Esophagectomy is a difficult, high-risk procedure with a much higher incidence and complexity of complications than other procedures. Bleeding, adjacent tissue and organ damage, anastomotic fistula, and pulmonary complications are common complications. Experienced surgeons will try to avoid these risks and you do not have to worry too much. Even if they do occur, doctors have ways to address them.
Below, we explain the intraoperative risks and the postoperative risks.
Intraoperative risks
The main risks include hemorrhage, injury to blood vessels, nerves, lymphatic vessels and adjacent organs (such as thyroid and parathyroid glands), and also cardiovascular accidents such as respiratory and cardiac arrest, arrhythmia, heart attack and heart failure. This is mainly related to the stage and location of the tumor, as well as your general physical condition.
To avoid these risks as much as possible, your doctor will perform adequate staging and risk assessment before surgery. For example, heart pumping function is assessed by electrocardiogram and cardiac ultrasound to identify potential surgical risks, and pulmonary function tests and arterial blood gas analysis to determine whether you can tolerate thoracic surgery.
Postoperative risks
Postoperative complications are divided into general complications and complications related to esophagectomy, with anastomotic fistula being the most common, along with recurrent laryngeal nerve palsy, pulmonary complications, and celiac disease.
General complications
1. Cardiogenic complications: The most common are supraventricular arrhythmias and myocardial infarction, with incidence rates of about 13% and 1%, respectively. Treatment involves multiple aspects of your fluid management, electrolyte balance, surgical procedures, and management of underlying disease, and will be managed on a case-by-case basis by experienced physicians.
2. Deep vein thrombosis/pulmonary embolism: This is a very common complication after all surgical oncology procedures. The incidence of deep vein thrombosis and pulmonary embolism is 29% and 1.6%, respectively. Of these, pulmonary embolism has a very high lethality rate. This type of complication is important to prevent, and your surgeon will give you prophylactic use of low-molecular heparin or lower extremity compression stockings before surgery, depending on the circumstances.
Complications associated with esophagectomy
1. Anastomotic fistula: This is the most serious complication after esophagectomy, with an incidence of about 11% to 19%. Currently, its incidence has decreased significantly in experienced esophageal cancer centers, but it can still be 3% to 5%, with a lethality rate of up to 40%. Because anastomotic fistula is more serious, thoracic surgeons take it very seriously and will try to avoid it during surgery, so you don’t need to worry too much about it.
If you develop a high fever, chest and back pain, dyspnea, or changes in drainage or wound ooze after surgery, you should be alerted to the possibility of an anastomotic fistula and seek medical attention as soon as possible. Mild anastomotic fistulas are not easily detected and usually do not require special treatment; symptomatic anastomotic fistulas require medication and surgical drainage, etc.; and individual severe life-threatening cases require tracheal intubation, ventilator-assisted breathing, and intensive care.
2. Respiratory complications: These include pneumonia, pulmonary atelectasis, respiratory failure, persistent air leak, pneumothorax, bronchospasm, pleural effusion, abscess chest, and thoracic hemorrhage, with an overall incidence of approximately 26.52%.
To reduce the incidence, you need to quit smoking before surgery; eat small meals and avoid overfeeding after surgery; rest in a left-sided position to prevent inadvertent aspiration of food into the trachea; and follow medical advice to actively cough and cough up sputum and massage your own abdomen. The doctor will pay extra attention to patients of advanced age, with underlying lung disease, pulmonary insufficiency, and high mass location, and will promptly deal with such complications once they occur.
3. Anastomotic stenosis: The incidence is low and causes mainly dysphagia. In most cases, symptoms resolve with the gradual resumption of daily feeding. Approximately 5% to 44% of patients with anastomotic stenosis will require anastomotic dilatation. The exact management should be determined by the physician.
4. Dumping syndrome: During esophageal cancer surgery, a portion of the stomach needs to be lifted up to replace the function of the removed esophagus. This causes the stomach to become smaller and the food that is eaten quickly enters the intestine. In order to digest the food as soon as possible, the intestines secrete a lot of digestive juices, which causes the rapid absorption of sugar substances, resulting in a series of severe fluctuations in blood sugar, such as sweating, palpitations, tachycardia, nausea, abdominal distension and so on. This is known as “dumping syndrome” in medical science. Your doctor will give you the appropriate medication and instruct you to adjust your diet, such as eating fewer meals, avoiding water at meals, and reducing your carbohydrate intake.
5. Gastric emptying disorder: The main manifestation is difficulty in passing food through the pylorus, resulting in retention of large amounts of gastric contents, which is medically called “thoracic gastric dysfunction. It has a low incidence and can be effectively prevented by pyloromyotomy and pyloroplasty during surgery. If gastric emptying does occur, pyloric dilatation can be performed on a case-by-case basis to relieve symptoms.
6. Celiac disease: The thoracic cavity also has lymphatic vessels, and if lymphatic fluid leaks out, it can make the chest fluid white or milky, a phenomenon known as “celiac disease. During surgery for esophageal cancer, structures such as the esophagus and lymph nodes need to be separated to facilitate accurate removal of the cancer. This is a very important part of the process, but it is inevitable that the thoracic lymphatic vessels will be injured, resulting in celiac disease, with an incidence of 0.4% to 4%.
Large amounts of lymphatic fluid leakage can lead to nutrient loss and disturbance of the internal environment, inducing anemia, hypoproteinemia, malnutrition, weight loss, and immune dysfunction. Eating high-fat, high-protein foods before surgery can help the surgeon identify lymphatic tracts during surgery and indirectly reduce the incidence of celiac disease.
The treatment of celiac disease is complex, and once present, most require strict fasting and the adoption of delicate fluid management. Without timely diagnosis and proper treatment, it may lead to respiratory and circulatory failure and even death. If you experience chest pain, shortness of breath, palpitations, fever and other symptoms after surgery, it is recommended to seek medical attention as soon as possible. Doctors can clarify the diagnosis by celiac test and try conservative treatment first, such as fasting with parenteral enteral nutrition, medication, chemical pleural fixation, etc. If conservative treatment is ineffective, prompt surgery is required.
7. Recurrent laryngeal nerve injury: The lymph nodes adjacent to the recurrent laryngeal nerve bilaterally are a common site of metastasis in esophageal cancer (especially in the thoracic segment), and physicians often focus on debridement, which may lead to injury and paralysis of the recurrent laryngeal nerve. The incidence of this complication has been documented to be 36% to 61.7%.
If you experience hoarseness and choking after surgery, you need to seek medical attention as soon as possible to confirm the diagnosis through laryngoscopy. After diagnosis, conservative treatment, such as neurotrophic drugs, is usually first used and most can be improved. If conservative treatment is not effective, surgical treatment is available.
Lastly, it should be noted that minimally invasive surgery has a lower rate of overall complications (43.8% vs 60.4%) and pulmonary complications (15.1% vs 22.9%) and lower perioperative mortality (1.9% vs 4.9%) than conventional surgery. If available, it is recommended that you undergo minimally invasive surgical treatment such as thoracoscopy.