Surgical treatment for cancer of the esophagus most often involves replacement of the esophagus with a gastric conduit. This gastric tube relies upon the continuity of the gastroepiploic artery for its blood supply. This case report involves a patient whose gastroepiploic artery became thrombosed by a percutaneous endoscopic gastrostomy, rendering his gastric conduit unusable.
Ivor-Lewis esophagectomy is associated with significant postoperative analgesic requirements and perioperative complications. A dual-epidural technique may improve perioperative outcomes compared with single thoracic epidural analgesia.This study identified all cases of Ivor-Lewis esophagectomy over a 3-year period. Eighty-one patients undergoing Ivor-Lewis esophagectomy who received general anesthesia supplemented by neuraxial analgesia with dual-epidural catheters (DECs) were matched 1:1 with patients who received general anesthesia and a single thoracic epidural catheter. Primary outcomes included quality of analgesia at rest and with movement on each of the first 3 postoperative days. Secondary outcomes included adverse events and the incidence of 4 major postoperative complications (anastomotic leak, pulmonary complications, atrial fibrillation, and sepsis).A DEC technique significantly improved analgesia (evidenced by reduced pain with movement on each of the first 3 postoperative days) when compared with a single epidural catheter technique. The placement of DECs did not increase catheter-related adverse events. A DEC technique was associated with a 50% reduction in the combined rate of major postoperative complications (36% vs. 18%; odds ratio, 0.40; P = 0.01) and increased number of hospital-free days measured at day 28 (21.2 vs. 22.3; P = 0.04).The DEC technique improved postoperative analgesia and reduced the incidence of major postoperative complications and hospital length of stay in patients undergoing Ivor-Lewis esophagectomy. Future studies should evaluate the efficacy of this technique in a controlled randomized clinical trial.
Objectives: Pulmonary complications remain a frequent cause of morbidity following oesophagectomy. Risk screening tools assist in patient stratification. Ferguson proposed a risk score to predict major pulmonary complications after oesophagectomy. Our objective was to validate this score externally. Methods: We analysed our institutional database for patients undergoing oesophagectomy from August 2009 to December 2012. We screened for variables necessary to calculate the risk score: FEV1, carbon monoxide diffusing capacity of the lung (DLCO), performance status and age. A total of 136 patients qualified for analysis. Outcome variables measured were major pulmonary complications, defined by reintubation for respiratory failure and pneumonia. The risk score was then calculated for each individual based on the model assigned, increasing points to variables. Incidence of major pulmonary events was assessed in the five risk groupings to assess the discriminative ability of the Ferguson score. Results: Major pulmonary complications occurred in 34.6% (47/136). Overall mortality was 5.9% (8/136). Patients were grouped into risk quintiles according to their Ferguson pulmonary risk score. Eight patients had a score of 0–2, 24 had a score 3–4, 49 had a score of 5–6, 29 with a score 7–8 and 26 with scores 9–14. The incidence of major pulmonary complications in these quintiles were 0%, 16.7%, 20.4%, 41.4% and 76.9 % (Fig. 1). The risk score system predicted pulmonary complications with an accuracy of 76.2% (P < 0.0001). Conclusion: The Ferguson pulmonary risk scoring system is a reliable instrument to be used preoperatively to differentiate those at higher risk for postoperative pulmonary complications after oesophagectomy. This data can assist in patient selection, education, informed consent, and guide postoperative management.
As part of our ongoing quality improvement effort, we evaluated our conventional approach to post-oesophagectomy management by comparing it to an alternative postoperative management pathway.Medical records from 386 consecutive patients undergoing oesophagectomy with gastric conduit for oesophageal cancer or Barrett's oesophagus with high-grade dysplasia were analysed retrospectively (July 2004 to August 2008). The conventional pathway involved a routine radiographic contrast swallow study at 5-7 days after oesophagectomy with initiation of oral intake if no leak was detected. In the alternative pathway, a feeding jejunostomy was placed for enteral feeding and used exclusively until oral intake was gradually initiated at home at 4 weeks after oesophagectomy. No contrast swallow was obtained in the alternative pathway group unless indicated by clinical suspicion of an anastomotic leak. Each group was analysed on an intention-to-treat basis with respect to anastomotic leak rates, length of hospitalisation, re-admission and other complications.A total of 276 (72%) patients underwent conventional postoperative management, 110 (28%) followed the alternative pathway. Patient characteristics were similar in both the groups. The anastomotic leak rate was lower in the alternative pathway with three clinically significant leaks (2.7%) versus 33 in the conventional pathway (12.0%; p=0.01). Among patients undergoing a radiographic contrast swallow examination, a false-negative rate of 5.8% was observed. The swallow study of 14 patients (5.9%) was complicated by aspiration of oral contrast. Postoperatively, 7.3% of patients suffered from pneumonia. There were no significant differences overall in postoperative pulmonary or cardiac complications associated with either pathway. Median length of hospitalisation was 2 days shorter for the alternative pathway (7 days) than the conventional pathway (9 days; p<0.001). There was no significant difference in unplanned re-admission rates.An alternative postoperative pathway following oesophagectomy involving delayed oral intake and avoidance of a routine contrast swallow study is associated with a shortened length of hospitalisation without a higher risk of complication after hospital discharge.
