48
that further deterioration does not occur. A high index of sus-
picion is required. A low threshold for endoscopic examination
is recommended to examine the state of the conduit and anas-
tomosis whenever there are signs of deterioration. Gross isch-
emia dictates taking down of the conduit, adequate drainage,
and staged reconstruction later once sepsis is under control. In
selected cases with ischemia limited to a small portion of the
gastric conduit, when the patient is hemodynamically stable
with minimal sepsis, and when an adequate length of stomach
remains after resection of the ischemic portion, immediate re-
anastomosis is an option.- Recurrent laryngeal nerve injury—this should be uncommon
unless bilateral recurrent laryngeal nerve lymphadenectomy is
carried out, which is not routine for esophageal adenocarci-
noma. In these cases, it is most often due to careless and force-
ful retraction. When it is unilateral, it would result in hoarseness
of voice, poor cough effort, and increased chance of aspiration.
When it is bilateral, airway compromise is the rule and trache-
ostomy and delayed feeding is required. Long-term quality of
life is also affected. - Chylothorax—routine mass ligation of areolar tissue on the
aorta just above the hiatus should lessen the chance of chylous
leak. Persistently high output from the chest tube, often more
than a liter a day, should prompt the search for this complica-
tion. A milk challenge via a nasogastric tube or by mouth look-
ing at the color change of the drain effluent into a milky fluid
is diagnostic. Other biochemical parameters that could be
looked at include triglyceride level, and the presence of chylo-
microns in the drain output after milk challenge. After the
diagnosis is confirmed, low output chylothorax (less than 1 L
per day) could be treated by a short period of nil by mouth
with total parenteral nutrition, or a diet with mid-chain triglyc-
eride. Early surgical re-exploration however has a higher chance
of success and prevents deterioration related to constant loss of
lymphocytes and proteins from the effluent fluid. Preoperative
lymphangiogram may help locate the site of chylous leak [ 20 ]. - Anastomotic leak—conduit vascular perfusion plays a signifi-
cant part in the etiology of this complication. The actual tech-
nique of anastomosis probably is less important than its proper
application. Thus, hand-sewn or stapled methods should have
similar leak rates [ 17 – 19 ]. Cervical anastomosis tends to have
a higher leak rate compared to intrathoracic leaks, though it is
believed to be less lethal because drainage is more easily accom-
plished. Death from leaks should be uncommon with modern
management.
Clinically apparent thoracic anastomotic leaks usually occur
within the first week. Signs of sepsis, excessive output from the
Simon Law