47●● Liquid by mouth is started on day 1 post-operation; usually, a
carbohydrate drink can be taken as sips of fluid. This is gently
advanced. Early commencement of oral intake enhances patient
comfort and has metabolic advantages with caloric intake.
Generally, by day 3–4 patients can take a liquid diet freely. A
soft diet is started on day 5 post-operation. An oral contrast
study is not routine unless leakage is suspected or if there is
evidence of delayed gastric emptying. The author does not
place feeding jejunostomy as a routine because early oral ali-
mentation is successful in most patients, and most do not need
supplementary nutritional support. Should oral intake is
delayed, such as when anastomotic leak occurs; endoscopic
placement of a naso-duodenal tube for feeding will suffice.4 Notes
- Success of esophagectomy depends on coordinated efforts
among different members of a multidisciplinary team, and not
just surgical method alone. Medical complications after esopha-
gectomy are mostly cardiopulmonary in nature. Arrhythmia,
usually in the form of atrial fibrillation and supraventricular
tachycardia, may occur in up to 25% of patients [ 14 ]. Although
its occurrence is usually benign in itself, it should trigger a care-
ful search for underlying causes; surgical sepsis and pulmonary
complications being most common. Sputum retention, atelec-
tasis are also common, proactive pulmonary support should be
instituted to prevent progression to pneumonia [ 15 ]. - Conduit ischemia—Preparation of the gastric conduit requires
care. The method of gastroplasty may affect vascular perfusion.
The length of the right gastroepiploic arcade varies among
individuals but the blood supply of the fundus of the stomach
relies more on the intramural plexus. A narrower gastric tube
may compromise the blood supply to the stomach (significant
contribution comes from the lesser curvature side has been
removed), but then the tube is longer and the suboptimally
perfused top of the stomach can be resected. A wider gastric
tube on the other hand tends to have a better blood supply,
but is shorter. Recent advances in indocyanine green fluores-
cence allows for intraoperative assessment of gastric perfusion,
with the potential to reduce the incidence of ischemia and
anastomotic leaks [ 16 ].
Gross ischemia of the conduit usually presents early, within
the first 2–3 days after operation. Sepsis is obvious. However, in
the early stage signs may be subtle, which could simply be unex-
plained tachycardia, atrial arrhythmia, or poor arterial oxygen-
ation. It is important to treat this complication expeditiously so
Surgery for Esophageal Adenocarcinoma