** Otherwise TPN and mid-chain      triglyceride diet
* Leak 12.9%
** Risk factors
*** Inflammation
*** Shock
*** Hypoperfusion
*** Steroids
*** Nutritional status
*** Smoking
*** Alcohol consumption
** Investigation
*** Contrast CT
*** Evaluate with oesophagram       using WSC or CT
*** Gastroscopy might also be       helpful if careful - can determine viability of conduit
** Presentation
*** Usually becomes evident       within the first week
*** Cervical leaks       characteristically present on day 5 with wound erythema, drainage and       fever
*** Intra-thoracic leaks can be       more insidious, with low-grade fever, malaise and leucocytosis, but can       deteriorate to sepsis and multi-organ failure quickly
*** Other features - empyema,       mediastinal air, pneumothorax
*** Sepsis, excessive chest       drain output (turbid)
** Small leak contained or      appearing to drain back into the oesophageal lumen will usually heal      without intervention, if asymptomatic
** Small leak with no conduit      necrosis is likely amenable to drainage +/- stenting
** Larger uncontained leaks      require drainage
*** Sometimes open at bedside
*** But generally require OT
** Control leak
*** Operate -       refashion/repair/t-tube/divert/resect
*** Endoscopically manage -       endosponge and suction
*** Aggressively manage and       drain any pleural collections
** Persistent sepsis or      multiloculated collections need thoracotomy
* Conduit ischaemia
** Usually seen on CT or      gastroscopy
** Resection (conduit      take-down, debridement, return to abdomen), cervical oesophagostomy, and      reconstruction at a later date
** Focal necrosis may be      salvageable with debridement and flap buttressing
* Anastomotic stricture     (14-50%)
** Usually technical factors or      ischaemia
** Can be dilated or stented
** Balloon dilatation best      initially
** Recalcitrant strictures -      monthly dilatation +/- steroid injections
* Delayed gastric emptying
** Prevent intra-operatively      with pyloromyotomy, avoidance of intra-thoracic redundancy, and securing      the conduit to the edges of the hiatus
** Consider - lack of a pyloric      drainage procedure, obstruction at a tight hiatus, or a redundant      intra-thoracic stomach
** Promotility agents
** Can attempt balloon      dilatation of the pylorus
** UTD says don't routinely do      pyloromyotomy, but pyloric dilatation when necessary is extremely      effective
* GORD
** Common
** Lower anastomoses more      common
** Lifestyle measures
* AF
** Usually a/w leak or      pulmonary complications
* RLN injury
* Incomplete resection
** Even T3 R0 rates are >90%      in most published series
** Positive lymph nodes -      increased likelihood with stage and tumour volume
*** T1 5%
*** T2 30-40%
*** T4 80%
** Aim for a margin of 5cm at      both sides

[[Category:UGIS operations]]