Management and Considerations for Esophageal Treatments and Surgery

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic.

Daniel Raymond, MD:

Good morning and thank you for coming. My name's Dan Raymond, I'm one of the thoracic surgeons and the quality officer at Cleveland Clinic. Today we're going to talk about esophagectomy patients and considerations in their anatomy and physiology and how that affects the first 24 to 48 hours of management.

Esophagectomy, the procedure itself is performed primarily for mid to distal esophageal cancers and proximal gastric cancers. Esophageal cancer itself is one of the most rapidly increasing cancers in our nation presently, that being mostly in middle-aged white males because that's where obesity is concentrated and it's likely a reflux-related phenomenon.

The challenge is, is you can't take out a little piece of the esophagus and especially the lower end of the esophagus in the gastroesophageal junction. If you were to do that, say there's a cancer right here, and just take out this and put the stomach to that, you create wide open reflux. And if you think about the physiology of the differences between the stomach, the abdomen and the chest, the abdomen is consistently positive pressure. Whereas how we breathe is negative pressure. We take a breath in, our diaphragm flattens, our ribs expand, and we generate negative pressure. So if you've created a pressure gradient that favors reflux and you have no gastroesophageal junction, those people have in some circumstances debilitating reflux.

And so you have to bring the esophagus up higher really to kind of create a passive reflux mechanism, anti-reflux mechanism. And so to do that, we turn the stomach into a tube and pull it up either into the chest or the neck, and you will see various labels for what that is, a McKeown esophagectomy, an Ivor Lewis, a transhiatal thoracoabdominal. They're all just different approaches to achieve that. And they each have their pluses and minuses.

The two most common are what we call a hybrid McKeown, and the classic McKeown is also called a three-hole, where you used to start with a thoracotomy incision and mobilize the entire thoracic esophagus and then turn the patient onto their back and then do a laparotomy and a neck incision and essentially just pull the stomach up through the chest after it's been freed up. Now what we do is that portion in the chest is mobilized by VATS, and the big concern with a thoracotomy was pain and problems with pulmonary hygienes. And so doing it minimally invasively helps. If you look through the literature, everyone does this a different way. There are, I think it's something like 20 different permutations of how to do an esophagectomy when you add in all the MIE, hybrid, robotic, everything.

The other population we do here that you would not see very commonly elsewhere is the gastric, the substernal pull-ups. And that is for people who had an esophagectomy, but at the time, for reasons either an esophageal perforation or due to cancer reasons, they couldn't connect the stomach to the chest. So the esophagus is pulled out in the anterior abdominal wall, the chest wall to an esophagostomy. It's just not a common procedure to see. And we're one of the few centers in the country that reconnects people after that's been done. And to do that, you use, if the stomach's preserved, you can use the stomach and pull it up and connect it in the neck. If not, then you have to use a piece of colon and pull it up and attach it in the neck.

So regardless of how it's done, and most of them is done with a gastric conduit, we talk mostly about that, the common element is the vulnerability that we are thinking about constantly. And the reality is, is to turn this stomach into a tube. Essentially what you do is you separate the stomach from, this is the omentum here in the colon, but you end up separating it from all of its vascular supply so that the left gastric artery gets divided over here, the short gastric arteries, those get divided. Sometimes the right gastric artery gets divided. So the entire conduit is dependent on this one blood vessel, the gastroepiploic artery. And you make this tube and that vessel usually doesn't come up this high. That vessel is usually about here. So there's an area of the stomach up here that is inherently ischemic and it is very vulnerable, and that's the area you sew together.

And so our big fear is anything that impairs blood flow in that gastric conduit could lead to anastomotic failure. A lot of our strategies are pointed right at that common issue. And so how do we protect the conduit? Number one, with esophagectomies, we avoid any kind of vasoconstricting agents. That's why we stay away from pressors in esophagectomy. You can contest that in the literature, but the reality is most places work in that fashion. You just avoid pressors. You do tons of fluid. That comes at a cost later down the line because you can volume overload them. You can have lots of edema issues. But the main way to protect that and prevent vasoconstriction, decrease profusion of that conduit is to avoid pressors. And that's a very important part of the consideration.

What else do we do? All of the stuff, the NG tube, the not feeding, we don't want conduit distension. And the problem is, if you distend the conduit, you increase the pressure in the wall of the conduit, and that decreases the perfusion pressure. And so, again, conduit distension, decreased perfusion, anastomotic failure. And that's also why in the esophagectomy population, no masking, no CPAP, BiPAP, avoid conduit distension, avoid conduit ischemia.

The other thing that is partially conduit protection, but also you'll see that we do our gastric outlet procedures, and it's more because when you do the esophagectomy and you separate the stomach, you divide both vagus nerves. So the stomach should technically be paralyzed, as should the gastric outlet. And so you could end up with gastric outlet obstruction. So we do things to the pylorus muscle at the end of the stomach so that the stomach can freely empty, and that's partially conduit protection, but partially, there are other reasons to do that. That has evolved from, we used to totally cut the pylorus and sew it back together to now we do things like Botox and dilation. So that component of it has evolved.

Now the last thing we can do, specifically, you may see with the colonic inner positions again, so this is someone that is having their GI tract reconstructed after some kind of esophageal disaster. And we use colon. We take a segment of colon out that has an artery and a vein that run right along the edge of the colon called the marginal artery. And so when you turn that colon up and you connect it, you actually have the ends of those two vessels sitting there. And we have the microvascular surgeons plug the ends of the artery and the vein into the mammary vessels. And so it enhances the profusion of that colon and decreases the risk of, again, conduit ischemia and anastomotic problems.

When do we tend to see those problems? It's kind of the surgeons know exquisitely. When you take two pieces of tissue that are not well perfused and sew them together, how long does it take to fail? About eight to 10 days. And so that's when we typically are seeing anastomotic leaks. Early anastomotic leaks are technical problems. That eight to 10-day range is when we're seeing them, and that's because there was low blood flow and it just gradually started falling apart. So that's why you don't see them immediately. It's that it takes about eight to 10 days for ischemia to lead to a loss of tissue integrity.

So what are, in the esophageal realm, the other things we're thinking about? So conduit leak, conduit necrosis, and the leak is anastomotic leak. It doesn't always have to be, there can be staple line leaks, there can be other reasons. That's why patients have drains. It could be, if one of those drains starts looking frothy, you send it off for amylase because the one thing the patient is still doing is swallowing saliva. And so any saliva that leaks out is going to have salivary amylase. And so that's a way to detect leaks in drains. A dreaded complication is complete conduit necrosis. Fortunately, it's a very low frequency event. I can't remember the last time it happened here, but essentially the whole gastric conduit loses its blood supply. And that's typically some kind of torsion or compression event where the conduit has been brought up through the esophageal hiatus and somehow the vessels have gotten kinked or compressed. Oftentimes it's the vein itself gets compressed, and so the whole conduit dies. And in that circumstance, you have to take out the conduit and do an esophagostomy and then bring them back later for a substernal pull-up. That's a dreaded complication and you could see that very quickly and early on, and in that circumstance, that patient starts to look septic, very toxic quickly. And it's one of the things that we would consider in the evaluation is sticking a scope down because you'll stick a scope down and the mucosa of the stomach will be black and you just know we got to go take it out.

The most common complications after esophagectomy are respiratory. And especially coming from a time where our most common operation was the thoracoabdominal esophagectomy, which we were one of, I think two or three places in the country that was regularly doing thoracoabdominal esophagectomies. And the big problem with that is that the thoracoabdominal incision is considered a very morbid incision because you have to take the diaphragm down and bring it back up. So you have some inherent diaphragm dysfunction. You have the pain of a thoracotomy, but also the pain of a laparotomy. So it's a much maligned procedure, yet we actually had really fabulous outcomes with our thoracoabdominal approaches.

The key though, as you guys know in this circumstance, regardless of approach, is pain control. Pain control and pulmonary hygiene, getting people out of bed, making them cough, watching for aspiration risk, keeping them upright. In all of thoracic surgery patients, pulmonary hygiene is our number one concern, and that's why we order tons of nebs and things is we want to keep those secretions moist. We want the patients expectorating them. And if we don't, we get down this pathway going towards shrinking them. Pulmonary embolus, we monitor our patients fairly closely here. Most places wouldn't. For instance, that post-op day one duplex scan that we do in all of our esophagectomies is not a common practice. But what we have found is that if we detect even something below DVT, a significant percentage of those patients even on therapy will progress. And so we tend to be very aggressive about it, and we think that's one of the reasons why our overall mortality rates are lower than most other centers because we don't have those day 20, day 25 sudden deaths at home from a massive PE.

Lymph leaks are a big challenge. The main lymphatic system comes out of the gut, fuses together, comes up next to the esophagus, and that is just a conduit of lymph fluid, which we know is white cells and protein. Lymph doesn't clot, so if it leaks, then you hope that the body can scar in the area. The way to slow down lymph flow is to stop any kind of enteral nutrition. And so that's why you'll see patients with lymph leaks on TPN is we're trying to slow down the flow and allow the body to seal up. If not, then we have to sometimes re-operate on them.

The other recurrent nerve injuries is a big deal, and I put up the anatomy of the recurrent nerve and you can see where this is the vagus nerve here on the left side. And for some reason the recurrent nerve loops around the aorta and comes all the way back up to the voice box. And so this is what we call the area of the AP window, and we're also next to it in the esophagus. And so an esophageal procedure, you're basically trying to separate the esophagus and the trachea from and not damage that recurrent nerve. And so that doesn't happen if you do the incision in the chest only because you're not working up that high. So it's with those neck incisions that we worry about the recurrent nerve. And it's also left-sided pulmonary procedures where you are working in this AP window area and you can get the recurrent nerve taking out lymph nodes.

And then tracheal injury. And again, the intimate association between the esophagus and the trachea makes tracheal injuries a possibility. And that's another thing to keep in the back of your mind. If, for instance, someone develops a new air leak or their trach balloon isn't holding suction or something strange is going on, think that the trachea may not be intact. So that's one thing to keep in mind.

So I hope what it does is it allows you to kind of compartmentalize these patients much easier and say, oh, this is this patient. This is what we do. This is why we think this way. But it's really, in esophagectomy patients, it's the vulnerability of that conduit and keeping the perfusion of that conduit maximized. That is our primary concern.

So what's a recurrent nerve injury? So normally when we speak, what we're doing is we're forcing air through our vocal cords and they're vibrating, and that's making the noise. And what can happen is one of them is not working. So you have one vocal cord vibrating and the other just sitting there. Now, if it sits there in the midline, you wouldn't know. If it just sits there, then the patient may notice because the character of their voice may be a little different. If it's pushed out laterally and that other one tries to come in and it doesn't hit anything, their voice sounds like this and their cough is... Because the cough is hold your vocal cords tight, push against it, and then open explosively. And so the cough and the talking like this, that's the recurrent nerve injury.

What are the problems with the recurrent nerve injury? It's actually not being able to cough is the one we fear most because if you can't generate a cough, you can't clear secretions. The second is that you can aspirate because your vocal cords are part of your airway protection mechanism. The challenge in recognizing them is that the vocal cords are edematous at the end of surgery and at the end of excavation. And so they can pseudo-correct themselves. So you can have a paralyzed swollen vocal cord that the other one can oppose against. And as that swelling goes down, all of a sudden their voice starts to get worse and worse and worse. And so sometimes we're not noticing that until two or three days later. That's why, for instance, I have a very low threshold to have the laryngology team scope the patients in the ICU the day after surgery and inject them because they can do a bedside procedure to push the vocal cord over so that their voice returns to normal and they can effectively cough. Now, that patient ultimately may need a surgery to permanently medialize it. If the nerve wasn't divided, it should recover within a year. But if it hasn't, they can actually, what they do is they take a little piece of cartilage and they put a little triangular piece of cartilage in and sew it to the vocal cord to push it over permanently. The great thing, we have excellent laryngology services here, so if there's a concern about that, I mean, they just come in and put a scope down and look at the vocal cords. It's a low risk thing, so we should have a threshold to do it.

Esophageal stenting. This picture, it shows esophageal stenting being used for a malignant stricture. The more common reason you'll see it here from us is for esophageal perforations to cover that perforation. The challenge we face with esophageal stenting is the way that the esophageal stent anchors is that it has... This is an expandable stent that comes through a catheter and you can put it in with an endoscope. The way it anchors is by radial pressure based on these two flares at the top and the bottom of the stent. And the challenge there is that those flares don't always work. Our esophagus does something called peristalsis. It will try to push the stent down into the GI tract.

This is especially true when you're dealing with perforations that are at the most common location, which is the GE junction, because you have this flare sitting here and this flare is just floating in the breeze in the stomach. And that creates problems because, one, you can't necessarily seal this as well so they can retrograde reflux and come out, so they can still leak, but, two, the stomach will pull that sucker down into the stomach in a day or two. It's just peristalsis will move it. So that's why we use bridles and bridles are an uncommon use. Again, something you're not going to see a lot of if you're not here. But those bridles are essential to hold that esophageal stent in place, prevent it from going distally and, again, prevent that from uncovering the area of the defect and causing more leakage and mediastinal soilage.

And so those bridles, if you see someone with a bridle and nothing else, don't cut the bridle please because that bridle has a purpose. The first thing to do is go look and see if they have an esophageal stent in. And you can even see it on a chest x-ray. You can see the stent in the esophagus. But if they do, that bridle is essential. If it gets cut, we have to go it back in. So that's esophageal stenting. They actually take the stent out of the sheath that it's in. They put an umbilical tape through it, and then they reinsert it in the sheath, deploy it, and then the bridal gets anchored around their nose.

The alternative is esophageal repair or esophagectomy. And so it comes down to how sick the patient is and could they tolerate it. And the big thing, especially if you have an esophageal leak, mediastinal contamination, that's a patient that's going to be on pressors. And so that's not a patient that you want to consider doing a full esophagectomy. So here, if the patient, we can get them to the operating room, they're healthy enough, we will try to do a repair. And if we can't repair, then esophagectomy and diversion. It's not a treatment for cancer. Technically, a perforated cancer is a stage 4 cancer that should not have surgery, but it's really if you have a perforated cancer, that person goes on palliative care.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts, or listen at clevelandclinic.org/cardiacconsultpodcast.