Clinical Analysis of Postoperative Complications in Radical Resection of Esophageal Carcinoma.pdf

1、BACKGROUND: Esophageal resection is a demanding and complex procedure due to the massive blood loss, with high rate of intraoperative and postoperative complications, including major complications like pulmonary complica

2、tions, anastomotic leakage, chylothorax, anastomosis stricture, laryngeal nerve palsy, delayed gastric emptying etc. Surgical resection is the only effective approach for esophageal carcinoma and esophagogastric junction

3、. Esophageal resection and reconstruction still remains an inevitable challenge. Challenges of removing esophagus traversing 3 distinct anatomic zones in the body(neck, chest and abdomen) and reconstruction of the gastro

4、intestinal tract has led to a considerable variation in technique. Although various kinds of instruments can be used during surgical procedure but there are many well-known risk factors for morbidity and mortality during

5、 esophageal resection, with poor long-term outcomes and adverse effect in the patient quality of life. Numerous variables including etiology of the disease,patients demographics, comorbidities, disease state, treatment v

6、ariables, age criteria,gender， surgeons experience, preoperative variables and the surgical procedures should be considered when discussing operative complications.
　　 Aim: The aim of this clinical analysis was to c

7、linically analyze the postoperative complications in radical resection of the esophageal carcinoma. To analyze and understand the main causes for the major postoperative complications and to study the effective methods t

8、o minimize the postoperative complications.
　　 Objectives: To evaluate the complications after esophagectomy, to investigate the causes and reasonable methods to help prevent the complications to possible extent. Thi

9、s retrospective clinical analysis was done to conduct and evaluate the postoperative complications, factors effecting the complications, surgical approach, blood loss, total hospital stay, duration of ICU stay and many o

10、ther factors.Methods:From the period of December 2009 to December 2012, total of 211 clinical patients underwent the procedure of radical esophagectomy: transthoracic esophagectomy (TTE-involving a thoracotomy) or transh

11、iatal esophagectomy (THE-not involving thoracotomy), with lymphadenectomy. The detailed necessary medical information for all the patients undergoing esophagectomy was noted. The median age was 61.95 years(range 61.95±7.

12、56 yrs). In accordance with the histology, squamous cell carcinoma(SCC) in 202 cases (95.73％), adenocarcinoma (AC) in 8cases (3.79％) and other carcinoma in 1 case (0.47％) were noted.The clinical TNM staging, according to

13、 the UICC[6]，were as following: Stage 0-I 15 cases (7.1％), Stage Ⅱa 39 cases (18.4％),Stage Ⅱb 46 cases (21.8％), Stage Ⅲa 87 cases (41.2％), Ⅲb 18 cases (8.5％) and Stage Ⅲc 5(2.3％) cases.ASA class was assigned by the anest

14、hesiologist after completing a structured review of physical status just before the surgery, and 3cases of ASA 1,123 cases of ASA 2, 84 cases of ASA 3, and 1 case of ASA 4 were noted respectively.The esophageal reconstru

15、ction was performed by the gastric tube in all the 21 1 patients, out of which patients undergoing Traditional Open Thoracotomy (TOT) (n=122) and VATS(Video Assisted Thoracic Surgery) (n=89) were noted.After the esophage

16、al resection with the reconstruction of the stomach, the fundus of the stomach was then anastomosed with the remaining normal esophagus stump, making a complete conduit allowing the later delivery from the stomach to the

17、 thoracic cavity of the neck.In the 211 clinical patients, the esophagogastric anastomosis done by stapling technique is 183 cases, the manual suturing technique 28 cases. Out of which, the intrathoracic anastomosis by s

18、tapling technique were performed in 183 cases, cervical anastomosis by manual suturing technique in 28 cases, and cervical anastomosis by stapling technique in 47 cases.
　　 Result: The median duration of the operatio

19、ns was 307.53±79.59 minutes (120 to 615 min).Also the overall mean surgery duration for patients undergoing TOT was relatively shorter than patients undergoing VATS(282.85±78.77 min vs 341.36±67.71min; p=0.036).The mean

20、volume of blood loss was 284.36±197.43 ml (range 40 to 1500 ml),with mean volume of blood transfusion: RBC 54.98±132.42 ml and Plasma 42.18±113.69 ml.Patients undergoing VATS, the mean volumes of bleeding (207.19±143.85

21、ml vs 340.66±212.19 ml, p=0.018) and blood transfusion (RBC 29.21±106.82 ml vs 73.77±145.91 ml, p＜0.001; Plasma 43.48 ±58.76 ml vs 63.11±137.99 ml, p＜0.001) respectively, were markedly less then patients undergoing TOT.T

22、he total number of patients who received blood transfusion were noted 40 cases(18.9％) and number of patients without blood transfusion were 171cases (81.1％).The metastases to lymph nodes were noted in 84 cases (39.8％).Th

23、e median numbers of resected lymph nodes were 6-8(range 12±2).Postoperative complications were seen in 113 cases (53.5％), with different complications.Two or more than two complications in 48 cases (22.7％).Out of the 211

24、 clinical patients, pulmonary complications occurred in 78 cases (36.96％).Among which ARDS in 4 cases(1.8％), respiratory failure noted in 5 cases(2.3％), pulmonary lung infection in 78 cases(53.55％), pulmonary embolism in

25、 1 case(0.4％), pulmonary edema in 3 cases (1.4％) and atelectasis in 4 cases(1.8％)respectively.Pulmonary complications were closely related with factors like elderly,gender, history of active smoking, chronic lung disease

26、 and operation duration exceeding 5 hours (all p＜0.05).Also the postoperative pulmonary complications was associated with tumor occurrence site, with upper and mid-esophageal tumor being higher than the lower esophageal

27、tumor site (p＜0.001). Anastomotic leakage were noted in 18 cases (8.5％), which was closely associated with the anastomosis site, with the upper-aortic and post-aortic anastomosis site leakage rate higher than the lower-a

28、ortic anastomosis site leakage (p=0.02).Also the hand sewen or manual anastomotic leakage rate was seen to be higher than patients with mechanical stapling technique (p=0.001).Anastomosis Stricture was noted in 7 cases (

29、0.3％), which was 8significantly associated with anastomotic leakage site (p＜0.001).Chylothorax in 7 cases(0.3％) were noted, and occurrence of chylothorax after esophagectomy was seen to be related with the site of tumor

30、and the site of anastomosis (p=0.03; p=0.04) respectively.Recurrent Laryngeal Nerve injury occurrence rate was significantly associated with lymph node metastases (p=0.038) and TNM staging with mid-stage and late stage c

31、arcinoma were relatively higher than early stage carcinoma (p=0.02), but had no significant association with the tumor occurrence site (p=0.26).The wound infection was noted in 22 cases (10.4％).The median postoperative h

32、ospital stays for all patients were 21.93 days (range 21.93±7.48 d).Also the hospital stay for patients undergoing VATS was comparatively less then patients undergoing Open Thoracotomy (21.5±7.7 d vs 22.6±7.1 d, p=0.02).

33、The mean duration of the ICU stay was 4.4±3.1 d with range from 1 d to 19 d.Also the duration of ICU stay in patients undergoing VATS was comparatively less than patients undergoing TOT (4.6±3.4 d vs 4.3±2.8 d; p=0.047).

34、The mortality rate in the hospital was 1.8％.
　　 Conclusion: Esophagectomy is a very complicated surgical procedure with a high rate of morbidity and postoperative complications, which could affect the surgical outcom

35、e and affect the patients' quality of life, but still is the main treatment for esophageal cancer.The postoperative complications are curable and preventable to certain extent with improvement in anesthesia, strict and p