Matthew I. Goldblatt, MD, W. Scott Melvin, MD
Open esophageal surgery has long been associated with significant morbidity and pain. Upper abdominal incisions lead to respiratory compromise and significant risk of wound complications and late ventral hernia formation. In addition, due to the concave shape of the diaphragm, visualization of the esophageal hiatus can be quite difficult.
Laparoscopic esophageal surgery has evolved to allow significantly faster recovery times with less morbidity and mortality in qualified hands. Nonetheless, potential problems are associated with the most common esophageal procedures: Fundoplication, Heller myotomy, and esophagectomy.
Laparoscopic fundoplication has become one of the most common advanced minimally invasive procedures performed around the world. The complications of laparoscopic fundoplication have been covered in a separate chapter. This chapter will address complications specific to the esophagus.
Perforation of the distal esophagus is one of the most morbid complications that can occur in minimally invasive esophageal surgery. Perforation can be associated with prolonged hospital stays, multiple medical and septic complications, as well as long-term strictures. Delayed recognition of the perforation can lead to mortality. Perforation can occur during various time points in the operative procedure. In the process of dissecting the esophagus from the diaphragmatic hiatus, an esophageal perforation may occur. During the operative procedure, care must be taken to precisely identify the esophageal wall. Careful identification of anatomical landmarks, specifically identification of the crura may help in identifying the esophagus even when previous surgery or large hernias make dissection difficult. The muscular wall of the esophagus can be mistaken for the crura, so precise identification of the edge of the muscle is important. One should never have to dissect through muscle fibers. Dissection in the space posterior to the esophagus should be done only under direct vision. It is not acceptable to pass instruments around the esophagus with inadequate visualization. In most cases, the dissection of the distal esophagus can be done with blunt instruments without the use of any energy source. Electrocautery or ultrasonic dissectors should be used very sparingly in the region of the distal esophagus and the mediastinum to avoid injury.
Perforation of the esophagus is more likely in reoperative surgery, because the original dissection planes are no longer present or have been altered. Dense adhesions may prevent mobilization of the tissues in the area. This is also true in patients with large hernias or previous interventions including various techniques of endoluminal treatment of gastroesophageal reflux. Stretta has been shown to slightly increase the adhesions around the distal esophagus. Endoscopic fundoplication (ie, Esophyx, Endogastic Solutions, Redmond, WA) can cause adherence of the GE junction to the diaphragm and other tissues. Full understanding of the specific anatomy of the endoscopic repair is necessary to proceed with the dissection of the GE junction. Identification of the distal esophagus amongst previous scar tissue can be aided by a lighted Bougie. Some devices are made that incorporate infrared catheters into a balloon dilator to both size the esophagus and identify it safely. Perforation can also occur when instruments and bougies are passed into the esophagus. The perforation secondary to passage of dilators may be at the GE junction and readily visible, or could be higher including the oropharynx. The most important aspect of an esophageal perforation is to identify the perforation intraoperatively, repair it, and drain it. If it goes unrecognized and is not repaired, there is a high likelihood that peritonitis, mediastinitis, or empyema could result. To investigate a potential esophageal injury, methylene blue can be placed into the distal esophagus via nasogastric tube, or an intraoperative upper endoscopy with air insufflation with the esophagus underwater can be performed.1 At our centers, intraoperative endoscopy is a very sensitive and effective technique for identification of mucosal injury and adequate insufflation of the distal esophagus and is routinely used.
A recognized perforation of the distal esophagus can be repaired with single-layer absorbable suture. Running versus interrupted repair depends on surgeon preference and the size of the perforation. In most cases, reinforcement of the repair should be made with a wrap of the stomach. The wrap can be a partial anterior or posterior wrap fashioned to cover the repair or a full wrap. Extra care must be taken to pass an esophageal dilator to size the wrap if a full 360-degree wrap is being created after repair. The initial plan of the operation may need to be changed to enable the wrap to cover the repaired segment. A swallow study should be obtained prior to feeding. Various bio adhesives and sealants are now available. No solid data exist that mandate the use of these agents to help seal a high-risk repair. However, many surgeons would utilize these agents to help reduce the risk of failure.
The majority of perforations or leaks from an esophageal surgery will be noticed during the procedure and will be repaired at that time. Following fundoplication, most patients do exceedingly well. Signs of infection or sepsis are rare. Most patients have little nausea, and few need prolonged hospital stays. Any deviation of the routine postoperative course demands further evaluation. High-risk patients, such as those undergoing reoperative surgery, should be routinely investigated following surgery. If a patient has fever, tachycardia, or leukocytosis after surgery, an unrecognized leak may be the culprit. If the patient is otherwise stable, then the esophagus and wrap should be evaluated with a water-soluble contrast study. If the patient is septic, then an urgent trip to the operating room is warranted. Patients with continued clinical deterioration or equivocal or nondiagnostic studies are probably best treated with reexploration and wide drainage. At the time of exploration, primary repair may be accomplished. Primary surgical repair should be done, with an attempt to cover the repair with the rewrapped fundus and adequate drainage. However in some situations, specifically if there has been a delayed presentation of the perforation, primary repair may not be feasible, because of the inflammation of the surrounding tissues. In difficult situations, drainage may be all that is possible, creating a controlled fistula. Access to the GI tract and placement of a nasogastric tube is usually desirable. One should also consider diversion of the esophagus via a cervical esophagostomy, especially when the perforation of the esophagus is quite high or the patient is under severe duress.
Recently, coated esophageal stents have been shown to be useful in the treatment of esophageal or anastomotic leaks. The stents are placed endoscopically either at the time of exploration for the leak, or as a separate procedure. The stent allows the enteric contents to remain intraluminal, thereby decreasing or eliminating the inflammatory process and sepsis. The stents are left in place on average for 6 weeks. During that time, the patients are closely monitored for ongoing sepsis or additional complications. After stenting, the patients can be started on distal enteral feeds, with many patients progressing to oral feeds with the stents in place.
Achalasia is a relatively rare disease process. Treatment options have included endoscopic dilatation, injection of Botulism toxin, and surgical myotomy. Despite this, there is a significant interest in this disease by laparoscopic surgeons. Treatment of the disease incorporates several facets of minimally invasive therapies. Multimodality therapy includes endoscopy, laparoscopy, and possibly thoracoscopy. Laparoscopic Heller myotomy has emerged as the standard first-line therapy for this disease. The procedure involves dividing the muscular wall of the esophagus and separating the mucosal layer of the esophagus from the circular muscle. Because of the fine detail of this procedure, a number of complications can occur. Those resulting in esophageal injury will be addressed in this chapter.
The requirements of a Heller myotomy are to release the constricting bands of the circular muscle around the distal esophagus. One of the most likely intraoperative complications from this is a perforation of the esophageal mucosa. In many series of Heller myotomy, very few life-threatening complications occur postoperatively, including those in patients who have an esophageal perforation. The detection of perforation must be made intraoperatively if possible. As with other esophageal surgery, routine use of intraoperative endoscopy allows careful inspection of the esophageal mucosa and insufflation of the distal esophagus as well. Perforation is not a reason by itself to convert the procedure to an open operation. Care must be taken however to avoid a perforation. An experienced laparoscopist should do this phase of the dissection. Initial studies have shown that the use of a robot for this aspect of the surgery has a significantly lower perforation rate than laparoscopy alone (Melvin, personal communication, 2004).2 To safely repair the mucosa, most surgeons recommend simple closure with interrupted absorbable suture and then patched with a partial fundoplication either anterior (Dor) or posterior (Toupet). In the event of a mucosal suture line anteriorly, an anterior wrap that overlays the repair would be indicated.3
Many patients are not being referred for surgery until at least one or more attempts at nonoperative management of their disease have been performed. Because of the potential of scarring at the esophagus, particularly between the circular muscle and the mucosa, the question has been raised as the whether there is a higher incidence of perforation. Subjectively, it appears that the increased inflammatory response resulting from attempts at dilation or intrasphincteric injection would complicate the surgical procedure. Bloomston et al4 showed that there was no appreciable difference in the outcomes of those who underwent premyotomy interventions compared with those who had not.
Minimally invasive techniques have been used in a variety of different applications to accomplish esophagectomy. Three anatomical compartments must be addressed: the chest, neck, and abdomen. Some groups have advocated a right thoracoscopic approach for mobilization of the esophagus, followed by an abdominal approach with a neck incision. Others have advocated for a total abdominal approach using the abdominal access for the complete mediastinal dissection. The upper mediastinum is difficult to approach using standard laparoscopic instrumentation. Some centers have adopted the use of robotic telemanipulators to dissect the mediastinal esophagus, demonstrating the advantage of multi-articulated instruments and enhanced visualization inherent to robotic devices. Whichever technique is used, advanced surgical and laparoscopic skills are required. An esophagectomy is also a multi-step procedure with several potential pitfalls.
The blood supply to the stomach is quite redundant. The gastric tube is dependent on the right gastroepiploic artery for its entire length through the chest. Throughout the procedure, care must be taken to handle the stomach atraumatically. The minimally invasive approach is significantly different in this regard, because rigid laparoscopic instruments may tear or injure the stomach. The mobilization must be stepwise to ensure no trauma to the epiploic vessels, keeping division of the greater omentum just outside the gastroepiploics. At the transition point to the short gastric vessels, dissection can proceed directly along the stomach wall. As energy is applied, care must be taken to avoid burning the stomach wall, which could manifest later as a perforation of the gastric tube. Division of the vessels close to the wall of the stomach also avoids large omental attachments to the stomach that could hinder passage into the mediastinum. Creation of the gastric tube should proceed with an endoscopic stapling device from distal to proximal. The width of the gastric tube is controversial, but large redundant tubes are not desirable and offer little benefit over more narrow tubes. Many authors favor suture reinforcement of the long gastric staple line. The most proximal portion of the tube will develop ischemic changes first; unfortunately, this is the end of the tube that will be used for the anastomosis. If ischemic changes are manifest before completion of the proximal anastomosis, then reevaluation of the gastric tube is mandatory. Unfortunately, it is very easy to twist the stomach graft, especially when the pull through is performed relatively blindly through the hiatus. Stay sutures should be used to orient the gastric pouch.5 Visualization of the tube as it is pulled up into the mediastinum is also necessary to ensure that torsion or undue tension is not seen. If the proximal tip appears necrotic, then it must be resected followed by reevaluation to ensure that the anastomosis is of an adequate length. In the event of a catastrophe where a large portion of the tube is necrotic, one must be prepared to use a different conduit, either colon or jejunum.
In the process of completely dissecting the esophagus free from the hiatus, a large potential hiatal hernia is created. This must be closed and the gastric tube must be secured to the crura. Straining and valsalva maneuvers can put stress on this area, and herniation of abdominal contents through this potential space has been described.5 Basic hernia principles must be adhered to including good approximation of tissues between the stomach tube and both the crura that does not put the tissues under tension. In addition, care must be taken not to close the hiatus too tightly around the stomach creating a relative outlet obstruction.
While dissecting the esophagus out of the mediastinum, transhiatally or thoracoscopically, the lung parenchyma can be damaged. This can be in the form of a contusion, or a tear. Contusions should be left alone and allowed to heal conservatively. Tears may require wedge resection if they are large; otherwise, chest tube drainage should be sufficient. Pulmonary complications are frequent in this operation, so care should be taken to avoid damaging the lung. In addition, good communication between the surgical and anesthetic teams is imperative. If thoracoscopy is being performed, the right lung must not be ventilated during that phase of the operation. In procedures where the chest cavity is not instrumented pneumothorax can still occur. A postoperative chest radiograph will help demonstrate the final position of a gastric tube and screen for fluid collections or pneumothorax.
Great Vessel Injury
The pulmonary and systemic vessels run in close proximity to the esophagus. Patients undergoing a minimally invasive approach for esophagectomy should be selected carefully. Transhiatal approaches are not a good choice for patients with large bulky tumors above the GE junction. Tumors at the level of the pulmonary hilum can be challenging and should be considered with great care. When the azygous vein is transected during the thoracic approach, undue tension on that vessel during dissection must be avoided. Hemostatic control with staplers rather than ligatures can help prevent hemorrhage. The best way to prevent an injury to these vessels is to perform careful dissection and limit the amount of blunt dissection. During open transhiatal surgery, the mediastinal structures can be palpated. This perception is not possible using laparoscopic approaches, and therefore it is necessary to do as much of the dissection as possible using direct vision. In the event of an injury to one of the pulmonary or systemic great vessels, emergent thoracotomy, usually from the right side, is the only correct action. Therefore, thoracotomy instruments must be available in the operating room to facilitate a rapid conversion to an open procedure.
Recurrent Laryngeal Nerve Injury
In a transhiatal esophagectomy, the final dissection of the esophagus is done blindly as the esophagus is removed. The recurrent laryngeal nerves are sometimes immediately adjacent to the esophagus and therefore their injury cannot be avoided. All dissection from the cervical side should avoid the visible nerves. Attention should focus on staying posterior to the trachea and protecting the nerve higher in the neck. The nerve injury will likely go unnoticed until extubation when the patient attempts to talk. If the injury is unilateral, the patient will be hoarse, but will not have airway compromise. If the injury is bilateral, an urgent compromise of the airway will ensue upon extubation. This will likely require tracheostomy.
To avoid this complication, a thoracoscopic dissection of the esophagus would help to eliminate the blind dissection of the upper esophagus. There is a trade-off with this approach, as there is reportedly a higher pulmonary complication rate.6 If recurrent laryngeal nerve injury is suspected and there has been no resolution of symptoms after 4 weeks to 6 weeks, a laryngoscopic examination from an Otolaryngologist will confirm the deficit. At that time, the palsied cord can be injected to improve airway compromise and voice quality.7,8
The primary reason for avoiding an anastomosis in the chest is to avoid an intrathoracic leak. Uncontrolled drainage into the chest is very morbid and is often associated with pulmonary failure and a prolonged hospital stay. Routine evaluation at postoperative day 5 through 7 is used in most centers to screen for anastomotic leaks and graft patency. If a leak is suspected earlier due to hemodynamic compromise or a septic appearance, the anastomosis or gastric staple line needs to be evaluated. A water-soluble contrast study should be obtained as soon as possible if the patient is stable. If a leak is confirmed and the drains placed at surgery are functioning adequately, then further intervention is not necessary. If a fluid collection is present or drainage is not adequate, then tube thoracostomy or re-exploration with drainage may be needed. A feeding jejunostomy should be placed at the time of the initial surgery. The long-term result following a leak is still good.10 Most leaks will heal, given time and adequate nutrition. Although some go on to stricture formation, operative intervention is rarely needed.
Cervical Anastomotic Leak
One of the biggest advantages of having the proximal anastomosis in the neck is so that in the event of an anastomotic breakdown, the drainage procedure can be performed at the bedside. At the initial operation, a drain should be placed in the wound bed. We prefer a soft Penrose drain brought out through the bottom of the incision. If a leak develops, saliva is seen in the drainage and the wound can be opened down to the level of the anastomosis and packed open. Only local wound care with dressing changes is necessary. A nasogastric tube should be left in place if possible to facilitate drainage.7,8 As with an intrathoracic leak, jejunostomy feedings should be the sole source of nutrition until the leak has healed.
Delayed Gastric Emptying
Unless the esophageal conduit is the colon and a vagal-sparing esophagectomy was performed, the vagal nerves will be sacrificed in the esophagectomy procedure. Because of the associated poor motility of the pyloric channel, many surgeons will perform a pyloroplasty. This should facilitate the free flow of food through to the small bowel. More and more surgeons, however, are electing to either perform a pyloromyotomy to avoid another enterotomy or just do nothing with the pylorus. Some patients will experience temporary delayed emptying, but almost all will eventually allow passage of food and have normal emptying.9
To help with delayed emptying, either in the short- or long-term, promotility agents can be used. These would include metoclopramide or erythromycin. If the dysmotility is refractory to medical therapy and a pyloric stenosis is confirmed by contrast study or endoscopy, then balloon dilatation or Botox injection of the pyloric channel can be attempted. Rarely, if dilation is unsuccessful and symptoms persist, then a surgical pyloroplasty may need to be done to alleviate the delayed emptying.8
The advantages of minimally invasive surgery can be used to reduce the significant risks associated with esophageal surgery. Despite multiple significant problems that can occur while laparoscopic esophageal surgery is being performed, these procedures can be performed safely and effectively. Though these operations are associated with steep learning curves, over time surgeons can become adept at doing these cases expeditiously and with minimal complications. Nonetheless, complications will arise. But with careful management, the setbacks that occur should not discourage a skilled surgeon from continuing to perform these procedures.
Address correspondence to: W. Scott Melvin, MD, Department of Surgery, The Ohio State University, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA. Telephone: (614) 293-4499, Fax: (614) 293-4030, E-mail: [email protected]
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