Abstract
Oesophagectomy is a complex surgical procedure that requires meticulous multidisciplinary care. The procedure, which typically requires multiple incisions, involves tumour resection and creation of a gastric conduit followed by its anastomosis to the remaining oesophagus in the thorax or the neck. Although respiratory failure is the leading cause of postoperative morbidity, non-invasive ventilation is frequently unfeasible. Special care is required to secure the multiple catheters and drains inserted during the procedure; accidental dislodgement of any of which may increase postoperative morbidity. Among the potential complications of this procedure, the anastomotic site is susceptible to ischaemia because of the limited blood supply of the gastric conduit from the right gastroepiploic artery. Conduit ischaemia and anastomotic leak are the most serious complications and may result in prolonged morbidity or mortality. Furthermore, patients with oesophageal tumours and dysphagia are frequently cachectic, prehabilitation may reduce the incidence of postoperative complications. Dietitian-prescribed intensive nutritional support may limit the extent of postoperative weight loss and the risk of severe complications.
Keywords
Introduction
Oesophageal cancer is the eighth most common cancer and affects men more frequently than women. 1 This condition is particularly common in central Asia, in the area known as the Asian Oesophageal Cancer Belt, which extends from Turkey through China. Although squamous cell carcinoma is the most prevalent form of oesophageal cancer, the incidence of adenocarcinoma has increased in recent decades, particularly in western countries. 2 While the 5-year survival for oesophageal cancer has improved significantly over the past four decades, most studies suggest that it remains at less than 50%. 3
Locally advanced tumours are best treated with a multimodal approach, including oesophagectomy with perioperative chemotherapy or neoadjuvant chemoradiation therapy. There is an emerging role for immunotherapy.4,5 The tumour’s location in the oesophagus determines the extent of oesophageal resection required and the preferred anastomotic site. The common surgical approaches include trans-hiatal, Ivor Lewis (two-stage: abdomen and chest), and McKeown (three-stage: abdomen, chest, and neck) oesophagectomies. 6
Oesophagectomy is a complex surgical procedure with a high risk of postoperative complications that requires a comprehensive multidisciplinary perioperative approach. In Australian settings, at least 50% of the patients develop at least one postoperative complication, and consequently, the failure-to-rescue rate has been reported to be 6.3%. 7 The results of recent studies suggest that oesophagectomies performed at high-volume centres are associated with better outcomes. Data from Australia and New Zealand suggest that hospitals which performed more than 12 oesophagectomies per year may have fewer complications like the need for mechanical ventilation. 8 While centralisation of oesophagectomy to high-volume centres is associated with lower mortality, it may also necessitate long travel distances for the patients and families. 9 The latter may increase the carer burden and financial stress. 10
Aim and scope of review
In this article, we aim to provide a comprehensive narrative review of postoperative management after oesophagectomy. We also discuss the applied anatomy of the oesophagus, the preoperative preparation, and the details of the anaesthetic technique and surgery, as a thorough understanding of these is crucial for high-quality postoperative management.
We searched for Medline and Cochrane Library databases for English language articles published between 1 January 1980 and 15 July 2024. We used the following terms in our search: ‘oesophagectomy’, ‘Ivor Lewis oesophagectomy’, ‘postoperative management after oesophagectomy’, ‘ICU management after oesophagectomy’, ‘oesophageal surgery’, ‘oesophageal cancer’, ‘chylothorax’, ‘prehabilitation for oesophagectomy’, ‘anaesthesia for oesophagectomy’, ‘analgesia after oesophagectomy’, ‘nutrition after oesophagectomy’ and ‘complications of oesophagectomy’. We also searched the ClinicalTrials.gov database using the search terms ‘oesophagectomy’ and ‘oesophageal cancer’ to identify any ongoing clinical trials. In addition, leading journals in critical care were scanned for publications related to oesophagectomy in the past 10 years. While articles older than 1980 were reviewed as appropriate, more recent articles were chosen (to the extent possible) for the final list of references. While the authors participated in many discussions focused on the contents of this manuscript, this review remains subject to bias based on the authors' interpretation of the literature and their clinical experience.
Applied anatomy of the oesophagus
As oesophagectomy is an extensive procedure, and serious complications may arise from injury to any of the surrounding structures, a knowledge of the anatomy and anatomical relations of the oesophagus remains an important consideration for the perioperative physicians.
The adult oesophagus is approximately 25 to 30 cm in length, beginning at the lower border of the cricoid cartilage posterior to the trachea and anterior to the C6–C7 vertebrae. It descends through the superior and posterior mediastinum along the right side of the descending thoracic aorta, passes through the oesophageal hiatus in the diaphragm, and ends at the gastro-oesophageal junction at approximately the T11 vertebral level. The oesophagus and several of the structures in its proximity are illustrated in Figure 1.
Applied anatomy of the oesophagus. (Made with biorender.com).
As the oesophagus descends through the mediastinum, its successive anterior relations include the trachea, the tracheal bifurcation, the right pulmonary artery, the left main bronchus and the heart. In the lower mediastinum, the thoracic duct runs posterior to the oesophagus, crosses to the left at approximately the T5 level, and then runs along the left side of the oesophagus. The left recurrent laryngeal nerve lies on the left side of the oesophagus in the superior mediastinum.
Preoperative preparation
Preoperative preparation for oesophagectomy requires a careful assessment of patient fitness, and careful consideration of a patient's comorbidities, nutritional status, functional capacity, and psychological stress to reduce the risk of perioperative complications and mortality.
Emerging evidence suggests that formal prehabilitation programs are safe, feasible, and efficacious for improving patient fitness and strength before oesophagectomy. 11 Cardiopulmonary exercise training may result in a reduction in postoperative respiratory complications.12,13 Neoadjuvant chemotherapy for oesophageal cancer typically spans 8 to 12 weeks, providing an optimal window for concurrent prehabilitation and nutritional intervention. A standard multimodal prehabilitation program comprises one to two supervised exercise sessions per week, thrice-weekly home-based training sessions, cardiopulmonary exercise testing, and structured psychological support. 14
An experienced dietitian should undertake nutritional assessment; tailored nutritional intervention should be implemented until the day of surgery. 15
Neoadjuvant therapy refers to the treatment given as a first step to shrink a tumour before the main treatment, which is usually surgery. The fluorouracil, leucovorin, oxaliplatin, and docetaxel regimen is commonly used as neoadjuvant chemotherapy before oesophagectomy. Durvalumab is a monoclonal antibody which acts as an immune checkpoint inhibitor, is being evaluated and there is emerging evidence that it may reduce the risk of relapse. 5
Details of the surgical procedure
Patients with localised disease (T1N0M0 or T2N0M0) may present for surgery without previous neoadjuvant chemo or radiotherapy. By contrast, patients presenting with a full-thickness invasion of the oesophagus or localised spread will generally undergo preoperative chemotherapy or chemoradiotherapy. The selection of one of the several approaches to oesophagectomy typically depends on the location of the tumour and the available surgical expertise. The key features of each of the different techniques are outlined in Table 1. With advances in laparoscopic, thoracoscopic, and robotic techniques, minimal access oesophagectomy has become more common.
Surgical approaches to oesophagectomy.
The Ivor Lewis oesophagectomy is among the more traditional surgical techniques commonly used, see Figure 2. This method, named after Ivor Lewis (1895–1982), the prominent Welsh surgeon who pioneered the right-sided thoracic approach to oesophagectomy, is commonly performed in patients presenting with lower oesophageal cancers. 16 In this procedure, the distal oesophagus is resected, and the stomach is fashioned into a gastric conduit which is then anastomosed to the mid-oesophageal remnant in the chest. This procedure requires both abdominal and right-sided thoracic approaches. As a first step, the surgeon performs a laparotomy or uses a laparoscopic approach to mobilise the stomach, a procedure that involves division of the phreno-oesophageal ligament (often with a cuff of the crura), the gastro-hepatic ligament, the gastro-colic ligament, and short gastric arteries around the greater curvature, and ligation of the left gastric artery. The blood supply of what will eventually become the gastric conduit and its anastomosis to the oesophageal remnant will be provided by the right gastro-epiploic artery (from the stomach end of the anastomosis) and the submucosal network of vessels in the remaining segment of the oesophagus. Thus, the anastomosis will be at risk of ischaemia. The longer the length of the gastric conduit, the higher the risk of ischaemia at this site. It should be noted that a colonic interposition in the retrosternal region is sometimes employed when gastric conduit is not possible. 17
Ivor Lewis oesophagectomy. (Made with biorender.com).
A feeding jejunostomy tube is typically inserted at 30 to 40 cm from the ligament of Treitz. In patients with severe obstructive symptoms and malnutrition, a feeding jejunostomy or nasojejunal (NJ) feeding tube may be placed before neoadjuvant treatment or surgery.
After the abdomen is closed, the patient is positioned in the left lateral position. An open or thoracoscopic approach may be used to complete this segment of the procedure. In the open approach, a right posterolateral thoracotomy is performed from the fifth or sixth intercostal space. To reach the oesophagus, one-lung ventilation (OLV) is required (i.e., ventilation of the left lung only). The oesophagus is mobilised, the azygous vein is divided, the thoracic duct is identified (and may be ligated), and lymph node dissection is completed. The oesophagus is typically divided well above the tumour site, often at the level of the azygous arch or higher, to account for possible tumour extension into the submucosal plexus. The portion of the stomach serving as the gastric conduit is then delivered into the chest; tumour resection is then completed, and the specimen is removed. The oesophagus is anastomosed to the stapled stomach conduit with either hand sewing or by using a stapling technique. A nasogastric tube is then passed across the anastomosis to the stomach conduit, which decompresses the conduit. Apical and basal pleural drains are placed, and the thoracotomy incision is closed.
Recent advances in minimally invasive and robotic oesophagectomy
Minimally invasive oesophagectomy has gained popularity in recent years. Approaches include hybrid techniques, such as laparoscopy combined with thoracotomy, or thoracoscopy combined with laparotomy, as well as fully minimally invasive techniques which employ thoracoscopy and laparoscopy or robot-assisted oesophagectomy. Studies have shown that minimally invasive oesophagectomy may be associated with fewer respiratory complications. 18 Further trials are currently underway to compare hybrid and fully minimally invasive approaches. 19 Thoracoscopic oesophagectomy may be done in the lateral decubitus or prone position. The latter has not been shown to reduce the risk of postoperative pneumonia. 20
Anaesthetic considerations and postoperative analgesia
Patients with obstructive oesophageal symptoms are at high risk for aspiration. All patients should be evaluated preoperatively for the possibility of aspiration pneumonia before induction of anaesthesia. Rapid sequence induction followed by intubation may be required for patients presenting with obstructive symptoms. A double-lumen endotracheal tube is generally used as for OLV during the thoracic or thoracoscopic phase of the surgery. Bronchial blockers may be used as an alternative to a double-lumen endotracheal tube without compromising oxygenation or surgeon’s satisfaction with surgical manipulation. 21 Their use may be associated with lesser incidence of sore throat compared with the double-lumen tube. If the thoracic component of the surgery is done before the abdominal component in a three-stage procedure, the double-lumen tube may be changed to a single-lumen endotracheal tube after the patient is turned supine. If the thoracic component is done second, and the patient is not extubated at the end of the surgery, this should be replaced with a single-lumen endotracheal tube. In a large randomised trial that was limited to patients undergoing oesophagectomy, the use of intraoperative goal-directed fluid therapy to maintain stroke volume variation at less than 12% and systolic blood pressure at greater than 90 mm Hg was associated with a reduced risk of mortality and major complications. 22 However, these findings have not yet been replicated.
The intraoperative regional anaesthesia technique adopted by the anaesthetist will have an enormous impact on the management of postoperative pain. Multiple incisions (abdominal, thoracic, and/or cervical) contribute to significant pain in the early postoperative period, as does the use of thoracostomy tubes and other surgical drains. The various regional anaesthetic approaches to analgesia after oesophagectomy are outlined in Table 2.23–29
Regional and local analgesia after oesophagectomy.
Postoperative care
Admission to the intensive care unit
In the immediate postoperative period, patients are generally cared for in an intensive care unit (ICU) or high dependency unit (HDU) as per local practice and available resources. However, this choice is increasingly being challenged by Enhanced Recovery After Surgery (ERAS) protocols. 30 Nonetheless, in our opinion, patients recovering from oesophagectomy should be managed in a high-acuity environment in the immediate postoperative period.31,32
ERAS care system
In 2019, the ERAS Society published guidelines for the management of post-oesophagectomy patients that outlined a system of care that could be used as a template and ultimately tailored to meet local needs. Adherence with ERAS protocols after oesophagectomy has been shown to reduce the risk of respiratory complications and overall complication rate, and the hospital length of stay. 33
Care of catheters
After an oesophagectomy, the patient returns to the ICU with several drains and catheters in place. These devices should be labelled and optimally secured to prevent accidental dislodgement. Accidental dislodgement of drains and catheters may lead to significant morbidity. Some of these catheters used in this procedure are highlighted in the image shown in Figure 3. A list of the catheters and drains that are usually placed in the patient after oesophagectomy is summarised in Table 3.34,35 It should be emphasised that the nasogastric tube is not for feeding. On chest X-ray, the tip of the nasogastric tube is often visible just below the level of the anastomosis between the gastric conduit and the upper oesophagus. It should be secured well. In the event of accidental dislodgement, it should not be reinserted, and the surgical team should be informed.
Care of drains and catheters after oesophagectomy.
Note. Any central venous catheter, arterial catheter, urinary catheter, abdominal drain, and epidural/ paravertebral catheter should be secured per the unit's protocols.
Incision site, catheters, and tubes after oesophagectomy.
Respiratory support
Pulmonary complications are frequent after oesophagectomy and may occur in more than 50% of patients. 36 The reasons are multifactorial and include (but are not limited to) pre-existing respiratory disease (for example, chronic obstructive airway disease), malnutrition and associated weakness, pain leading to hypoventilation, fluid accumulation, and surgical complications such as anastomotic leak. 37
Extubation after oesophagectomy
The decision to extubate in the operating room at the end of surgery is made by the anaesthetist and the surgeon. The ICU should be prepared to receive a patient who remains intubated after leaving the operating room.
Effective analgesia is essential prior to extubation. Epidural analgesia has been associated with earlier extubation and improved postoperative respiratory outcomes. 38 Premorbid respiratory disease, intraoperative oxygenation status, and suitability for non-invasive ventilation (NIV) post-extubation are important considerations when deciding to extubate. There has been a move towards earlier postoperative extubation, as recent evidence suggests that this is a safe approach that leads to early mobilisation, reduces the risk of respiratory complications, and results in shorter stays in the ICU.39,40 Nonetheless, an experienced clinician must determine whether a given patient is stable and thus suitable for extubation. In general, failed tracheal extubation is associated with an increase in postoperative mortality. 41 In patients who arrive in the ICU intubated during late evening hours, it may be clinically prudent to defer extubation assessment until the following morning.
NIV after oesophagectomy
Non-invasive ventilation to prevent or treat respiratory failure after major surgery is associated with a reduced incidence of reintubation. 42 Use of NIV after oesophagectomy can be problematic due to the risk of increased intraluminal pressure, which (at least theoretically) may result in conduit distension, impaired perfusion, and anastomotic leak. Although results from ex vivo models of cadaveric oesophagus-to-oesophagus and oesophagus-to-stomach anastomoses suggest that these sites may be stable at pressures used for NIV, this type of study cannot account for variables that may be encountered in clinical practice; for example, impaired blood supply at the conduit, risk of aspiration, and others. 43 Given the overall lack of evidence that supports or refutes the safety of NIV after an oesophagectomy, the ICU team must always confer with the surgical team before NIV is initiated post-oesophagectomy. 44
Early mobilisation and other strategies to prevent respiratory complications
Despite the lack of specific evidence, mobilisation and physiotherapy after oesophagectomy are strongly recommended as strategies to reduce pulmonary complications. Challenges encountered in early mobilisation include haemodynamic instability, respiratory failure, pain, the need to accommodate multiple medical devices, fatigue, and sometimes delirium. 45 Structured multidisciplinary approaches for mobilisation and physiotherapy that overcome these restrictions should be designed. Optimum postoperative analgesia, avoiding fluid overload, and keeping the head of the bed elevated at approximately 30 degrees to 45 degrees to reduce the risk of reflux and aspiration are other strategies that can be introduced to reduce the incidence of postoperative respiratory complications. 46
Recent advances in respiratory management
Introduction of a perioperative multidisciplinary team approach to the postoperative care of patients after oesophagectomy was associated with a decrease in risk of pneumonia. 47 The use of high-flow nasal cannulae after oesophagectomy seems to reduce the risk of developing respiratory complications without increasing the risk of anastomotic leak.48,49
Haemodynamic support and fluid management
As previously discussed, the anastomotic site is highly vulnerable to ischaemia. Both systemic factors, for example, low cardiac output, and local factors such as vasoconstriction secondary to the use of vasopressors, may contribute to anastomotic ischaemia.
Results from a prospective review of an institutional database revealed that vasopressor use and the absolute volume of intravenous fluid administered were not associated with the risk of anastomotic leak. 50 Ultimately, the goal of intravenous fluid administration should be to achieve and maintain euvolemia; excess fluid accumulation should be avoided. Vasopressor therapy should be considered when hypotension persists in euvolemic patients or when hypotension is believed to be due to vasodilation; for example, because of thoracic epidural analgesia.
The optimal intravenous fluid for use in the perioperative period has not been identified. The results of one retrospective study revealed that a serum albumin level of less than 35 g per litre on the day of surgery was an independent predictor of an anastomotic leak. 51 It is not known whether supplemental intravenous albumin will decrease the risk of developing a leak.
Recent advances in haemodynamic management
Current evidence suggests that goal-directed fluid therapy using various techniques may improve outcomes after major gastrointestinal surgery. While a cause-and-effect relationship is not established, recent evidence suggests that a significantly positive fluid balance is associated with an increased risk of postoperative complications like pneumonia and anastomotic leakage. It is important that the fluid balance is carefully and frequently measured and strictly controlled. 52 Haemodynamic monitoring with cardiac output monitoring systems like the FloTrac sensor along with the Vigileo monitor (Edward Lifesciences, Irvine, CA, USA) have evaluated the role of stroke volume variation as a measure of fluid responsiveness, with mixed results.53,54
Atrial fibrillation
Atrial fibrillation, which occurs in as many as 20% of patients undergoing oesophagectomy, has been associated with an extended hospital stay and higher perioperative mortality. 55 Although it is not a direct cause of severe morbidity, atrial fibrillation may be an early predictor of developing infectious complications or anastomotic leak. 55 Atrial fibrillation should be considered a ‘red flag’ and followed by vigilance directed at identifying complications in affected patients. While amiodarone may reduce the risk of postoperative atrial fibrillation, its use is associated with hypotension, bradycardia, and QT interval prolongation. 56
Prevention and management of delirium
Delirium may be an early sign of developing complications. Delirium may preclude mobilisation, use of patient-controlled analgesia, and engagement with physiotherapy, thereby exacerbating the risk of further complications. Particular attention should be paid to securing all drains and catheters in agitated patients. Premature removal of catheters and drains may lead to significant morbidity, and it may not be possible to reinsert them (for example, an NJ tube) after accidental dislodgement. Delirium should be managed judiciously, preferably with non-pharmacological strategies but with pharmacotherapy if necessary. In patients with alcohol use disorder, withdrawal should be anticipated, and prophylactic therapy should be instituted. 57
Haematological issues
Transfusion threshold
Preoperative anaemia is associated with higher mortality after oesophagectomy. Every attempt should be made to optimise patient haemoglobin levels before surgery (e.g., via nutritional and iron supplementation, among other interventions). 58 However, the urgency of the surgery and the inability to eat due to cancer may prevent the development of preoperative anaemia.
The haemoglobin concentration that should optimally trigger transfusions in patients undergoing oesophagectomy remains unknown. At this time, a restrictive transfusion practice is encouraged based on a body of literature that supports this approach in other patient cohorts (e.g., cardiac surgery, septic shock, ICU admission), as well as the known risk factors associated with this procedure and evidence of the harmful effects of allogenic blood transfusion in patients with oesophageal malignancy. 58
Prophylaxis to prevent deep vein thrombosis
Patients undergoing oesophagectomy are at higher risk of developing postoperative deep vein thrombosis compared with those undergoing other gastroenterological cancer surgeries, with a reported incidence between 3% and 14%. 59 Chemoprophylaxis with low molecular weight heparin is recommended, beginning at 2 to 12 hours preoperatively and continuing for at least 7 to 10 days postoperatively. 60 The timing of deep vein thrombosis chemoprophylaxis and removal of regional anaesthesia catheters should be guided by institutional protocols and local practice guidelines.
Nutrition
Oesophageal cancer is associated with substantial malnutrition which has significant prognostic implications. Of all the cancers, oesophageal cancer is associated with the greatest extent of weight loss because of associated dysphagia. 61 At the time of diagnosis, most patients have experienced an unintentional loss of up to15% of their total body weight. Preoperative loss of more than 10% of one’s body weight is associated with worse postoperative outcomes. 62 Patients may continue to lose weight postoperatively, and those with greater than 20% weight loss after surgery have a higher risk of all-cause mortality. 63
The enteral route is preferred over total parenteral nutrition after oesophagectomy. Local practices may vary, but the enteral route may be accessed in one of the following ways: 1) feeding jejunostomy—some patients with severe dysphagia may receive a jejunostomy tube before oesophagectomy to improve preoperative nutritional status, or alternatively, a jejunostomy tube may be placed during surgery, 2) a NJ tube may also be inserted at the time of surgery, or 3) early oral feeding.
In intubated patients, indirect calorimetry may provide an accurate assessment of the nutritional requirements of intubated patients. 64
Dietitian-prescribed intensive nutritional support can prevent weight loss and reduce the risk of severe complications after oesophagectomy. 65 A dietitian should be involved in developing a tailored nutritional program during the immediate postoperative period.
Proton pump inhibitors are commonly used to prevent reflux oesophagitis, which may be associated with the long-term risk of developing an anastomotic stricture. 66
The risk of malnutrition is high in patients who develop chyle leak after oesophagectomy. In this setting, total parenteral nutrition is often required. When enteral nutrition is restarted, a diet rich in medium-chain triglycerides is commonly used. The medium-chain triglycerides are absorbed directly into the portal vein, and not via the lymphatics. As chyle contains long-chain triglycerides, avoiding those in the diet helps reduce the chyle volume. 67
Recent advances in nutritional management
Ghrelin, popularly referred to as the ‘hunger hormone’, is produced by the stomach. Its role is emerging as a strategy to prevent loss of skeletal muscle mass after oesophagectomy. 68 The use of protein-enhanced enteral feeds may be associated with attenuated catabolism after oesophagectomy. 69 There is increased recognition of micronutrient deficiency after oesophagectomy. 70 In high-risk patients, micronutrient deficiency should be suspected, investigated and treated.
Specific complications that may develop in the ICU
Anastomotic leak and conduit ischaemia
Anastomotic leak and conduit ischaemia are serious and closely related complications that can develop after oesophagectomy. While a wide range in the incidence of anastomotic leak has been reported, a recent meta-analysis indicate that the risk is about 9%. It is associated with a 30-day mortality of 1.9% and a 90-day mortality of 2.4%. 71
An anastomotic leak is defined as a full-thickness gastrointestinal defect involving the oesophagus, anastomosis, staple line, or conduit, regardless of the presentation or method of identification, which frequently presents in the second week after surgery. 72
Clinical features of anastomotic leak
The anastomotic leak may be asymptomatic, or it may present as drainage of bile or feed from the chest drains, new-onset sepsis, or respiratory failure. Cervical anastomotic leaks may present with leak of saliva-like fluid or pus from the neck. Persistent elevation of serum C-reactive protein or procalcitonin levels and peripheral neutrophil and total white blood cell count are all associated with the development of an anastomotic leak. 73 The development of a new pleural effusion can have several causes but should raise suspicion of anastomotic leak specifically in this setting. However, non-specific signs such as new-onset atrial fibrillation or delirium may sometimes be the only feature of this critical complication. 55 In the event of sudden and severe clinical deterioration, a leak or ischaemia of the conduit should be suspected.
Diagnosis of anastomotic leak and conduit ischaemia
A computed tomography (CT) scan with intravenous contrast is the cornerstone for diagnosis of an anastomotic leak. It allows a concomitant review of the cervical, thoracic, and abdominal region. It can diagnose the presence of a leak, the presence of a collection, mediastinal air, and ischaemia of the conduit. A multimodal approach using CT diagnosis scores, measurement of air bubble density in the mediastinum, endoscopy, and amylase level in the pleural fluid may improve the diagnostic accuracy. 74
Following a contrast-enhanced CT scan, an endoscopy may be done to confirm the diagnosis, assess the vascularity of the conduit, and guide further treatment (e.g., conservative therapy, endoluminal or extraluminal vacuum therapy, or surgery). 74
Management of anastomotic leak and conduit ischaemia
The general principles of tailored management of leaks and conduit ischaemia are outlined in Table 4.75,76 Because blood flow to the conduit at the anastomotic site is vulnerable to ischaemia, hypotension and hypovolemia should be treated promptly. Non-invasive ventilation may lead to mediastinal contamination; therefore, early endotracheal intubation should be considered if positive pressure ventilation is required. An anastomotic leak without ischaemia may be managed conservatively with antibiotics and drainage. By contrast, conduit ischaemia may require resection and a cervical oesophagostomy. In either case, a prolonged ICU stay should be anticipated, together with all the complications that are associated with chronic critical care. 76
Principles of management of anastomotic leak and conduit ischaemia.
Note. Recent advances in prevention and management of anastomotic leak.
The use of real-time indocyanine green imaging with a near-infrared indocyanine green camera (Karl Storz SE & Co. KG, Tuttlingen, Germany) can detect inadequately perfused gastric conduits, which may reduce the risk of subsequent anastomotic leak. 77 Endoluminal vacuum therapy with commercially available devices like Eso-Sponge has become popular in recent years. In one study, in 69 patients with anastomotic leak, Eso-Sponge was successful in closing the leak in 91% of subjects. 78
Chylothorax
Chylothorax occurs due to injury to the thoracic duct or one of its tributaries and may occur in as many as 0.4% to 4% of patients post-oesophagectomy. 79 To prevent this complication, some surgeons routinely ligate the thoracic duct in the supra-diaphragmatic location during surgery. Chylothorax is associated with a higher incidence of pneumonia and longer hospital stays. 79 Due to the lack of randomised controlled trials that address the prevention and treatment of chylothorax, management of this condition is dictated by clinical experience and local expertise. The diagnosis and management of chylothorax is outlined in Table 5.80–83
Diagnosis and management of chylothorax.
Recurrent laryngeal nerve injury
Recurrent laryngeal nerve (RLN) injury may occur during oesophagectomy in response to its division, stretching, compression, thermal injury, or vascular compromise, and is more common in cases involving cervical rather than thoracic anastomosis. The RLN innervates all muscles of the larynx (except the cricothyroid), and also carries sensory fibres from the larynx, below the level of the vocal cords. Recurrent laryngeal nerve compromise may result in hoarseness or recurrent aspiration, and an increased risk of respiratory complications. 84 Approximately 40% of patients will recover from RLN injury within one year. Persistent and symptomatic RLN injury may require vocal cord medialisation. 85
Recent advances in preventing RLN injury
Robotic surgery may be associated with a reduced risk of RLN injury during lymph node clearance. 86 Intraoperative nerve monitoring has been shown to reduce the risk of RLN injury during oesophagectomy. This may be achieved by special nerve monitors or with the use of bronchial blocker-facilitated lung separation and special electromyographic (endotracheal tubes (e.g., NIM EMG ETT, Medtronic Xomed, Jacksonville, FL, USA) with electrodes embedded just above the tracheal cuff, positioned to make direct contact with the vocal cords.87,88
Prolonged ICU stay
Regardless of the original cause for admission, following a prolonged stay in the ICU a significant proportion of patients develop a similar constellation of problems, including (but not limited to) physical deconditioning, diminished mental health, symptomatic distress (e.g., dry mouth, sleep deprivation), newly acquired organ dysfunction (e.g., renal failure), ICU-associated complications (e.g., problems with access lines, acquisition of multi-resistant organisms), and high levels of family and caregiver stress. 75 Patients who experience prolonged ICU stays following complications after oesophagectomy are no exception and are at high risk for developing chronic critical illness. One-year survival from chronic critical illness regardless of aetiology ranges from 30% to 50%. 75 Individuals who develop chronic critical illness after oesophagectomy should have their treatment goals reviewed on a regular basis with a focus on premorbid conditions, fragility, prognosis of the oesophageal cancer, and the patient's expressed values and wishes.
Conclusion
Oesophagectomy is a complex procedure. Patients undergoing oesophagectomy are at high risk for life-threatening complications and deserve the best care that the multidisciplinary team in the hospital has to offer. Patients should be carefully evaluated on admission to the ICU, closely monitored, and provided with excellent analgesia, nutrition, and physiotherapy. Because timely intervention may be life saving, heightened vigilance should be maintained to prevent and detect any post-procedural complications. There is a dearth of published guidelines on intensive care management following oesophagectomy and its complications. Further research will be required to evaluate the effectiveness of and compliance with ERAS pathway guidelines. Future studies will highlight the most appropriate targets for regional analgesia, the safety of NIV, appropriate indications for transfusions, fluid strategies, and haemodynamic targets in patients recovering from oesophagectomy.
Footnotes
Author contribution(s)
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
