The incidence of postoperative complications of esophageal cancer is higher compared with other post-surgical complications, and with the aging of the population and the expanding indications for esophageal and cardia cancer surgery, it is therefore of great clinical significance to explore the management and treatment of postoperative complications of esophageal cancer.
1.Anastomotic fistula
1.1 Cause.
After anastomosis of esophagus with stomach, jejunum, or colon, the spillage of digestive tract contents found from the anastomosis, thoracic cavity or neck incision is called anastomotic fistula. Anastomotic fistulas are divided into cervical anastomotic fistulas and intrathoracic anastomotic fistulas. Cervical anastomotic fistulas are safer than intrathoracic anastomotic fistulas because they can often drain through the neck wound if they occur, whereas intrathoracic anastomotic fistulas often produce fatal mediastinitis.
The cause of anastomotic fistula is related to the time of presentation. Early fistulas (within 3 days postoperatively) are mostly related to anastomotic technique, anastomotic site and anastomotic approach. Mid-stage fistulas are mostly related to patient age, systemic factors, poor blood flow due to excessive gastric distraction, postoperative perioperative management, postoperative neck incision and local infection in the thoracic cavity. Late stage fistulas are to be associated with patient age and systemic factors.
1.2 Diagnosis.
Generally, fever, systemic toxic symptoms, chest tightness, chest pain, dyspnea and palpitations, and decreased blood pressure may appear 3-14 days after surgery, and there may be obvious symptoms of incisional infection, such as redness and swelling of the neck incision, exudate, and purulent secretions exuding, which may increase with swallowing and feeding movements. Chest plain film can be seen in the chest cavity with gas and liquid planes or mediastinal shadows significantly widened, chest percussion with solid or drum sounds, respiratory sounds significantly weakened or disappeared, thoracic puncture to draw foul-smelling pus, gas, food residue or necrotic tissue, oral melanoma can be flowed from the closed drainage tube of the chest, esophageal barium swallow or iodine oil imaging can clarify the size and location of the fistula.
1.3 Treatment: The principle of treatment for anastomotic fistula is early diagnosis and early treatment.
Conservative treatment.
General conservative treatment: fasting, closed chest drainage, adequate drainage (local exchange therapy), intravenous application of broad-spectrum antibiotics to control infection, effective nutritional support (intravenous high nutrition, or jejunostomy) and correction of water-electrolyte disturbances.
Conservative treatment of anastomotic fistulas
(a) Intrathoracic lavage: large amounts of saline with chloramphenicol or gentamicin directly orally or repeatedly flushing the pus cavity through the highest point of the pus cavity with an intercostal tube.
(b) Three-tube treatment: placement of chest drainage tube, and jejunostomy tube, jejunal reverse gastrointestinal decompression tube. When the color of the gastrointestinal decompression fluid is normal and the chest drainage fluid is oral fluid, the three tubes are connected, and the negative pressure of intestinal peristalsis and respiratory movement are used to drain and recover digestive fluid. To maintain electrolyte balance and nutritional support.
c) Splenda powder mucus plugging method: 10g of splenda powder is given orally three times a day for one month. This is indicated for smaller anastomotic fistulas. The mechanism may be that the powder forms a gelatinous film in contact with water and acts as a mechanical blockage in the fistula.
Surgical treatment: anastomotic fistula repair and anastomosis resection.
The indications for surgery are: (i) the general condition is still good and can tolerate a second surgery. ② Short duration of symptoms and mild intrathoracic infection ③ The length of the thoracic stomach is long enough to cut out the original anastomosis and then perform a high level anastomosis. ④Ineffective by conservative treatment or sudden aggravation of symptoms.
Surgical methods: anastomotic fistula repair and anastomotic resection.
2.Celiac disease
2.1 Causes.
① Injury to the thoracic duct during intraoperative stripping of the esophagus ② Injury to its branches or vagal thoracic duct due to variation of the thoracic duct.
2.2 Diagnosis.
① early massive celiac leakage into the thoracic cavity produces clinical symptoms of intra-thoracic compression leading to cardiopulmonary dysfunction. It usually appears within 7 days after surgery, with chest tightness, shortness of breath, shortness of breath, palpitations, discomfort in the anterior thoracic region, feeling of pressure in the affected thoracic cavity , and clinical manifestations of dyspnea, tachycardia, shock, hypotension and non-increasing body temperature if a large amount of celiac fluid has been fed and leaks rapidly.
Late stage malnutrition due to large amount of celiac fluid loss. Malnutrition symptoms such as indifferent expression, weakness, fatigue, hunger, thirst, weight loss, and oliguria may occur after several days of continuous loss of large amounts of nutrient-rich celiac fluid.
③Thoracic puncture or chest drainage, a large amount of light red, or orange-red, or medium yellow slightly turbid celiac fluid can be drained from the chest every day.
④ Chest X-ray examination shows a moderate amount of fluid accumulation or more in the chest cavity and a positive celiac test, but it is negative when fasting and not infused with fatty milk.
2.3 Treatment.
Conservative treatment.
Fasting, or discontinuing fatty milk, entering high-protein, high-sugar, low-fat or fat-free fluids. Replenish fluids and electrolytes in a timely manner to prevent water-electrolyte and acid-base imbalance. Replenish whole blood, plasma, amino acids, albumin, etc. Place closed chest drains to induce lung reopening. Thoracic injection of sterile tetracycline, erythromycin, talc or hypertonic sugar to induce pleural adhesions and eliminate pleural cavity.
Surgical treatment : Surgery is required when the drainage is more than 1000 ml per 24 hours.
Surgery ① direct closure of the thoracic duct fistula and suturing of the pleura with thoracic duct ② diaphragmatic low ligation of thoracic duct ③ thoracic peritoneal cavity shunt ④ thoracoscopic treatment
3.Disorder of thoracogastric emptying (thoracogastric obstruction)
3.1 Causes.
①Intraoperative resection of vagus nerve trunk and branches ②Gastric anatomical location variation ③Decreased gastrin secretion ④Insufficient postoperative gastrointestinal decompression ⑤Stenosis of gastric outlet due to adhesion of esophageal fissure retraction and surrounding tissues.
3.2 Diagnosis.
After removal of the gastric tube, chest tightness, shortness of breath, panic, dyspnea, dyspnea, vomiting, vomit mostly brown-green or coffee-colored gastric juice, symptoms were obviously relieved after reinsertion of the gastric tube, and the above symptoms appeared again after removal of the gastric tube again; chest X-ray showed obvious dilatation of the chest and stomach and visible fluid plane. The respiratory movement on the operated side was weakened, and the breath sounds were significantly weakened or disappeared, and there could be vibro-hydraulic sounds. Gastrointestinal angiography or gastroscopy showed dilated stomach with reduced peristalsis, but the pylorus was basically unobstructed.
3.3 Treatment.
Conservative treatment.
Fasting, gastrointestinal decompression, oral gastrodynamic drugs, correction of electrolyte disorders, maintaining acid-base balance, supplementation of trace elements and vitamins, maintaining the stability of the internal environment. Strengthen nutrition, provide sufficient heat, and infuse albumin, whole blood or plasma in appropriate amounts. Usually the thoracic gastric emptying disorder can be improved after conservative treatment. Taxis Yueping reported that 9 patients with postoperative thoracic gastric emptying disorder occurred in this hospital since 1983-2002, and after the above conservative treatment: the total effective rate was 89%.
Surgical treatment: If the obstruction is caused by mechanical factors, and the symptoms do not improve after conservative treatment and the obstruction is too severe to maintain nutrition, surgical treatment can be performed according to the cause of the obstruction after thoracotomy or dissection.