32: Complications of Esophageal Surgery

There has been a huge increase in antireflux operations over the last two decades. The emergence of minimally invasive surgery has led to a widening of surgical indications for the operation. Reflux disease remains a functional disorder and it must still be assessed with objectivity if unequivocal evidence of mucosal damage within the esophagus is to be documented before indicating a medical treatment or a surgical approach. As hiatal hernias and reflux esophagitis have been closely associated over the last half century, complications in their surgical management will be treated together.

Preoperative Complications

Gastroesophageal reflux disease (GERD) is a pathologic reflux disorder that causes mucosal damage. The presence of symptoms suggestive of reflux without any mucosal alteration is considered a functional reflux disorder.¹ As all humans have physiologic episodes of reflux, the diagnosis, to be clear, must be based on objective criteria if a wrong diagnosis with its unhappy results is to be avoided. Operations should not be planned on the basis of symptoms, alone, as they bear little relationship to the degree of damage present in the esophagus. At a minimum, radiologic and endoscopic documentation of the disease must be obtained. Classification of damage using the MUSE (Metaplasia, Ulcerations, Stricturing, and Erosions) classification or the Los Angeles classification are considered objective as they only consider mucosal breaks in the esophagus to be evidence of damage (Table 32-1).

Complications during the Operation

Most of the antireflux operations completed today are by laparoscopic approach. The reported morbidity varies from 4% to 7% with a 0.1% mortality.² Morbidity, however, even if these new approaches have modified its prevalence, must be looked at independently of open abdominal, thoracic, or minimally invasive incisions. Open repairs, especially those utilizing laparotomy, are thought to produce more splenic trauma, primarily during mobilization of the gastric fundus for fundoplication or by simple traction on the omentum causing avulsion of adhesions on the splenic capsule. The open approach is also associated with a greater number of incisional hernias. However, the transition from open surgery to minimally invasive operations has not resulted in morbidity becoming part of the past. Looking at medical liability issues in Canada in 109 closed liability files allowed us to document that while 37% of these files before the era of minimally invasive surgery were related to antireflux operations, that proportion increased to 76% during the 15-year period following the appearance of the new approach. Central issues for complaint were mostly iatrogenic injuries incurred during the operation. Organ perforations (esophagus, stomach, small and large bowel) were the most frequent complications. Vagal nerve injuries were responsible for 7% of these files, whereas major vessel (vena cava, left hepatic vein, aorta, inferior pulmonary vein) injuries accounted for 8%. Splenic injury also remained a major source of intraoperative complications. These lesions emphasize the need for conversion readiness whenever immediate control of bleeding is needed. Although a 1% to 3% prevalence of splenic injury is reported during open repairs^3,4 in a much larger cohort of patients treated laparoscopically, the overall frequency of splenic injury was only 0.2%.⁵

Esophageal perforation results from blind dissection of the posterior intra-abdominal esophagus. Urschel⁶ reported it in 2% of operated patients. Zaninotto et al.⁷ reported the complication in 1% of patients with a minimally invasive approach. Dissection under direct vision with palpation when open, or careful visual mobilization during laparoscopy, should prevent the problem. When present, the traumatized organ must be repaired primarily, observing all the principles of esophageal perforation repair. Healthy tissue coverage over the repair is essential. Inadvertent gastrotomy or enterotomy usually results from inappropriate manipulation or from the excessive use of the cautery. In Urschel's report, gastroesophageal leaks occurred in 2% of open antireflux surgery and this increased to 8% if previous hiatal surgery had been completed.

Nerve injury to both vagal trunks can occur during the esophageal dissection or when constructing the fundic wrap around the esophagus. Reoperations are always seen as a major risk for vagal injury, especially those with a thoracic approach. When this occurs, delayed gastric emptying with gastric outlet obstruction can be expected. Pyloric dilatation or an eventual pyloromyotomy or pyloroplasty can be planned after a reasonable attempt at conservative management. Pneumothorax may occur when an abdominal or a minimally invasive approach is used, or when using a left thoracic incision, and consequently is part of the repair. Entry into the right chest through the middle mediastinum behind the heart is considered an important part of the operation for repair of the hiatus for both antireflux and massive paraesophageal hernia repairs. This ensures proper identification of the right diaphragmatic crus for proper suture positioning on both cruses behind the esophagus. The additional use of mesh is not indicated with this technique.

Postoperative Complications

Immediate: Intra-abdominal Infections

Complications resulting in fistula formation are rare but may result from unrecognized injuries during the dissection or from poorly repaired injuries during the operation. Thick stitches on the wall of the esophagogastric junction can produce similar results when transmural necrosis occurs at their level. Prolonged ileus and progressive abdominal or mediastinal sepsis must be managed aggressively by reoperation to obtain control of the contamination site. Emergency esophagectomy or gastrectomy may even be indicated to control the septic condition.

Bleeding, although rare, may result from direct injury to the liver or spleen or from poor hemostasis on the gastrosplenic vessels.

Early

Dysphagia following antireflux operations usually results from unmeasured tension exerted by the fundic wrap on the esophageal wall. Although dysphagia may be transient when influenced by postoperative inflammation and with the repair, it may persist over time if the tension exerted affects the integrity of the esophageal lumen. This is usually prevented by using a 48F or 50F bougie within the esophageal lumen during the repair. Severe dysphagia can also result from tight crural sutures behind the esophagus. This is rarely seen when the index finger passes easily between the newly repaired hiatus and the esophageal wall at the end of the repair. A total fundoplication made too long will result in the same obstructive effects. Reoperation becomes indicated if complete obstruction is present or if significant obstruction persists over time. Acute early herniation of the fundoplication or even major portions of the stomach may occur after complete dissection of the hiatus with division of the phrenoesophageal attachments. Tenuous suture repair of the hiatus with significant intra-abdominal pressure may simply push the stomach above the hiatus. This is seen mostly in obese patients or in patients who produce sudden pressure increases immediately after the operation. The presence of shortened esophagus, as seen with stricture or in patients with massive hernias or with a circumferential Barrett esophagus, is usually the result of a repair under tension if a standard antireflux operation has been used: early migration in the mediastinum is frequently seen in these patients.

Late

Failure of the antireflux repair over time may be secondary to wrap disruption or malposition of the wrap around the gastric smaller curvature. A slipped fundoplication from a periesophageal position to a perigastric position creates an hourglass stomach with reflux symptoms and dysphagia. Pressure of the fundoplication on a tightly closed hiatus may produce this complication, especially if the wrap has not been fixed to the esophageal wall and if the esophagus is shortened. Complete transhiatal herniation of the wrap usually results from a deficient hiatal repair or from an esophagus shortened by disease. If a partial fundoplication has been completed, reflux disease will result with the fundoplication in the chest. If a total fundoplication has been used, it may still offer good reflux control even if in the mediastinum. Proper gastric drainage is important in that situation and the hiatus must be widely open to allow easy emptying of the herniated stomach.

Complications Related to Massive Hernia Repair

Massive paraesophageal hernias show a failure rate of 10% to 18% when an open abdominal approach is used. Maziak and Pearson^8,9 when using an elongation gastroplasty reported a recurrence rate of 4%. Laparoscopic repair of paraesophageal hernias shows an early recurrence rate of 15% to 66%. The three significant aspects of massive hernia repairs that are still open to discussion in the surgical literature are: first, the notion of esophageal shortening, second, the prevalence of reflux disease and its evolution and third, the large hiatal defect. These three factors are probably influential in the early failure rate of the operations selected to treat them.

Primary esophageal dysfunction is seen at the pharyngoesophageal junction or on the esophageal body and at the esophagogastric junction. Cricopharyngeal myotomy is the preferred treatment offered to patients with oropharyngeal dysphagia of various causes. Esophageal body myotomy and the modified Heller myotomy aim at controlling symptoms resulting from primary esophageal motor disorders. These operations, even if successful in the majority of patients, can be responsible for significant morbidity and even mortality.

Operations on the Pharyngoesophageal Sphincter

Idiopathic Oropharyngeal Dysphagia

This form of idiopathic dysphagia affects the cricopharyngeus but has no neurologic or muscular condition to explain it. It is seen as an obstructive upper esophageal sphincter by itself or accompanied by its complication, the pharyngoesophageal or Zenker diverticulum. The cause for the muscle abnormality resulting in this constrictive and obstructive condition remains unknown. In the previous era, when no antibiotics were available, it was considered a treacherous problem where inflammation, perforation, mediastinitis, tracheoesophageal fistulas, and carcinoma formation could be expected when untreated. These complications are rarely seen today. Still, 61% of patients treated today complain of dysphagia and 17% mention aspiration episodes and pulmonary symptoms.¹⁰ Complications at operation for Zenker diverticulum may first be related to poor exposure. We prefer an incision along the anterior border of the sternocleidomastoid muscle, which allows wide exposure of the pharyngoesophageal junction. Small oblique incisions along the skin lines are limiting. These incisions were used in all the patients presenting with an incomplete myotomy that had failed to improve the oropharyngeal dysphagia.¹¹ Sacrifice of the superficial branch of the cervical cutaneous nerve results in hypoesthesia and paresthesia of the ipsilateral submandibular area. This may subside over time.

The diverticulum, if large, is usually visualized under the buccopharyngeal fascia, the fibroareolar tissue covering the posterior pharyngoesophageal junction. As the majority of the diverticula seen today are smaller than 3 cm, they can be easily missed if this fascia is not opened, allowing protrusion of the diverticulum. Once exposed, its tip is seized with a small Duval clamp and lifted to allow the safe insertion of an intraesophageal bougie. This bougie serves as a stent to support the myotomy, while also protecting the esophageal lumen integrity. As diverticulectomy alone for a Zenker has been reported to result in a high recurrence rate over time, a myotomy or myectomy of the pharyngoesophageal junction is considered the essential part of the treatment whereas diverticulectomy or diverticulum suspension is seen as treatment for the complication of the dysfunction.

Mucosal perforation during the myotomy is usually recognized and repaired using small resorbable sutures. When the diverticulum is resected, the endoluminal bougie is there to prevent narrowing of the esophageal lumen during the resection. The resection line is usually made transverse. When the diverticulum is suspended, its tip is usually tied to the transected muscle margin of the hypopharynx. Fixation to the prevertebral fascia has been seen to cause fasciitis and osteomyelitis as the sutures made through the tip of the diverticulum are considered contaminated. To be complete, a cricopharyngeal myotomy must include the fibers of the inferior constrictor of the pharynx, the cricopharyngeus, itself, and a small portion of the cervical esophagus musculature. The cut margins of the myotomy must allow outpouching of the mucosa over 50% of the circumference to avoid reclosure of the myotomy.

Postoperative complications may be significant. This is not only related to the technique, but also to age as a majority of those patients are elderly and frail. Wound infection and fistula formation are the most frequent complications seen. For a one-stage diverticulectomy, the reported infection rate was 3%, with half of these patients showing a fistula. In our own experience, with close to 100 patients, infection was the most frequent complication. The fistula rate was 1.5%. The Mayo Clinic experience suggests a recurrent nerve palsy in 3% of their 888 patients.¹² When reoperated, however, patients can expect the morbidity to increase to as high as 20%, explained by a more difficult mobilization of structures. When a fistula occurs, wide drainage of the wound is preferred as a first step. If there is no spontaneous early closure, a pedicled muscle flap of the sternocleidomastoid muscle is used to repair the fistula.

Recurrences were seen in 7% of Payne's experience with 164 patients followed 5 to 14 years. Nicholson¹³ in a radiologic follow-up of 20 patients showed that 13 had a recurrent pouch. Hansen et al.¹⁴ saw recurrences in 3 of 19 patients, Bertelsen and Aasted¹⁵ in 14 of 68 cases, and Einarsson and Hallen¹⁶ in 17 of 20 patients. Pouch formation probably develops over a significant period of time. This emphasizes that long-term radiologic documentation is necessary if objective results are to be obtained. When only cricopharyngeal myotomy is offered to treat the diverticulum, less than satisfactory results are found in patients in whom a small but dependent pouch persists.

Endoscopic esophagodiverticulostomy had initially been popularized by Dohlman using coagulation and, later, using laser to create a single lumen between the diverticulum and the cervical esophagus.¹⁷ The use of surgical linear staplers has gained popularity in recent years. Initially proposed for high-risk patients, it has now been used in large reported series. Although clinical results seem less satisfactory, the complication rate is low. Decreased operating time and avoidance of recurrent nerve injury are often proposed as advantages. Chang et al.¹⁸ report a 2% complication rate without mortality. These include dental complications (7%), fever (4%), aspiration pneumonia (0.7%), and esophageal perforation (0.7%). Transient cord paralysis was seen in one patient. Case and Baron¹⁹ reported minor bleeding in 23%, perforation in 27%, and neck abscesses in 4.5% of treated patients.

Neurologic, Myogenic, and Idiopathic Dysphagia

Table 32-2 describes the morbidity and mortality resulting from cricopharyngeal myotomy for indications other than Zenker's diverticulum. With proper selection, significant improvement in oropharyngeal dysphagia can be obtained.

Although in neurologic patients the dysphagia is usually related to poor coordination between swallowing, pharyngeal contraction, and upper sphincter relaxation, patients with muscular dysphagia have symptoms resulting from poor pharyngeal contraction and propulsion with incomplete sphincter opening. Adequate symptom documentation and quantification with videoradiologic assessment are essential for appropriate patient selection. Complications related to the myotomy in these patients are less frequent than in Zenker's patients. Mucosal penetration, although frequent, is rarely followed by infection or fistula formation. Campbell et al.,²⁰ however, report pharyngeal leaks in 8% of their patients. In our experience, primary repair with resorbable sutures or a pedicled muscle flap is usually satisfactory to prevent this complication. Persistent aspiration with pulmonary complications may have to be approached by a permanent tracheostomy with laryngeal diversion or resection. Mortality was seen mostly in the muscular dysphagia group (4%) and is always secondary to severe lung infection.

Operations on the Esophageal Body and the Lower Esophageal Sphincter

Achalasia

Achalasia is the most frequent and best described esophageal motor dysfunction. The diagnostic criteria are well established and recently three types of the same abnormalities were proposed to classify these dysfunctions.²¹ A wrong diagnosis remains a possibility as a number of medical conditions can mimic this primary disorder clinically, radiologically, and manometrically. Pseudoachalasia by an obstructive subcardial lesion must especially be ruled out before reaching the diagnosis. A comprehensive approach to investigation is essential to allow an objective diagnosis in all patients and prevent misdirected therapy.

Preoperative Complications They are related primarily to the consequences of esophageal retention/obstruction. Aspiration pneumonia was reported in 10% of patients by Ellis and Olsen²² and Clouse and Lustman,²³ whereas Effler et al.²⁴ observed nocturnal aspiration in 24% of their patients and Black et al.²⁵ in 46%. Olsen²⁶ reported a 10% incidence of pulmonary infection in their series, including a chronic form of mycobacterial infection suspected to be caused by the fatty supernatant found frequently in the achalasic esophagus. Acute airway obstruction may require rapid intubation. This is seen mostly with end-stage achalasia. One of the dreaded complications is massive aspiration during the induction of anesthesia. Allen and Clagett reported that one of the two deaths in their series resulted from that complication.²⁷ Whenever an esophagus is dilated with documented retention, a safe approach remains a liquid diet for the days preceding the operation, emptying and lavage of the esophagus the morning of the operation, and awake intubation by the anesthetist before the induction of anesthesia.

Intraoperative Complications These are related to the technique and to the type of approach selected. Even to this day there is no consensus on what an ideal myotomy for achalasia should be. The modified Heller myotomy in use today varies significantly in length on the esophagus and in its extension on the gastric wall. Independent of the surgical approach selected, the principles for treatment should be identical: remove the obstructive effect of the lower esophageal sphincter. The ­overall mortality reported varies between 0.7% and 2.8% with smaller series showing a higher mortality.²⁸ Mucosal perforations during the myotomy are usually inadvertent and immediately repaired using resorbable sutures. Andreollo and Earlam²⁹ documented mucosal penetration in 1.1% of their review of over 5000 myotomies. This led to a fistula and empyema in 0.4% of all patients. Moreno González et al.³⁰ found a similar prevalence in their European study. In most large series, the morbidity is related to mucosal penetration. Ellis³¹ reported it in 25 of their 262 patients whereas Okike et al.³² observed leaks and sepsis in 1% of their 468 patients. Repeat myotomies are at higher risk of mucosal damage.^33-35 Little et al.³⁶ proposed a posterior myotomy in this situation to improve the safety of the operation. Mortality in surgery for achalasia is usually the immediate consequence of fistula formation and sepsis. In view of the severity of this technical mishap, added protection after the repair is indicated with the use of a partial fundoplication, or pleural or muscular flap, depending on the level of the mucosal damage in the myotomized area.

Persistent dysphagia immediately after the operation usually results from an incomplete myotomy.³⁷ Reoperation gives satisfactory results in 75% of the group.

Paraesophageal hernias are usually the result of a disrupted hiatus after the operation. This complication has been reported frequently in open surgery series.^38-41 Immediate reoperation is indicated to prevent complications on the herniated stomach or on the mucosa denuded of its muscularis. Anatomic restoration of the hiatus with a partial Belsey-type fundoplication should allow a proper seal of the abdominal cavity from the chest.

Late Complications Complications can result from altering the function of the lower esophageal sphincter;^38-41 or when esophageal body dysfunction is not modified by the operation and aperistalsis persists; an insufficient myotomy fails to relieve dysphagia; or adequate sphincter division exposes to the possibility of reflux disease.

When dysphagia recurs 6 months to 1 year after the operation, this usually suggests healing of the myotomy.^31,42 The absence of esophagitis at endoscopy with a competent lower esophageal sphincter on manometry and at endoscopy suggests either rehealing or an incomplete myotomy. Difficulty in identifying the myotomy zone at the operation usually confirms that impression. Periesophageal sclerosis with hyalinization also has been reported by Fekete and Lortat-Jacob³⁷ and Peracchia et al.⁴³ Recurrent dysphagia is also seen with late-stage achalasia. Esophageal cancer must be ruled out.

Reflux esophagitis and stricture are the most frequent complications of the modified Heller myotomy. Extension of the myotomy on the gastric wall is considered important but if the myotomy extends more than 2 cm on the stomach, reflux disease will result in all patients.^44,45 Reflux disease increases with the passage of time: 24% at 1 year, 48% at 10 years, and stabilization at 52% after 13 years. At that time, 19% of patients present with a stricture. The more objective the evaluation, the higher the prevalence of reflux complications on the esophageal mucosa. Failed myotomies are predominantly caused by peptic esophagitis. Long-term reflux exposure may induce the appearance of columnar-lined metaplasia with its related morbidity. Ulcerations, fistulas, strictures, perforations, and malignant transformation may ensue if the condition goes untreated.

Diverticulization of the myotomized esophagus is another potential problem. The longer the myotomy on the esophageal body, the higher the chances of observing progressive diverticulization of the mucosa through the myotomized area. This has been observed in over 60% of patients with a long myotomy. It happened in patients with a total fundoplication at the end of their myotomy but also in those who had a partial fundoplication of the Belsey type.^46,47 We have now reduced the length of the myotomy to 4 cm, when the lower esophageal sphincter alone is divided. Extension on the stomach is 2 cm. The myotomy zone is then completely covered by the partial fundoplication. Dysphagia is well controlled, the denuded mucosa is protected, but reflux control remains imperfect.

The advent of minimally invasive operations has significantly influenced the management of achalasia patients. This approach, however, must respect the same principles for treatment. The same objective reassessment must take place to rule out the complications that have been documented in open surgery series. Achalasia patients are at increased risk of developing a cancer. This risk is about 140-fold than that of the general population.⁴⁸ This has not been modified by cardiomyotomy. When achalasia is untreated for more than 20 years, the esophageal mucosa irritation by the stagnant and putrescent food is seen as increasing the risk for transformation significantly.⁴⁹ Once treated by myotomy, 1.5% to 2.2% of the patients can be expected to develop an esophageal cancer.^50,51

Spastic Disorders

Spastic or hyperdynamic esophageal disorders include diffuse esophageal spasm, hyperperistalsis, and the hypertensive lower esophageal sphincter. The importance of obtaining an objective and reliable diagnosis cannot be overemphasized. A wrong diagnosis and a wrong orientation in treatment are bound to produce poor results.⁵²

The high strung personality in these patients requires special care and evaluation. Following psychological evaluation and treatment with calcium channel blocking agents and anxiety medication, endoscopic botulinum injection can be considered.⁵³ Surgery is never a first approach in treatment. When an epiphrenic diverticulum is present, most patients are found to have an associated spastic disorder. Treatment in that condition must be similar to that of achalasia. Division of the lower esophageal sphincter must accompany the esophageal body myotomy to the upper level of the diverticulum as the lower sphincter shows intermittent abnormal relaxation. Failure to extend the myotomy on the stomach wall may result in significant morbidity and even mortality, especially if a diverticulectomy has created a suture line on the esophageal body.⁵⁴ The complications of myotomy for spastic disorders are similar to those seen and reported for achalasia.

Injury to the esophageal wall may result from multiple causes. Those have been summarized by Bladergroen et al.⁵⁵ in their series: 55% are iatrogenic, 15% are spontaneous or postemetic (barotrauma), 14% are secondary to foreign-body impaction and/or transgression, and 10% are seen after a trauma. Five to seven percent of esophageal perforations are associated with the evolution of an esophageal pathology. Trends in survival have improved over the last 50 years, mainly the result of earlier diagnosis and treatment as well as improvement in intensive care management. However, the overall mortality remains high at 22% and is still significantly influenced by the delay in diagnosis.⁵⁶ Thoracic esophageal perforations result in a 20% to 30% mortality if the repair is completed within the first 24 hours after the rupture. The mortality exceeds 60% when more than 24 hours have passed since the perforation. Extensive mediastinal contamination by the buccopharyngeal flora is usually responsible for the rapid progression of pain, sepsis, and shock. For these reasons, procrastination in the investigation and management of these patients can only lead to uncontrollable sepsis and mortality. Treatment of mediastinitis requires correction or removal of the cause. Surgery is urgent, especially if best supportive care does not result in stabilization and improvement. For these reasons, in patients remaining septic after a delay in diagnosis of more than 72 hours, resection of the perforated esophagus with creation of a long parasternal esophagostome with gastric decompression and feeding jejunostomy has been shown by Gouge et al.⁵⁷ to be a safe and life-saving approach. Esophageal replacement is best delayed for when the patient is well recuperated from these events.

Complications after Primary Surgical Repair

Esophageal perforations require thorough cleaning and debridement of contaminants and necrotic tissue in the mediastinum. With the pleural contamination and empyema resulting from complete decortication one must permit full reexpansion of the pulmonary parenchyma. Once the esophagus is freed from its mediastinal attachments, the perforated area is inspected and debrided of all damaged esophageal muscle. The muscular layer must be myotomized to clarify the length of the mucosal laceration underneath. Once all layers of the esophageal wall are clearly identified, a single-layer repair of the esophageal wall is preferred using large resorbable sutures positioned with a distance of 0.5 cm from each other. As this repair is completed in a contaminated field, coverage protection with a muscular flap, thickened pleura, or healthy gastric fundic tissue is indicated. Gouge⁵⁷, in his review, documented that persistent sepsis and fistula formation occurred in 39% of all patients when the repair was completed without any buttressing. The mortality resulting was then 25%. If the same repair without coverage is made in patients with a late repair, persistent leaks and sepsis will be seen in 50% of treated patients. When the added protection of a well-vascularized muscle flap or fundic tissue is added, the documented fistula formation is reduced to 13% and the mortality to 6%. Richardson⁵⁸ reports persistent leaks in 17% and a mortality of 1.5% when the primary repair is covered with the added protection of a pleural or muscle flap. In those patients with a delayed diagnosis or a perforation related to esophageal disease, 13 of 14 patients undergoing an esophagectomy had excellent results. Vogel et al.⁵⁹ reported treating 47 patients with aggressive drainage of collections and frequent radiographic studies using gastrografin and computerized tomography documentation of the evolution. Two of 37 patients with thoracic perforations died but 34 patients were considered healed at discharge without operative treatment. Wright et al.⁶⁰ reported on 28 patients receiving either early or late treatment. All had reinforced primary closure. None of the patients treated early died and two showed a contained leak. Among those 13 receiving late treatment, 7 leaks occurred and 4 deaths resulted.

Alternative methods of treatment result in high morbidity and mortality: pleural drainage 43% to 66%, esophageal exclusion 35% to 42%, T-tube directed fistula with drainage 36% to 50%. Esophageal exclusion entails a complex reconstruction. More recently Linden et al.⁶¹ treated esophageal perforations in 43 patients with the use of T-tube drainage. Their observed morbidity was 47% with a mortality of 7%. If the condition was treated early, the mortality was 5%. If the diagnosis was delayed, it was 8.7%. If treatment was offered in less than 24 hours, the morbidity was less than 20%. This increased to 42% when the diagnosis was obtained between 24 and 72 hours, and to 82% if later than 72 hours.

A number of reports on endoscopic management of esophageal perforations have appeared in the literature with the appearance and popularity of self-expanding stents as an additional tool to help palliation and treatment of esophageal disease.⁶² Most published series, however, where stents are used to treat perforations are either for instrumental perforations or for postoperative fistula formation. Metallic stents must be fully covered to allow removal once healing is complete. Uncovered stents lead to progressive esophageal wall encrustation and they cannot be removed later. In a contaminated cavity, metallic stents also have been reported to erode into major vessels. The potential advantages of covered stents remain the reduction or elimination of the contamination, the possibility of better nutrition if the damaged area is well sealed, and the return to a normal healed structure after removal of the stent.⁶³

External trauma to the esophagus may be difficult to document on account of the presence of associated conditions. Delays that usually result might explain the overall complication rate of 47% to 53% and 7% to 19% mortality reported from major trauma centers.⁶⁴

Caustic Injury

Whether accidental or self-induced, ingestion of caustic agents may result in significant damage to the esophageal wall. Type and concentration of the agent and duration of the exposure will influence the extent of damage.

Alkali Agents

Sodium hydroxide causes liquefaction necrosis of the esophageal mucosa with rapid diffusion through the esophageal wall within 30 seconds of the exposure. Cell destruction with inflammation and vascular thrombosis follows. Secondary bacterial invasion supervenes. Necrotic tissue sloughing results in granulation deposition and chronic fibrotic strictures. The constant deposition of fibrous tissue is responsible for lifelong strictures.

Acid Agents

Strong acids (sulfuric, sulfanic, nitric) when exposed to the esophageal mucosa cause rapid coagulation of tissues on contact. Prolongation of the exposure results in deeper damage that may progress to transmural inflammation, necrosis, and perforation. With the ingestion of strong acids, as the longer exposure is frequently in the stomach, distal gastric wall damage is often documented as the end result of the exposure.

The ingestion of solid or liquid lye results in the greatest morbidity. Progressive and recurrent esophageal strictures with malnutrition and chronic aspirations are seen frequently. Normal esophageal function is lost.²⁴ Ten to twenty-five percent of patients present with chronic strictures requiring treatment. The liquid form of lye causes the worst damage. Anderson et al.⁶⁵ documented that no benefit can be expected from the use of corticosteroids to prevent damage. When initial assessment reveals mucosal necrosis and ulcerations, acute mediastinitis will be present in 20% and up to 15% of esophageal perforation will occur. The mortality approximates 5% and is usually related to extensive necrosis requiring total esophagectomy and total gastrectomy. Esophageal cancer may develop 30 to 40 years after the insult: its incidence is 1000 times greater in lye stricture patients when compared to the general population.^66,67 The severity of the stricture will usually be the indication for an esophageal resection with reconstruction using either the stomach or the colon.

Foreign Bodies

Food impaction is the most frequent cause for obstruction by a foreign body seen in adults. Some materials may be pointed or sharp and perforate the esophageal wall. Usually the impaction and subsequent damage will result from pressure and progressive erosion and ulceration through the esophageal wall. The fragility of the wall with the inflammation and relative ischemia may explain the ease of instrumental perforation when attempting to extract these impacted boluses.

When a foreign body remains impacted in the esophagus or progresses into the stomach cavity after impaction, 40% of patients will show an esophageal injury. With persistent impaction, superficial lacerations are seen in 28%, deeper wounds in 9%, and perforations in 4%. When the impacted bolus has progressed into the stomach, lacerations are still seen frequently but perforations are rarely documented. When bones are part of the impacted bolus, more injuries occur (76%) and perforations are seen more often (8%). Pure food impaction is considered as less threatening.

Endoscopic extraction is usually followed by radiologic control of the esophageal wall integrity. Wide-spectrum antibiotics are administered if there is any doubt of mediastinal contamination. Rapid initiation of treatment, with or without stent installation, is mandatory as soon as a perforation is documented. Close monitoring may dictate a surgical approach with a reinforced repair of the damaged area if the contamination area is not controlled and results in sepsis progression.

Esophagectomy is the most extensive operation performed in thoracic surgery. The risks related to the operation parallel its importance. Complications related to the underlying condition will not be considered here. Difficulties, morbidity, and mortality resulting from the operation itself are to be considered.

Preoperative Complications

Besides the natural evolution of conditions indicating an esophagectomy, especially when a malignancy is present, a number of key points should be considered if morbidity and mortality are to be anticipated and prevented.

Patient Selection

A good general condition with an adequate cardiopulmonary reserve is essential. Patients who have lost more than 10% of their body weight rapidly are at risk of morbidity, especially if already debilitated. Patients in their eighth decade, even if well in appearance, have a limited capacity to react to any form of trauma or complication. Heavy smokers should help themselves by complete abstinence from tobacco before the operation. Complications in these patients are not limited to the high risk of lung infection. Risks to the vascular supply of the interposed organ to be used as replacement must be part of the informed consent given to the patients. Catastrophic necrosis of the proximal stomach is seen mostly in this category of patients. In our multi- and univariate analysis of complications following esophagectomy, tobacco smoking remained the most significant risk factor resulting in pulmonary and vascular complications to the interposed stomach. A number of studies looking at risk factors and risk factor scores in patients undergoing esophagectomy have been published.^68–72

Hospital Volume

This is considered an important aspect to be considered by those interested in the management of esophageal diseases. Esophagectomy is a complex operation that should not be completed by a surgeon who can realize it only occasionally. Begg et al.⁷³ reported that whenever esophagectomies are completed by a surgeon who does fewer than five per year, the hospital mortality approximates 17%. This mortality decreases to 3.4% in high-volume hospitals.⁷⁴ These facts have led to regionalized care in many countries.

Operative Complications

Esophagectomy can be completed through a number of approaches (see Chapters 12-22). Complications during the operation can occur in the abdomen, in both chest cavities, or in the neck. In the abdomen, splenic injury may occur by either simple traction on the greater omentum during exploration or during the mobilization of the gastrosplenic vessels for the preparation of the gastric interposition. Conservative measures are used first for splenic conservation, as the bleeding lesion is usually limited to the capsule. If significant bleeding persists at the completion of the operation, a splenectomy is preferred. Mobilization of the stomach and duodenum may result in injury of the head of the pancreas. And if extensive node dissection is carried along the celiac axis, on the superior border of the pancreas, injury can occur as well, resulting in postoperative pancreatitis. If any damage is suspected, peripancreatic drainage is advisable. An extramucosal pyloromyotomy is usually completed to favor better gastric emptying. Once the mucosa is freed, the horizontal muscular layer is reapproximated vertically to insure pyloric enlargement. Mucosal penetration is rare but usually occurs on the anterior recess of the duodenal mucosa. If this is seen, the myotomy is transformed into a formal pyloroplasty closed by a single layer of separate sutures then covered by an epiploplasty.

A feeding jejunostomy is added in all esophagectomy patients as insurance against either potential complications or to prevent any malnutrition especially during the readaptation period after esophagectomy. The jejunostomy is created with a no. 18 t-tube installed on the antimesenteric border of the first jejunal loop. It is exteriorized and secured in a left paramedial position. Feeding is usually started on the third or fourth day after the operation when active peristalsis is heard. Resection of the diaphragmatic hiatus is considered part of the esophageal resection. The left pleura is frequently opened during this part of the procedure. Drainage of the left chest cavity is performed as insurance against the development of pneumothorax and for the prevention of pleural effusion which is frequent after resection. Complications during the thoracic part of the operation require attention to the azygos and hemiazygos veins especially if a modified radical resection is preferred where all intercostal veins are dissected and ligated to remove the vein “en bloc” with the thoracic duct and the adventitia of the aorta. Other risk areas for operative complications are injuries to the membranous trachea and bronchi, for example, the left recurrent laryngeal nerve lying deep in the mediastinum while the retrotracheal esophagus is dissected and the thoracic duct emerging behind the right crus of the diaphragm with some branches lying occasionally on the adjacent vertebral bodies. Most of the life-threatening vascular injuries (1.4%) have been reported during transhiatal esophagectomy (see Chapter 16).⁷⁵ Dissection in the left neck is frequently completed with resection of the left clavicular head in continuity with the manubrium and first rib. Once the deep cervical fascia is opened, the esophageal remnant is easily accessible if mobilization of the esophagus has been completed in the right chest. Safe and careful dissection of the left recurrent laryngeal nerve is usually completed under direct vision.

Postoperative Complications

Early Complications

Cardiac Complications These are mostly supraventricular arrhythmias and myocardial infarctions. This is recorded in over 35% of operated patients. Patients with ischemia on preoperative evaluation must be treated before proceeding to esophagectomy.

Pulmonary Complications These are mostly infectious and related to atelectasis and pneumonia. The respiratory distress syndrome with respiratory insufficiency is seen mostly in patients who have received neoadjuvant chemoradiotherapy. Prevention of atelectasis by early mobilization, physiotherapy, and aggressive tracheobronchial toilet is essential. This has been helped significantly by offering epidural analgesia for the postoperative period until the chest tubes are removed. Gastric tube decompression is insured to prevent tracheobronchial aspiration as gastric interposition is recognized as a free duodenogastroesophageal reflux model. Absent gastric retention and active peristalsis signal removal of gastric drainage. If significant restriction of pulmonary function has been documented, the transhiatal approach is preferred to limit the after effects of thoracotomy.^76,77

Anastomotic Complications Leakage at the anastomosis is always feared after esophagectomy. An intact repair depends on a good vascular supply to the esophageal remnant and to the stomach. Faulty anastomosis, when not technical, is usually the result of poor vascular supply to the proximal part of the stomach. The absence of tension on the reconstruction and healthy transection margins are the other conditions essential to good healing of the anastomosis. When this complication occurs, it causes mediastinitis, pleural contamination, and empyema. The leak rate in the chest seems less frequent than when the anastomosis is in the neck.^78-80 Orringer et al.⁸¹ report a less than 3% leak rate for cervical anastomosis. Although leakage in the neck usually requires wide drainage, leakage in the chest may require a more aggressive approach, especially if it is documented within 48 hours of the operation. This usually means necrosis and dehiscence of the anastomosis which then must be reconstructed immediately if mobilization and transplant quality are there. Sepsis and pneumothorax during the initial postoperative week also suggest disruption of the reconstruction or a vascular complication of the transplant. Reexploration to correct the situation is essential. Repositioning of the stomach in the abdomen and an esophagostome may be necessary. If the leak at the anastomosis is small and contained, a positive evolution can be expected. If, however, significant ischemia and necrosis are present on the proximal stomach, meticulous assessment of the available viable tissue is necessary before deciding if repair must be attempted, usually with a pedicled muscle transplant, or, if a more complex reconstruction must be planned at a later date. For smaller leaks, the use of self-expandable completely covered stents may help in sealing the leak and allowing more rapid healing of the defect.^82,62

Chylothorax

The prevalence of thoracic duct injury during esophagectomy is approximately 2%. It is reported as more frequent if esophagectomy is completed without thoracotomy.^83,84 Centers recognized for a high esophagectomy volume and experienced with this approach do not confirm this. Early management of large chylous fluid drainage may require temporary intravenous hyperalimentation. Nutritional and immunologic depletions are the disturbing consequences of prolonged conservative management. In their review of the problem, Wemyss-Holden et al.⁸⁵ report a mortality rate of 50% to 82% when a conservative approach is maintained. A more aggressive management is suggested by Lagarde et al.⁸⁶ If a high daily output persists despite 2 days of optimal conservative therapy, mass ligation of the thoracic duct is advised. We proceed with rethoracotomy over the ninth rib if chest drainage of more than 1000 mL per day persists for more than 5 days.

Recurrent Nerve Palsy

Injury to the left recurrent nerve may occur during exposure of the cervical esophagus in the left neck or during dissection of the esophagus in the chest.⁸⁷ In the neck, undue traction or compression results in left vocal cord paralysis. The immediate consequences are significant difficulties in obtaining a successful tracheobronchial toilet. The nonapposition of the cords reduces the efficacy of coughing and increases the risks of pulmonary infection. Oropharyngeal dysphagia may occur later with secondary aspirations. Adaptation, however, will usually result in improvement of the symptoms.

Late Complications

Technically, reconstruction with an end-to-side circular stapler has been shown to cause more strictures, possibly because of the mucosal gap present between the esophageal squamous epithelium and the gastric mucosa after the anastomosis. Strictures are seen mostly if there has been a leak or an infection at the anastomosis level. These strictures may also result from infection around the anastomosis, even if no fistula has become manifest. Early endoscopy with guided dilatation is a safe approach and offers good control of early dysphagia. Over time, narrowing of the anastomosis may also be the result of gastroesophageal reflux affecting the esophageal remnant. This is usually diagnosed by endoscopy as the symptoms are not as typical as in patients with idiopathic reflux disease.⁸⁸

Delayed gastric emptying results from gastric denervation. The pylorus is usually widened by pyloroplasty or pyloromyotomy. If no drainage procedure has been offered gastric retention may be increased, leading to more regurgitations and aspirations.

This can be managed by balloon dilatation, or if persistent in time, by pyloroplasty. The use of proton pump inhibitors (PPIs) with prokinetics (erythromycin, domperidone) has helped with gastric emptying. Duodenogastroesophageal reflux is a mixed refluxate, and the most damaging to the mucosal integrity of the esophageal remnant. Dumping may occur. Diarrhea may be debilitating but it usually decreases within the first 3 to 6 months after the reconstruction.

Hiatal Herniation of Abdominal Content

Resection and widening of the diaphragmatic hiatus may allow some space to persist between the wall of the stomach used for reconstruction and the resected hiatus. Although herniation through that space may be seen acutely immediately after the operation, it is usually seen and documented as a late complication, sometimes many years after the operation. Even if asymptomatic, these hernias must be repaired with closure of the opening that allows herniation.

Complications of the Interposed Stomach or of the Excluded Esophagus

The use of gastric interposition, even if bilateral vagotomy and pyloroplasty is part of the esophageal resection, shows normal acid secretion within a year after reconstruction of the esophagus.⁸⁹ The mixed refluxate in the gastric cavity may cause significant damage not only to the esophageal remnant but also to the gastric wall: gastric ulcers can bleed, perforate, or create a gastrobronchial communication. If, in a long-term survivor, damaging reflux disease is documented in the esophageal remnant, antral resection with a Roux-en-Y reconstruction has been shown to offer good results to protect the esophageal remnant.⁹⁰ For tracheogastric or bronchogastric fistulas, resection and repair of the affected tracheobronchial tree with resection of the stomach ulcer may control this difficult situation. A well-vascularized muscle transposition may help protect the repaired stomach and the reconstructed tracheobronchial tree.

In the rare situation where the esophagus must be excluded in the mediastinum, it must be decompressed since normal peristaltic activity persists with every swallow. Blowouts of the proximal or distal ends of the excluded esophagus could happen as in any closed loop obstruction. A Foley catheter installed distally as a directed fistula is usually sufficient to prevent these complications.⁹¹ The other complication that can be seen in that situation is a large mediastinal mucocele.

Complications after any type of esophageal surgery usually have significant impact because of the central role of the esophagus in alimentation and its location, which traverses the neck, thorax, and abdomen. Ensuring that the operation to be done is indicated and that the patient is prepared to undergo the surgery safely is paramount. Precise and careful anatomic dissection is mandatory with particular attention to avoiding esophageal injury and can help improve outcome. In surgery for reflux, for example, appropriate mobilization of the distal intrathoracic esophagus can reduce complications associated with “shortened esophagus.” Careful attention to postoperative progress with an almost expectant attitude regarding complications will lead to early identification, prevention, and treatment with lower ultimate mortality and earlier return to normal function. Any suspicious symptom must be aggressively pursued to ensure early diagnosis and treatment of potential esophageal perforation, leak, or necrosis. In this way, mortality can be reduced to less than 1%. The particular solution to a complication must be tailored to fit the specific complication, patient, and institutional expertise.