1. Pulmonary comorbidity
(1) Causes
Most patients are older and often have a combination of emphysema, chronic bronchitis, chronic obstructive pulmonary emphysema, long-term smoking history, longer anesthesia, surgery time, greater surgical trauma, and intraoperative side of the lung is easily squeezed in contusion, therefore, postoperative pulmonary complications are prone to occur. Common complications include pulmonary infection, pulmonary atelectasis, pulmonary edema, pulmonary torsion, and ARDS.
(2) Diagnosis.
Fever, cough, sputum, chest tightness, shortness of breath, dyspnea, rapid respiratory rate, cyanosis, excessive sweating, decreased blood pressure, irritability, and even coma are usually seen 1-7 days after surgery; wet rales can be heard in both or one lung; postoperative chest X-ray reveals lamellar dense shadows in the lungs.
(3) Treatment.
(1) effective antibiotics, strengthening anti-inflammatory ② phlegmolytic drugs ③ encourage coughing, coughing or aspiration Bronchoscopic aspiration if necessary ④ tracheotomy if necessary ⑤ treatment of ARDS: oxygen or assisted breathing, often positive pressure mechanical ventilation plus PEEP; bronchoscopic aspiration, bronchial and alveolar lavage; restriction of fluids; cardiotonic agents; diuretics; effective antibiotics; correction of hypoalbuminemia; application of high-dose hormones .
(4) Prevention of pulmonary complications.
Encourage and assist patients to perform deep breathing exercises to fully expand the alveoli; improve the surgical approach and perioperative management; shorten the operation time, such as simultaneous thoracoabdominal group and the use of gastrointestinal anastomosis to shorten the operation time; reduce blood loss and blood transfusion; postoperative incisional pain makes patients afraid to cough, and patients should be assisted to make coughing movements to facilitate sputum excretion; avoiding laryngeal recurrent nerve paralysis can reduce the pulmonary complications Effective postoperative analgesia can improve the patient’s mobility and reduce the incidence of pulmonary complications; nutritional support such as enterostomy tube feeding to correct nutritional disorders will reduce the incidence of postoperative respiratory complications. Postoperatively, patients are encouraged to sit up, cough more and cough up sputum; nebulized aspiration is given to dilute respiratory sputum so that it can be easily expelled and reduce infection. For those who have difficulty in sputum discharge, fiberoptic bronchoscopy aspiration plus bronchial and alveolar lavage can effectively eliminate respiratory secretions. For those whose condition does not improve easily in the short term, tracheotomy should be performed early, and whether tracheotomy can be performed in time is often the deciding factor for the success of resuscitation or not.
2.Anastomotic bleeding
(1) Cause: Stress ulcer; intraoperative pulling, squeezing and contusion of gastric mucosa; anastomotic bleeding.
(2) Diagnosis: symptoms of anemia; postoperative aspiration of coffee-colored or light-red bloody fluid or even vomiting blood via gastric tube; black stool.
(3) Treatment
Conservative treatment: give antacids such as metacyanidine or loxacarb; rehydrate, transfuse blood and apply hemostatic drugs if necessary.
Surgical treatment: If postoperative gastric tube aspiration of bleeding fluid or chest drainage of bleeding fluid exceeds 150 ml/h and there is no trend of reduction for 5 consecutive hours or there is no significant improvement of shock symptoms after massive blood transfusion or it is estimated that there is massive blood accumulation in the chest, the chest should be dissected immediately to stop bleeding.
3.Anastomotic stenosis
(1) Causes.
(1) Surgical factors: anastomosis is too small, esophageal and gastric mucosal alignment is not neat, sutures are too dense, knots are too tight, etc. (2) Postoperative anastomotic infection, anastomotic fistula (3) Late postoperative feeding or eating fluid or semifluid for too long (4) Recurrence of malignant lesions of the anastomosis.
(2) Diagnosis.
Initial symptoms are mostly obstructive feeding and progressive aggravation, the patient’s nutritional status is poor, barium meal of the esophagus can be seen as anastomotic stricture, while compensatory dilatation of the esophagus above the anastomosis; the anastomosis can be linear, “S” type, inverted garden vertebrae type.
(3) Treatment
Dilatation treatment.
It should be performed only after one month of surgery. According to the anastomosis obtained by barium meal and esophagoscopy, the anastomotic stricture is dilated by using different types of Shah’s soft probe expanders and then guided by esophagoscope and guiding wire. One hour after surgery the patient can eat a general diet.
Conservative treatment.
Infusion to maintain acid-base balance, supplementation of trace elements and vitamins to keep the internal environment stable. Enhance nutrition, provide sufficient calories, and infuse albumin, whole blood or plasma in appropriate amounts. Also give active dilatation treatment.
Surgical treatment.
Those who fail to dilate or have severe anastomotic stenosis and cannot maintain nutrition while tolerating surgery can undergo surgery. Circumferential resection of the anastomotic scar through the gastric lumen. A lateral anastomosis to the esophagus at the tip of the greater curvature of the stomach is possible after cardia surgery. If the anastomosis cannot be reconstructed, a jejunostomy is performed.
4.Reflux esophagitis
(1) Causes.
① loss of normal expansion function after cardia resection ② normal physiological function of the stomach is affected, so that the pylorus spasm.
(2) Diagnosis.
The patient’s symptoms are mostly acid reflux, pain behind the sternum, and burning sensation. In addition, esophagoscopy and biopsy, acid drip test in the esophagus, lower esophageal aspiration fluid examination, barium meal of the digestive tract are more accurate diagnostic criteria.
(3) Treatment.
Conservative treatment.
①According to the American Gastroenterological Association recommendations, proper life guidance is important for treatment. Patients are advised to enter a low-fat, high-protein diet, eat small and frequent meals; avoid eating too cold or too hot food, do not smoke, and do not drink strong tea, coffee, or strong alcohol. Weight loss. Keep bowel movement smooth. Avoid anti-vinylcholine drugs, theophylline, calcium channel blockers, Valium, anesthetics and other drugs. Sleep 3 hours after meals and raise the head end of the bed 15-20 cm during sleep. 25% of patients can be expected to reduce or alleviate clinical symptoms after the above life guidance.
②Acid-suppressing drugs: including proton pump inhibitors and H2 receptor antagonists. Acid-suppressing drugs can alleviate symptoms by inhibiting gastric acid and reducing the irritation of gastric acid on esophageal mucosa endoscopic treatment.
In recent years endoscopic anti-reflux surgery has been used clinically for the treatment of reflux esophagitis. This method is also known as fundoplication. A fold is created in the distal esophagus by endoscopic suturing to restore the function of the lower esophageal sphincter by wrapping the fundus around the esophagus. This method restores the function of the lower esophageal sphincter, reduces the severity and frequency of heartburn, and reduces reflux allowing reflux esophagitis to heal.
Surgical treatment.
Since reflux esophagitis is due to postoperative loss of anastomotic dilation, the core of all surgical approaches is to reconstruct the function of the valve at the anastomotic site. In recent years, various surgical procedures have emerged, including: esophagogastric anastomosis with encapsulated sutures, esophagectomy with preservation of the cardia and additional Nissen-type surgery, esophageal placement, and gastric wall flap-covered gastric-esophageal anastomosis.
5.Vocal cord paralysis
Hoarseness, weak cough, and choking during water intake are due to damage to the recurrent laryngeal nerve. Most of them are temporary and will heal on their own after one year, and there is no special effective treatment.