International International Multidisciplinary Multidisciplinary e Journal/ e-journal Dr. A. Razaque Shaikh, Dr. Khenpal Das, Dr Shahida Khatoon ISSN 2277. (133-140) - 4262 POSTOPERATIVE COMPLICATIONS OF TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL CARCINOMA Dr. A. Razaque Shaikh, Dr. Khenpal Das, Dr Shahida Khatoon Department of Surgery Liaquat University of Medical & Health Sciences, Jamshoro, Sindh, Pakistan Paper Received on: 19/05/2014 Paper Reviewed on: 30/05/2014 Paper Accepted on: 25/06/2014 Abstract The objective of this study is to determine the postoperative complications in patients with esophageal carcinoma underwent transthoracic esophagectomy at Liaquat University Hospital Hyderabad / Jamshoro. This one year (from january 2013 to Dec 2013 ) descriptive study was conducted in the department of Surgery Liaquat university hospital Jamshoro / Hyderabad. Patients of esophageal carcinoma, 40 to 70 years of age, either gender, were in stage I, II and III recruited and enrolled in the study. The data was entered and analyze in SPSS 11.00. The frequency and percentage was calculated while the mean ± standard deviation was calculated for numeri cal variables. During study period total fifty patients with esophageal carcinoma were recruited and studied, of which 30(60%) were males and 20(40%) were females. The majority of the patients 23(46%) were in 50-59 years of age. The mean age ±SD of the male an d female subjects was 57.86±6.43 and 53.62±8.73 respectively. Regarding the site of carcinoma, 32(64%) had middle 1/3 and 18(36%) had lower 1/3 while regarding the type of carcinoma, 40(80%) had squamous cell carcinoma and 10(20%) had adenocarcinoma. The postoperative complications observed were, cardiac 03(15%), pulmonary 04(20%), anastomotic leakage 02(10%), vocal cord paralysis in 02(10%), chylous leakage 02(10%), wound infection 01(05%), in-hospital mortality 01(05)% and mixed combination in 05(25%). The common postoperative complications were identified were cardiac pulmonary, anastomotic leakage and mixed complications. Keywords: Carcinoma oesophagus, transthoracic, complications. INTRODUCTION: Esophageal cancer is the eighth most common cancer worldwide, with a wide variation in its frequency between high- and low-incidence regions. There are two main histopathological subtypes: squamous cell carcinoma (SCC) and adenocarcinoma. SCC is the most www.shreeprakashan.com Vol-III, Issue-VI, June-2014 Page 133
common subtype in several endemic regions of the world with a high correlation to smoking and alcohol abuse, as well as chronic inflammation. 1, 2 On the other hand, adenocarcinoma is commonly associated with Barrett s metaplasia, gastroesophageal reflux disease (GERD), and obesity. 3 On the other hand, adenocarcinoma is commonly associated with Barrett s metaplasia, gastroesophageal reflux disease (GERD), and obesity. It has become the most common subtype in the western hemisphere, and frequently involves the gastroesophageal junction (GEJ) and proximal stomach. SCC and adenocarcinoma of the esophagus are distinct entities and should be considered as such when defining optimal therapy. Multiple approaches have been described for esophagectomy, and they can be thematically categorized under two major headings: transthoracic or transhiatal. The transthoracic procedure is performed more commonly by means of combined laparotomy and right thoracotomy (Ivor Lewis procedure). Other options include left thoracotomy with or without cervical incision, a single left thoracoabdominal incision, or a three incision resection with a cervical anastomosis (McKeown procedure). Transthoracic esophagectomy is most commonly performed via laparotomy followed by right thoracotomy and intrathoracic anastomosis (Ivor Lewis procedure). It was originally described in 1946 in two stages, 4 and historically, it is the standard procedure against which all other techniques are measured. Left thoracotomy or thoracoabdominal incision provides adequate exposure to the distal esophagus, but presents greater difficulty to access the upper and middle thirds and to perform an anastomosis high in the chest. The theoretical advantage of the transthoracic approach is a more thorough oncological operation as a result of direct visualization and exposure of the thoracic esophagus, which allows a wider radial margin around the tumor and more extensive lymph node dissection. The three-incision modification of the procedure effectively eliminates the potential for complications associated with an intrathoracic esophagogastric anastomosis. 5 The present study was conducted to determine postoperative complications in patient with esophageal carcinoma underwent transthoracic esophagectomy at tertiary care teaching hospital, so that such surgical technique can be applied in future and effective measures can be taken to prevent these complications. ATIENTS AND METHODS: This one year descriptive case series study was conducted in the department of Surgery Liaquat university hospital Jamshoro / Hyderabad The patients of either gender with esophageal carcinoma either adenocarcinoma or squamous cell carcinoma of lower and middle one third with stage I, II or III were recruited and entered in the study.carcinoma in upper one www.shreeprakashan.com Vol-III, Issue-VI, June-2014 Page 134
third of esophagus, advanced / non resectable carcinoma esophagus (Stage IV), and patients with comorbid were excluded from the study. All the detail history of the subjects was taken and relevant physical examination was performed. The informed consent was taken from every patient after explaining the full procedure of the study. The data was collected on predesigned proforma. The data was entered, saved and analyzed in SPSS version 11.00. The frequency and percentage (%) was calculated. The mean ± standard deviation was calculated for numerical variables. The stratification was done for age, gender and postoperative complications. RESULTS: During study period total fifty patients with esophageal carcinoma were recruited and studied, of which 30(60%) were males and 20(40%) were females. The majority of the patients 23(46%) were in 50-59 years of age. The mean age ±SD of the male and female subjects was 57.86±6.43 and 53.62±8.73 respectively. Regarding the site of carcinoma, 32(64%) had middle 1/3 and 18(36%) had lower 1/3 while regarding the type of carcinoma, 40(80%) had squamous cell carcinoma and 10(20%) had adenocarcinoma. The age in relation to gender is shown in Table 01 while the gender in relation to type and site of carcinoma are shown in Table 02 and 03 whereas the stage in relation to type of carcinoma is shown in Table 04. The complications were observed in 20(40%) patients and are shown in Table 05. TABLE 01: AGE IN RELATION TO GENDER GENDER Male Female AGE 40-49 8 3 11 26.7% 15.0% 22.0% 50-59 17 6 23 56.7% 30.0% 46.0% 60-70 5 11 16 16.7% 55.0% 32.0% 30 20 50 www.shreeprakashan.com Vol-III, Issue-VI, June-2014 Page 135
TABLE 02: THE GENDER IN RELATION TO TYPE OF ESOPHAGEAL CARCINOMA TYPE Squamous Adenocarcinoma GENDER Male 25 5 30 62.5% 50.0% 60.0% Female 15 5 20 37.5% 50.0% 40.0% 40 10 50 TABLE 03: GENDER IN RELATION TO SITE OF ESOPHAGEAL CARCINOMA SITE Middle Lower GENDER Male 20 10 30 62.5% 55.6% 60.0% Female 12 8 20 37.5% 44.4% 40.0% 32 18 50 www.shreeprakashan.com Vol-III, Issue-VI, June-2014 Page 136
TABLE 04: THE STAGE IN RELATION TO TYPE OF ESOPHAGEAL CARCINOMA Squamous TYPE Adenocarcinoma STAGE I 5 2 7 12.5% 20.0% 14.0% II 13 4 17 32.5% 40.0% 34.0% III 22 4 26 55.0% 40.0% 52.0% 40 10 50 TABLE 05: THE POSTOPERATIVE COMPLICATIONS IN RELATION TO GENDER GENDER Male Female COMPLICATIONS Cardiac 2 1 3 15.4% 14.3% 15.0% Pulmonary 2 2 4 15.4% 28.6% 20.0% Anastomotic leakage 1 1 2 7.7% 14.3% 10.0% Vocal cord paralysis 2 00 2 15.4% 0% 10.0% Chylous leakage 1 1 2 7.7% 14.3% 10.0% Wound infection 1 00 1 7.7% 0% 5.0% In-hospital mortality 1 00 1 7.7% 0% 5.0% Mixed 3 2 5 23.1% 28.6% 25.0% 13 7 20 DISCUSSION: The present study has identified 40% different complications in patients with esophageal carcinoma who underwent transthoracic esophagectomy. The transthoracic resections have the disadvantages of a formal thoracotomy that may leads to higher number of pulmonary www.shreeprakashan.com Vol-III, Issue-VI, June-2014 Page 137
complications and confirmed by the present study. It can be associated with transient deterioration of pulmonary function, although with modern anaethesia techniques and perioperative respiratory care the incidence of cardiopulmonary complications might decrease. The finding is consistent with the study by Jacobi CA, et al. 6 The incidence of anastomotic leakage varied widely (3% to 50%), which is probably a definitional problem: some authors mentioned only clinically significant leaks, whereas others included both subclinical and clinical leaks. In transthoracic resections, the anastomosis can be made in the cervical region, but often it is made in the chest. A cervical anastomosis carries a higher risk of leakage than an intrathoracic anastomosis, but the risk of (highly lethal) mediastinitis diminishes when leakage occurs. 7-9 However, most cervical leakages are subclinical, ie, only seen radiologically, and do not 10, 11 require surgical exploration because they resolve spontaneously 10 to 35 days postoperatively. Vocal cord paralysis from injury of the recurrent larynggeal nerve is another frequent complication of esophagectomy, but frequently the paralysis resolves within a few months. 12 A high incidence of vocal cord paralysis was mentioned after cervical anastomoses, after both transthoracic and transhiatal procedures, indicating that the recurrent nerve is mainly at risk during the cervical dissection and the construction of the anastomosis. The finding is consistent with the study by Gelpke H et al. 13 In present study 5% mortality was observed, twenty years ago the average hospital mortality rate after resection of esophageal carcinoma was 29%. 12 Ten years later the resection mortality rate was more than halved to 13%. 12 Mortality rates varied widely (0% to 27.8%) and decreased with increasing experience. 12 Transthoracic resections lead to more pulmonary complications, which might also be reflected in the prolonged stay in the intensive care unit. Transthoracic resections had a higher risk of chylous leakage or wound infection, but those complications rarely were lethal. The findings are consistent with the study by Weijs TJ et al and Rutegård M, et al. 14,15 The perioperative mortality of transthoracic esophagectomy in experienced centers ranges from 9% to as low as 1.4%. 16 Five-year survival in approximately 25% of patients who undergo transthoracic esophageal resection has been reported. 17 These reports include heterogeneous populations of patients with esophageal cancer that underwent a variety of surgical approaches, the use of adjuvant treatment in some but not all patients, and combined histologies (SCC and adenocarcinoma). 18 In a fit patient with evidence of a limited number of involved lymph nodes, there is some evidence that suggests a benefit in survival with the www.shreeprakashan.com Vol-III, Issue-VI, June-2014 Page 138
transthoracic approach. Former published literature suggests that experience of the surgeon and hospital is likely to be a more important factor than is the type of approach selected. 18 CONCLUSION: The postoperative complications were observed in 40% of patients with esophageal carcinoma underwent for transthoracic esophageal resection. Therefore surgeons interested in this lethal disease should direct their efforts to more accurate identification of those patients that will likely benefit from different treatment strategy and suggest their therapeutic measures accordingly. References 1. Kamangar F, Dores GM, Anderson WF. Patterns of cancer incidence, mortality, and prevalence across five continents: defining priorities to reduce cancer disparities in different geographic regions of the world. J Clin Oncol 2006; 24: 2137-2150 2. Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med 2003; 349: 2241-2252 3. Cameron AJ, Romero Y. Symptomatic gastro-oesophageal reflux as a risk factor for oesophageal adenocarcinoma. Gut 2000; 46: 754-755 4. Lewis I. The surgical treatment of carcinoma of the oesophagus: with special reference to a new operation for growths of the middle third. Br J Surg 1946; 34: 18-31 5. Barreto JC, Posner MC. Transhiatal versus transthoracic esophagectomy for esophageal cancer. World J Gastroenterol. 2010;16(30):3804-10. 6. Jacobi CA, Zieren HU, Mu ller M, Pichlmaier H. Surgical therapy of esophageal carcinoma: the influence of surgical approach and esophageal resection on cardiopulmonary function. Eur J Cardiothorac Surg 1997;11:32 7. 7. Horstmann O, Verreet PR, Becker H, Ohmann C, Ro her HD.Transhiatal oesophagectomy compared with transthoracic resection and systematic lymphadenectomy for the treatment of oesophageal cancer. Eur J Surg 1995;161:557 67 8. Tilanus HW, Hop WCJ, Langenhorst BLAM, Van Lanschot JJB. Esophagectomy with or without thoracotomy. J Thorac Cardiovasc Surg 1993;105:898 903. www.shreeprakashan.com Vol-III, Issue-VI, June-2014 Page 139
9. Putnam JB, Suell DM, McMurtey MJ, et al. Comparison of three techniques of esophagectomy within a residency training program. Ann Thorac Surg 1994;57:319 25. 10. Svanes K, Stangeland L, Viste A, Varhaug JE, Gronbech JE, Soreide O. Morbidity, ability to swallow, and survival, after oesophagectomy for cancer of the oesophagus and cardia. Eur J Surg 1995;161:669 75. 11. Daniel TM, Fleisher KJ, Flanagan TL, Tribble CG, Kron IL. Transhiatal esophagectomy: a safe alternative for selected patients. Ann Thorac Surg 1992;54:686 90 12. Iannettoni MD, Whyte RI, Orringer MB. Catastrophic complications of the cervical esophagogastric anastomosis. J Thorac Cardiovasc Surg 1995;110:1493 501 13. Gelpke H, Grieder F, Decurtins M, Cadosch D. Recurrent laryngeal nerve monitoring during esophagectomy and mediastinal lymph node dissection. World J Surg. 2010;34(10):2379-82 14. Weijs TJ, Ruurda JR, Nieuwenhuijzen GAP, van Hillegersberg R, Luyer MDP. Strategies to reduce pulmonary complications after esophagectomy. World J Gastroenterol. 2013;19(39):6509 14. 15. Rutegård M, Lagergren P, Rouvelas I, Mason R, Lagergren J. Surgical complications and longterm survival after esophagectomy for cancer in a nationwide Swedish cohort study. Eur J Surg Oncol. 2012;38(7):555-61 16. Chang AC, Ji H, Birkmeyer NJ, Orringer MB, Birkmeyer JD. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg. 2008;85(2):424-9. 17. Colvin H, Dunning J, Khan OA. Transthoracic versus transhiatal esophagectomy for distal esophageal cancer: which is superior?.interact Cardiovasc Thorac Surg. 2011;12(2):265-9 18. Hulscher JB, Tijssen JG, Obertop H, van Lanschot JJ. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg. 2001;72(1):306-13. www.shreeprakashan.com Vol-III, Issue-VI, June-2014 Page 140