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  • 1. Complication following esophagectomy Ri 羅青山 2008-02-04
  • 2. Esophagectomy
    • Method
      • Transthoracic approach
      • Transhiatal approach
      • Tri-incisional approach
      • Left thoracoabdominal approach
    • Conduit
      • Stomach
      • Colon
      • Jejunum
    • Anastomosis site
      • Thorax
      • Neck
    • Anastomosis technique
      • Hand-sewn
      • Stapling device
    Seminars in Thoracic and Cardiovascular Surgery, Vol 16, No 2 (Summer), 2004: pp 124-132
  • 3. Complications
    • Anastomotic leak
    • Conduit necrosis
    • Anastomic stricture
    • Hemorrhage
    • Chylothorax
    • Pleural effusion
    • Injury to the recurrent lanryngeal nerve
    • Tracheobhronchial injury
    • Cardiovascular and pulmonary complications
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215
  • 4. Anastomotic leak
    • Incedence: 23/307 (7.5 %)
    • Mortality rate: 8/23 (35 %)
    • Death predictor
      • Age (died, 72.8±8.3 years; survived, 65.3±8.8 years;p=0.063)
      • Location of anastomosis (cervical, 3/9 died; thoracic, 5/14 died; p=0.91)
      • Leak presentation (clinical, 6/12 died; contrast study, 2/11 died; p=0.11)
      • Time of leak (<7 days, 3/5 died; ≥7 days, 5/18 died; p=0.18)
      • Presence of gastric necrosis (necrosis, 3/3 died; no necrosis, 5/20 died;p= 0.019 )
      • Treatment (surgical, 4/4 died; conservative, 4/19 died; p=0.005 )
    Ann Thorac Cardiovasc Surg Vol. 10, No. 2 (2004)
  • 5. Anastomotic leak
    • Incedence: 19/291 (6.5 %)
    • Hospital mortality rate 6/19 (31.6 %)
    British Journal of Surgery 2001, 88, 1346-1351
  • 6. Anastomotic leak British Journal of Surgery 2001, 88, 1346-1351
  • 7. Anastomotic leak
    • Definition of Surgical Infection Study Group
    Seminars in Thoracic and Cardiovascular Surgery, Vol 16, No 2 (Summer), 2004: pp 124-132
  • 8. Anastomotic leak
    • Esophageal (intrinsic) factor
      • Absence of an outer serosal layer
      • Longitudinal orientation of the exposed esophageal musculature
    • Patient-related factor
      • Severe malnutrition
      • Not age, DM, perioprative steroid use
    • Surgical/Techenical factor
      • Tension
      • Vessel supply
      • Mucosal incorporation/apposition
    Seminars in Thoracic and Cardiovascular Surgery, Vol 16, No 2 (Summer), 2004: pp 124-132
  • 9. Anastomotic leak
    • Diagnosis
      • PE
        • Chest pain, dyspnea, saliva exuding, bile exiting, fever
      • Lab
        • CBC, CRP, Pleural effusion in CXR, contrast swallowing
    Seminars in Thoracic and Cardiovascular Surgery, Vol 16, No 2 (Summer), 2004: pp 124-132
  • 10. Anastomotic leak
    • Management
    Dig Surg 2002;19:92–98
  • 11. Anastomotic leak British Journal of Surgery 2001, 88, 1346-1351
  • 12. Conduit necrosis
    • Occurs in approximately 1% of cases
    • Etiologic factors
      • Similar to those indicated for leaks
      • Also conduit torsion, intrinsic vascular insufficiency due to atherosclerosis of the feeding vessel, technical mishaps
    • S/S
      • Initially subtle, progress rapidly
    • Operative intervention is always necessary
      • Refashioned, complete take-down with debridement of necrotic tissue, wide-drainage, proximal diversion, replacement of the remaining viable stomach within the abdomen.
    Seminars in Thoracic and Cardiovascular Surgery, Vol 16, No 2 (Summer), 2004: pp 124-132
  • 13. Anastomotic stricture
    • Incidence varies from 1% to 50%
    • Often occurs months after the procedure
    • Often associated with prior occurrence of a leak
    • S/S: Complaint of dysphagia
    • Should be carefully evaluated for recurrent disease with endoscopy, with or without endoscopic ultrasound (EUS), abdominal and chest CT
    • Benign stricture can be treated on a symptomatic basis by dilation or stenting
    • Proton-pump inhibitor
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215 Seminars in Thoracic and Cardiovascular Surgery, Vol 16, No 2 (Summer), 2004: pp 124-132
  • 14. Hemorrhage
    • Incidence of 3% to 5%
    • Requires urgent re-exploration
    • In most circumstances prevented with proper surgical technique
    • Diagnosis usually delayed by 12 to 24 hrs
      • Volume replacement
      • Fairly sizable fields of dissection
    • Unexpected tachycardia and decreased urine output are usually early clues to bleeding
    • Resuscitated with blood products to correct any coagulopathies and then reexplored
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215
  • 15. Chylothorax
    • Incidence of 1% to 5%
    • Diagnosed by the presence of pleural effusion, consisting of a milky fluid with a high triglyceride and lymphocyte count
    • Should be suspected when the chest tube output is high after postoperative day 4
    • Mamagement
      • Half conservatively by restricting the oral intake and on intravenous hyperalimentation
      • Embolization of the thoracic duct using interventional radiology techniques
      • Surgical exploration
      • Perioperative prophylactic thoracic duct ligation
      • Repair a thoracic duct leak during the course of esophagectomy
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215
  • 16. Pleural effusion, pneumothorax
    • Result from an injury to the pleura on the contralateral hemithorax
    • Should rule out hemorrhage, chylothorax, conduit leak, metastatic disease, airway injury
    • Managed by observation, percutaneous drainage or thoracostomy drainage
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215
  • 17. Injury to the recurrent laryngeal nerve
    • An incidence of 10% to 20% in cervical anastomoses
    • Diagnosis
      • Video-assisted swallow studies
      • Fiberoptic evaluation
    • Perioperative intubation caused vocal cord edema can mask the injury for a few days
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215
  • 18. Tracheobronchial injury
    • “ Neoesophageal”-to-bronchial fistulas
    • S/S: Recurrent pneumonia or empyema
    • Small injuries often heal without treatment or adverse sequelae
    • Can lead to fistula formation involving the “neoesophagus,” requiring stenting or operative repair
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215
  • 19. Cardiovascular and pulmonary complications
    • Esophageal ca patient
      • Ederly, malnourished, smoking, alcohol abuse
    • Cardiovascular complications: 5% to 10%
      • Most common: atrial fibrillation
      • Management
        • Intraoperative and postoperative Swan-Ganz for high-risk patients
        • Preoperative and postoperative use of beta-blockade or calcium channel blockers
    • Pulmonary complications: 20% to 30%
      • Pneumonia, aspiration, respiratory failure
      • Two principal reasons: malnourished, smoking
      • Early tracheostomy is favored in patients with prolonged ventilation requirements
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215
  • 20. Conclussion
    • Careful preoperative evaluation of the patient
    • Meticulous surgical technique
    • An awareness of the potential complications
    • Mortality rate of 2.5% at a high-volume center, in contrast to a nearly 10% mortality rate at a low-volume center
    Seminars in Thoracic and Cardiovascular Surgery, Vol 15, No 2 (April), 2003: pp 210-215
  • 21.  
  • 22. Povidone-iodine
    • Water-soluble complex of iodine with polyvinylpyrrolidone (PVP)
    • Works through disruption of pathogen cell walls
    • Bactericidal ability against a large array of pathogens
  • 23. Method
    • Search of MEDLINE (1966–2006) and EMBASE (1980–2006)
    • Focused on the efficacy or risks, or both, of povidone-iodine irrigation to prevent surgical site infection
    • Either a randomized controlled trial (RCT) or a comparative study
    • Exclusion
      • Treatment of surgical site infection
      • Used povidone-iodine topically
  • 24. Result
    • 15 studies met all the inclusion criteria
    • Years of publication: 1977 to 2006
    • General (8),cardiovascular (2), orthopedic (2), urologic (1)
    • RCTs (11), single-blind (3)
    • Level I (3), level II (12)
  • 25. Discussion
    • 5/15 not find povidone-iodine superior to saline, water or no irrigation
    • Surgery in general (1), general (3), cardiovascular (1)
    • Effectiveness even at low concentrations, concentrations less than 5% would seem appropriate
    • Whether povidone-iodine solution would show efficacy in conjunction with antibiotics is unknown
      • Several recent RCTs demonstrated povidone-iodine irrigation further reduced surgical site infection rates
    • The appropriateness of using povidone-iodine irrigation in children is unknown
    • Risk
      • Increased postoperative serum iodine
      • Should not be used in patients with iodine sensitivity, burns, thryroid disease or renal disease
    • The evidence suggests that povidone-iodine irrigation may be effective in preventing surgical site infection
  • 26.
    • Thank you for your attention !