Postoperative Complications – best surgical technique

On the first postoperative day, a portable chest film is taken. Not only will it indicate immediate chest findings, but it will also constitute a base line for future comparison should thoracic complications occur. The incidence of pulmonary complications has dropped markedly since the advent of the antibiotic drugs. It is rare to have lung infection of serious consequence. Not too many years ago, this was almost a regular occurrence. Occasionally, there may occur a pleural loculation of serosanguinous fluid posteriorly which will cause fever and malaise. Localization by a chest film and physical signs will indicate the site for thoracentesis. A second aspiration may be necessary before full lung expansion is obtained. Cardiac irregularities are not infrequent in the postoperative period and usually respond to digitalis therapy.

Overdistention of the transplanted stomach is a very rare complication in my experience. If the stomach has been handled gently during operation and hemostasis at the divided end has been thorough, accumulations of fluid and air rarely occur, especially since the swallowing function has been greatly curtailed. It is surprising to see how these patients cooperate in this regard. It has always been difficult to explain the absence of pylorospasm after this operation while it is known to occur almost routinely after resections for benign disease. I believe the answer depends on the type of operation that is carried out. In the cancer operation, there is extensive removal of the upper abdominal peritoneum posteriorlyand the subperitoneal tissues from the pancreas upward. In the operation for benign conditions, such extensive dissection is not done. Accordingly during the more radical operation, not only is the parasympathetic nerve supply ablated, but also the sympathetic nerve filaments are interrupted. Therefore, the pylorus remains in midposition as can be demonstrated by balloon studies, the administration of sympatheticometic and para – sympatheticometic drugs, and roentgen study of the stomach. It is for this reason that I do not do a pyloroplasty when performing esophagectomy for carcinoma.

There is one postoperative complication which the surgeon should constantly keep in mind. I refer to the ever present possibility of anastomotic leakage. May I repeat again that this complication is in direct ratio to the surgeon’s increasing experience in the performance of the operation. The greater the experience, the lower will be the incidence of leakage. As the surgeon masters all the operative details, he learns how to guard against this complication. But, in spite of every precaution, leakage may still occur. Usually from the third to the sixth day, the sudden development of chest pain, sudden rise in temperature, a marked elevation of pulse rate, increase in respiratory rate, and, frequently, the clinical picture of shock should alert the surgeon to the probable occurrence of a leak. There may be a change in the character of the drainage coming through the intercostal tube. In any event, this clinical picture calls for an immediate portable film of the chest. The finding of a pneumothorax which was not evident in previous postoperative films confirms the clinical impression of a leak which may be verified by additional x-rays after giving gastrografin by mouth. On other occasions, the perforation may not be a sudden one into the free pleural cavity. The walling-oS process in association with a “slow” leak will confine the contaminated field. This may result either in a mediastinal collection or one located between the lower lobe of lung and diaphragm. The sudden free perforation calls for immediate exploration of the thoracic cavity. Although the risk of this heroic gesture is great, the surgeon has no other choice because, untreated, this complication has a 100 percent mortality. What can be done when the chest is opened will depend on the local findings. Nine years ago, I removed a carcinoma of the esophagus located above the aortic arch. The stomach was brought into the neck and anastomosed to the cervical esophagus. On the fourteenth day, the patient went into a shocklike state which was soon diagnosed as a leak from the stomach into the right pleural cavity. Exploration through the original incision disclosed a breakdown of the upper 2 inches of the inverted end of the stomach. There was no evidence of stomach necrosis. The opening was resutured and the chest was drained extensively. The patient subsequently developed a chronic empyema which was finally closed by a limited thoracoplasty. He is alive and well at this writing, nine years later.

On another occasion, an acute perforation was treated by emergency thoracotomy. A small area of stomach necrosis was found and repaired. This patient also recovered. Usually, however, this happy outcome cannot be expected. The mortality of this complication is exceedingly high. When a slow leak permits a walling – off process, the prognosis is somewhat better, because drainage of the localized collection carries with it much less risk. I have had two instances of infrapulmonary empyema due to a walled-off leak from a localized area of stomach necrosis where drainage of the collections resulted in recovery. In our entire series, there have been 16 patients with leakage, an incidence of 7 percent; 7 were from the suture line and 9 from localized areas of gastric wall necrosis. Four of the sixteen (25 percent) patients recovered after secondary procedures. The mortality among those patients who developed a leak was therefore 75 percent.

There is another serious postoperative complication which merits mention. Although of rare occurrence, emergency treatment will frequently result in recovery of the patient. I refer to acute severe bleeding soon after the operation has been completed. The appearance of fresh blood in the intercostal drainage tube in rapidly increasing amounts means bleeding from a sizable vessel and calls for emergency treatment. This will entail rapid reopening of the chest wound and exploration for the bleeding vessel. The first site to be inspected as a possible source is the location of the intercostal vessels posteriorly. The stump of the excised rib could tear the contiguous intercostal artery. The next site to be explored, after clearing the thoracic cavity of clots and liquid blood, is the point of ligation of the esophageal vessels arising from the thoracic aorta. A recent vivid experience merits recording. The patient was one of the group given preoperative radiation. Three hours after operation, profuse bleeding required reexploration, and the source of the hemorrhage was found to be from one of the esophageal vessels. Apparently the previously carefully applied silk ligature had slipped off or cut through. It is difficult to state whether or not the preoperative radiation was a factor. Fortunately, the patient recovered.

During the immediate postoperative period, not only are breathing and leg exercises practiced regularly, but frequent turning and early ambulation are encouraged. In the elderly decrepit patient, it is sometimes ill-advised to insist on early walking. But change of position to a bedside chair should be encouraged. Overseda – tion should be avoided, especially in the older age groups. Digitalization is usually continued during the early postoperative period. The patient should always recline on two or three pillows, to prevent regurgitation. The chest wound sutures should not be removed too early; otherwise separation of the edges of this large incision might occur. I prefer to remove these on the eighth or ninth day.

After the patient is discharged, the most important feature of the aftercare is the establishment of effective eating habits. Whatever the basic reason may be, it is almost routine for most of these patients have eating difficulties when they reach their homes. This is a trying period of readjustment for all concerned. To overcome the anorexia, tempting appetizers may be offered. There is really no reason to deny the patient any type of food he wishes and can swallow. Frequent small feedings are more desirable than three large daily meals. Not infrequently, the patient may complain of dysphagia and will not attempt to eat solid food. In such cases, early roentgenographic examination of the esophagus has always disclosed a widely patent anastomosis with no evidence of pylorospasm. Perhaps this is a subconscious remembrance of the preoperative dysphagia which necessitated operation. A large element of fear is present which must be dispelled by the sympathetic encouragement of the surgeon. In time the appetite returns and the patient begins to eat more and more. Considerable weight gain is not to be expected. The average is about 10 to 12 pounds. To prevent reflux of gastric contents, the patient should always sleep on two or three pillows and never eat before retiring. With the patient who does not respond and continues to complain of anorexia, weight loss, and recurring episodes of dysphagia, there is every reason to suspect residual carcinoma as the cause. It is difficult to prove this for some time by either physical signs or roentgenographic methods. Eventually, however, the clinical picture becomes obvious.

Preoperative and Postoperative Radiation Therapy. About 12 years ago with the advent of supervoltage irradiation techniques, we initiated a program of postoperative cobalt radiation therapy for every patient who had recovered from the operation of esophagectomy for squamous-cell carcinoma. It has been amply demonstrated in many clinics around the world that irradiation has practically no beneficial effect on adenocarcinoma of the cardia. Our interest was, therefore, centered largely on the squamous-cell group. It is difficult to assess accurately the effect of postoperative irradiation from the standpoint of long-term survival as compared with those patients who were not subjected to this adjuvant therapy. Suffice it to say that, in the overall appraisal, a significant difference was not noted. We, therefore, abandoned the program of postoperative irradiation and shifted to a trial ofpreoperative radiation therapy with a twofold objective. In the first place, it was believed that preoperative irradiation might have the effect of changing an inoperable tumor to a more easily resectable one, thereby increasing the overall rate of operability. This, of course, is difficult to prove unless one performs a preliminary thoracotomy, which, in itself, would hardly be justifiable. As a matter of fact, an inoperable tumor was found in one of this group of patients after a preoperative course of radiation therapy. The tumor was inseparably joined to the thoracic aorta.

The second objective of this therapeutic approach was to destroy cancer cells and to produce a fibrous encasement not only of the primary tumor but also of any nests of cancer cells permeating the lymphatic channels. It was thought that this would minimize the risk of dissemination by the manipulations of the surgeon during the subsequent esophagectomy. It is possible to demonstrate in the histological sections of the excised esophagus that this does occur. Our group of patients accorded preoperative radiation is too small and too recent to warrant any definite conclusions. But, I believe, a few important observations can be made at this time. It is most desirable to know the optimum time to embark upon the operation after completion of the radiation treatment. Dr. lohn Boland, who supervised this therapy, administered to each patient a total dosage of 6,000 R through three portals in each instance, and the course of treatment extended over a period of four to six weeks. The time interval between completion of irradiation and operation varied between three and seven weeks. Every effort was made to note increased vascularity, technical difficulties other than those encountered in the unirradiated patient, extent of fibrosis, and postoperative healing difficulties. In addition, the excised esophagus was subjected to careful histological evaluation.

It would appear, from this study, that the most opportune time to undertake the operation is between three and four weeks after the completion of radiation therapy. While there is some increased vascularity in the mediastinum, it is not enough to complicate the procedure. When operation was delayed until the seventh week, the increased fibrosis seemed to augment the difficulties attendant to mobilizing the esophagus. The histological sections proved, without doubt, the destructive effect of the irradiation and the encasement of lymphatic cancer cells in a layer of fibrous tissue. In fact, in one instance, the pathologist found it necessary to cut many sections before he could demonstrate any cancer cells in the excised esophagus.

As I see it, the most important feature of this study is concerned with the longitudinal extent of the radiation therapy and the subsequent healing at the site of esophagogastric anastomosis. Our first patient brought this into sharp focus. This man, 69 years of age, had a middle third cancer with histological proof by esophagoscopic biopsy. He was given a course of betatron 22 Me V x-rays amounting to 6,000 R directed to the entire thoracic mediastinum via three portals. Swallowing was markedly improved, and he returned to his home in South America for business reasons. Operation was not carried out until seven weeks after completion of the radiation therapy. Other than some increased difficulty in mobilizing the tumor-bearing area, the operation proceeded without incident, and a supra – aortic anastomosis was effected. When gastric contents were discharged through the tracheostomy tube (tracheotomy became necessary for aspiration of viscid secretions), it became evident that a walled-off suture line leak had perforated into the bronchial tree. The patient’s condition was too precarious to warrant reoperation, and he died soon after. Fortunately, an autopsy was performed. This disclosed a walled-off cavity between the site of the original esophagogastric anastomosis and the upper lobe of the left lung with a fistula into one of the smaller bronchi. Most importantly, the esophagogastric anastomosis showed no evidence of healing and the two organs at this site were sparated for a distance of an inch. There was no indication of any area of gastric necrosis. This represented a unique experience for me. The histological sections showed some evidence of endarteritis of the vessels in the end of the esophagus, and it is to be assumed that this was responsible for the absence of healing at the site of the anastomosis. This experience would seem to indicate that it is inadvisable to direct the radiating modality to that portion of the esophagus which must be used subsequently for anastomotic purposes. The radiation technique has been changed to obviate any such occurrence.

Time and a larger experience will eventually tell us whether preoperative irradiation is desirable and should be continued. A careful study of the long-term survivors will undoubtedly be the deciding factor. Certainly, from the limited experience so far, I have been impressed by the results of this treatment in terms of the findings on histological study of the removed esophagus.

One comment

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