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44 M. B. Orringer
Fig. 4.8 Once the thoracic esophagus has been complete-
ly mobilized, several centimeters are elevated into the
cervical wound and the esophagus divided obliquely (not
transversely) from front to back so that the anterior tip is
longer than the posterior. The esophagus is then delivered
downward and out of the mediastinum by gentle traction
on the stomach. (Reproduced with permission from [9]
© Elsevier)
as originally planned by bringing the stomach
through the posterior mediastinum and carrying
out the CEGA.
A more common “bleeding scenario” occurs
when after dividing the cervical esophagus with
the stapler and delivering the mobilized esophagus out of the mediastinum, dark venous blood is
seen flowing from the hiatus and often from the
cervical wound as well. Exposure of the posterior mediastinum for control of bleeding is always
easier when the esophagus has been removed.
If it has not been, and major venous bleeding is
identified during performance of the esophagectomy, for example, flowing out of the cervical
incision, if possible, quick blunt division of the
few relatively small remaining periesophageal attachments allows removal of the esophagus and
better visualization through the hiatus. Once the
esophagus has been removed, the 28 Fr. Argyle
Saratoga sump catheter at the head of the table is
quickly inserted into the cervical wound and ad-
vanced into the posterior mediastinum to evacuate blood. In the abdomen, as described above, a
narrow Deaver retractor is inserted into the hiatus,
and the posterior mediastinum is packed tightly
with two large laparotomy packs, which are advanced well superiorly to the level of the carina
with the help of a long Russian forceps. The sump
catheter is removed from the neck wound, and
the superior mediastinum is packed tightly with
two narrow thoracic packs continually protecting
the recurrent laryngeal nerve by placing a finger
across the tracheoesophageal groove as the packs
are advanced into the wound (Fig. 4.9). While
hemodynamic stability is assessed by the anesthesiologist and intravenous fluids are administered to assure an adequate intravascular volume,
bilateral chest tubes are placed low in the anterior axillary lines, advanced to the apices of the
chest, and connected to under water seal suction
drainage (Fig. 4.10). The output from each side is
assessed. If the bleeding seems to be controlled,
the anesthesiologist is given time to administer
more IV fluids and blood as indicated. With a
normal blood pressure, and after waiting 5 min
for natural hemostatic mechanisms to come into
play, the cervical thoracic packs are slowly and
sequentially removed from the superior mediastinum and the wound assessed for bleeding. If no
blood wells up from the superior mediastinum
and out of the cervical wound, attention is redirected to the abdomen. The abdominal packs are
slowly and sequentially removed from the posterior mediastinum through the diaphragmatic
hiatus, and the Deaver retractor is inserted into
the hiatus to facilitate exposure. With the sump
suction catheter inserted into the superior mediastinum through the cervical wound, the low
and mid-posterior mediastinum is inspected for
the source of bleeding, aided by a standard Yonkaur suction to “spot suck.” Statistically, a tear
of the azygos vein during THE is the most likely
source of dark major venous bleeding from the
mediastinum, and at times after suctioning clotted blood from the mediastinum, the thrombosed
end of the completely divided azygos vein may
be seen. A large hemoclip may be placed across
the end of the divided vein through the diaphragmatic hiatus in those cases where visualization
454 Transhiatal Esophagectomy—Intraoperative Disasters
Fig. 4.9 If posterior mediastinal bleeding is documented,
in order to tamponade the bleeding, two large laparotomy
packs are quickly advanced upward through the retracted
hiatus into the mediastinum using long Russian forceps,
and two narrow “thoracic” packs are advanced downward
through the hiatus is possible. If no bleeding site
can be seen while looking up into the mediastinum through the hiatus, the cervical wound has
no bleeding, and the chest tube output is minimal,
the mediastinum should be repacked as above
(two large laparotomy packs from below through
the hiatus, and two narrow thoracic packs from
above through the cervical wound while protecting the recurrent laryngeal nerve). The esophagus
is separated from the stomach using progressive
applications of the GIA stapler 5–6 cm distal to
the esophagogastric junction and preparing the
gastric conduit for esophageal replacement. The
into the mediastinum through the cervical incision ( inset).
The recurrent laryngeal nerve in the tracheoesophageal
grove is protected by a finger held across it to prevent direct contact between the forceps and the nerve as packing
of the superior mediastinum is performed
specimen is removed from the field, and after
oversewing the gastric staple suture line, attention is redirected to the mediastinum where another 10–15 min have passed allowing for further
natural hemostasis. The mediastinal packs are
slowly removed and the mediastinum inspected.
If the field is “dry,” the stomach is transposed
through the hiatus into the posterior mediastinum
and the tip delivered into the cervical wound for
construction of the CEGA. On the other hand, if
after removing the packs from the mediastinum,
excessive dark venous bleeding from “high up”
and to the right of the midline is encountered,
46 M. B. Orringer
Fig. 4.10 When bleeding within the posterior medias-
tinum is documented, the priority is tamponade. This is
achieved with two large laparotomy packs pushed high
into the posterior mediastinum through the hiatus and two
narrow “thoracic” packs inserted into the superior mediastinum through the cervical incision. Bilateral chest tubes
are placed to ensure that ongoing bleeding into either
chest is not occurring. After 5–10
bleeding
with this pressure, during which time intravascu-
min of control of the
an azygos vein tear is virtually a certainty. The
mediastinum is quickly repacked from below
through the hiatus and above through the cervical wound as described above, the abdominal and
cervical wounds quickly closed and covered with
adhesive plastic surgical drapes, and the patient
turned to the left side for a fifth intercostal space
right posterolateral thoracotomy.
The third and even more frightening scenario
involves bright red arterial bleeding from the
hiatus either during performance of the transhiatal dissection or immediately after the esophagus
has been removed from the mediastinum. With
arterial bleeding, there may not be time to complete the esophagectomy before the bleeding
must be addressed. The Argyle Saratoga sump
catheter is quickly inserted into the posterior mediastinum through the cervical wound to evacuate blood and facilitate exposure. Exposure of the
posterior mediastinum is achieved with a Deaver
retractor placed into the hiatus and “spot suction” with the Yankauer suction from the lower
lar volume can be replaced and fashioning of the gastric
conduit carried out, if a “second look” into the mediastinum indicates persistent bleeding, the mediastinum is
repacked, the abdominal incision is closed quickly with
three or four through-and-through heavy sutures ( inset),
the cervical wound similarly closed quickly, both incisions covered with adherent plastic surgical drapes, and
the patient turned and positioned for a posterolateral thoracotomy
end of the table. If the bleeding site is identified
as being from an aortic esophageal artery, it
is clamped through the hiatus with a long rightangle clamp and ligated. The mediastinum is then
carefully packed as above and inspected again
after an additional 5 min have passed. If there
is no further bleeding, the operation proceeds as
planned. It cannot be overemphasized that when
performing a THE in a patient who has undergone a prior esophagomyotomy, the exposed
esophageal submucosa may be fused to the adjacent descending thoracic aorta. An ill-advised attempt at blunt dissection between the esophagus
and aorta may end in a disastrous aortic tear. In
most cases, the esophagomyotomy involves the
distal esophagus, and if a transthoracic approach
to the aorta is required for repair, a left posterolateral thoracotomy in the sixth intercostal space
is the preferred approach to the low descending
aorta. This should be done if mediastinal packing
temporarily controls the bleeding, which resumes
when the packing is removed. The mediastinum
474 Transhiatal Esophagectomy—Intraoperative Disasters
should be packed again, the abdominal and cervical wounds closed quickly as described above,
and the patient turned to the right side. The groin
should be prepped and draped into the field to
allow access to the femoral vessels in the event of
the need for aortic cross-clamping and institution
of aortofemoral bypass to repair the injury. If the
surgeon is unfamiliar with techniques of aortic
bypass, support from cardiac surgery colleagues
should be requested immediately. Massive bleeding from the mid or upper thoracic aorta is not
likely to be controllable through the hiatus, and
an urgent repositioning of the patient and a left
posterolateral thoracotomy through the fifth intercostal space may be attempted for control/repair. This is the worst-case scenario of bleeding
associated with a THE, and salvage of the patient
before fatal exsanguination occurs is unlikely.
Tracheal Tear
It has been emphasized repeatedly that in performing the transhiatal esophageal mobilization
from the level of the carina and superiorly, the
fingers must be kept as posteriorly as is possible
to minimize the risk of injury to the posterior
membranous trachea. One of the worst experiences in the performance of a THE is the sudden
rush of cool air over the fingers in the posterior
mediastinum. The anesthesiologist will generally then “sound the alarm” that he is “losing
air” from his anesthetic circuit. There can be
little doubt that a posterior membranous airway
tear has occurred. This is not a time for bronchoscopy. The anesthesiologist should be told
to quickly untape the endotracheal tube so that it
is completely mobile. At the same time, the surgeon’s hand is quickly inserted through the hiatus anterior to the esophagus with the palm and
volar aspects of the fingers facing forward. As
the subcarinal area is approached and the hand
slowly advanced superiorly behind the trachea,
the posterior membranous trachea is carefully
palpated to define the site of the tear and control the air leak with gentle pressure (Fig. 4.11a).
The injury is usually distal to the endotracheal
tube balloon. The anesthesiologist is told to deflate the endotracheal tube balloon and advance
the tube further into the airway as the surgeon
guides the tube into the left mainstem bronchus
(Fig. 4.11b). This may require several passes but
eventually coordination of occlusion of the right
mainstem orifice by pinching it and simultaneous advancement of the tube will result in a successful left-sided intubation. When the end of the
tube is felt several centimeters beyond the carina
down the left mainstem bronchus, the balloon
cuff is gently inflated, and single lung ventilation
of the left lung instituted. The anesthetist should
secure the tube in place. Adequate oxygenation
is confirmed. With the air leak controlled, there
are several options for management of the airway
tear.
If the airway tear appears to be relatively
small, the transhiatal esophageal mobilization
can be completed, the stomach brought through
the posterior mediastinum, and the CEGA con-
structed. The cervical wound is closed over a ¼ʺ
Penrose drain placed into the superior mediastinum to permit egress of any escaping air. The
patient is awakened from general anesthesia as
soon as possible and extubated to eliminate positive airway pressure. It has been reported that
some tracheal tears “seal off” against the wall of
the adjacent intrathoracic stomach and do not require suturing. However, this is such a rare complication of THE that no one has reliable experience as to which tears may be managed expectantly as above. The author is most comfortable
addressing the problem directly before the patient is awakened. Posterior membranous tears
of the lower trachea and carinal area involving
the mainstem bronchi are repaired through a right
posterolateral thoracotomy in the fifth intercostal space. After initiating single lung ventilation,
securing the airway, and documenting satisfactory oxygenation and hemodynamics, the abdomen is temporarily closed with interrupted heavy
through and through sutures as described above
in the section on major intraoperative bleeding,
the neck wound is closed, and both incisions covered with adhesive plastic drapes. The patient is
turned to the left side, and the right thoracotomy
performed. The mediastinal pleura is opened at
the level of the azygos vein, which is divided
and suture-ligated. The carina rests immediately
under the azygos vein. This exposure provides
48 M. B. Orringer
Fig. 4.11 a Identification of the site of the posterior
membranous tracheal tear and temporary control of the air
leak is achieved with the volar aspect of the middle finger
inserted through the diaphragmatic hiatus. b As the orifice
of the right mainstem bronchus is partially occluded by
access to the entire intrathoracic posterior membranous trachea, the carina, the right bronchus,
and the first several centimeters of the left mainstem bronchus. If the esophagectomy has not
been completed, it is done so now. The membranous tracheal tear is repaired with interrupted 4- 0
polydioxanone (PDS) sutures. The endotracheal
tube is left undisturbed with its tip in the left
mainstem bronchus and not withdrawn into the
trachea where positive airway pressure may disrupt the tracheal repair. The patient is then turned
supine once again, positioned as before, the adhesive surgical drapes removed, and the abdominal and cervical wounds reopened. Gastric transposition through the posterior mediastinum and
construction of the CEGA are performed. The su-
perior mediastinum is drained with a ¼ʺ Penrose
drain brought out through the cervical incision.
The patient is extubated, preferably in the operating room, to avoid injury to the airway suture line
by an indwelling endotracheal tube.
pinching it, the anesthesiologist simultaneously advances
the endotracheal tube into the left mainstem bronchus so
that single lung ventilation of the left lung can be instituted and maintained until the airway injury is repaired
A third alternative approach is the use of a
partial upper sternal split to gain access to the
posterior trachea for repair of the injury. From
experience with mediastinoscopy for the evaluation of mediastinal lymphadenopathy in patients
with lung cancer, it is known that the carina can
generally be reached through a suprasternal incision. It is reasonable, therefore, to attempt repair
of a posterior membranous tracheal tear above
the carina through a partial sternotomy. Once the
endotracheal tube has been guided down the left
mainstem bronchus and the airway is secure, the
standard oblique left anterior cervical incision
paralleling the anterior border of the sternocleidomastoid muscle used for a THE is extended
downward in the midline over the upper sternum, just across the sternomanubrial junction
(Fig. 4.12). A partial upper sternal split is then
carried out. If the esophagus has been extracted,
visualization of the posterior membranous tra-
494 Transhiatal Esophagectomy—Intraoperative Disasters
Fig. 4.12 A tear of the posterior membranous trachea
recognized after transhiatal mobilization and removal of
the esophagus may be managed by extending the oblique
anterior left cervical incision downward in the midline
over the manubrium across the sternomanubrial junction.
chea is generally feasible. The tracheal tear is repaired with interrupted 4- 0 PDS suture, and the
esophageal replacement with stomach completed
without the need to reposition the patient. If the
tracheal tear cannot be adequately visualized
through this approach, the cervical/partial sternotomy and abdominal incisions are temporarily closed as described above, and the patient is
A partial sternotomy is performed, and after insertion of a
small sternal retractor, access to the posterior membranous
trachea to the level of the carina allows direct suturing of
the tracheal wound and avoids the need for a thoracotomy.
(Reproduced with permission from [9] © Elsevier)
turned to the left side for a transthoracic tracheal
repair through the right chest as described.
Among 3200 patients who have undergone a
THE at the University of Michigan since 1976,
there have been eight (0.25 %) tracheobronchial
tears, four repaired through a right thoracotomy
and four through a partial sternal split. All healed
without added postoperative morbidity.
50 M. B. Orringer
Summary
Disastrous intraoperative events—major mediastinal bleeding and tracheal tears—occur in < 1 %
of patients undergoing a THE. Their successful
management requires a well thought-out protocol
and knowledge of the best approach to the site of
the injury. Because of their relative infrequency,
facility in management is seldom achieved by repetitive direct treatment. It is therefore prudent
that surgeons undertaking a THE periodically
“rehearse” with their operative team the approach
to intraoperative bleeding or an airway tear
occurring during the procedure, so that efficient
and effective treatment can be undertaken when
these disasters are encountered. Recognition of
telltale risk factors such as a mid-third esophageal carcinoma or stricture, mediastinal calcification on CT scan, a prior esophagomyotomy, a
prior esophageal perforation, or an obese, “soft”
body habitus may alert the surgeon to the possibility of major intraoperative technical problems
and hopefully their avoidance.
Key Points: Avoiding Catastrophic Complications—Mediastinal Bleeding and Airway Injury—During Transhiatal Esophagectomy
1. Be especially vigilant in patients with a history of prior esophageal surgery, particularly
a thoracic esophagomyotomy or megaesophagus of achalasia.
2. In those with a prior thoracic esophagomy-
otomy, dissect the esophagus away from the
descending aorta sharply and under direct vision through the hiatus, not bluntly.
3. Mediastinal lymph node calcifications on
preoperative CT scans may portend a more
difficult mediastinal esophageal dissection,
particularly in the subcarinal region.
4. Perform the blunt mediastinal esophageal dissection with the volar aspects of the fingers
against the esophagus.
5. When dissecting the esophagus away from the
trachea working through the hiatus and the
cervical incision, push toward the esophagus
and NOT the posterior membranous trachea.
Key Points: Diagnosing and Managing Catastrophic Complications— Mediastinal Bleeding and Airway Injury—During Transhiatal Esophagectomy
1. Dark venous blood issuing through the hiatus
from the high mediastinum during a THE is
most often due to a torn azygos vein.
2. Bright red blood issuing through the hiatus during dissection of the distal half of the
esophagus is most often due to a bleeding
thoracic aortic vessel or an aortic injury.
3. During the transhiatal esophageal mobilization, feeling a sudden rush of air at the same
time that the anesthesiologist reports loss of
air in his/her circuit is indicative of a posterior
membranous tracheal tear.
4. If excessive mediastinal bleeding through the
hiatus occurs, the mediastinum should be
packed immediately with two large abdominal packs through the hiatus from “below” and
two narrower “thoracic packs” placed through
the cervical incision from “above” (while protecting the left recurrent laryngeal nerve), allowing volume replacement and stabilization
of the patient.
5. If an intraoperative tracheal tear occurs, the
anesthesiologist should advance the endo-
tracheal tube—guided by the surgeon’s hand
through the hiatus—into the left mainstem
bronchus so that single lung ventilation with
the endotracheal balloon distal to the tear can
be established.
References
1. Orringer MB, Sloan H. Esophagectomy with-
out thoracotomy. J Thorac Cardiovasc Surg.
1978;76(5):643–54.
2. Ong GB, Lee TC. Pharyngogastric anastomosis
after oesophago-pharyngectomy for carcinoma of
the hypopharynx and cervical esophagus. Br J Surg.
1960;48:193–200.
514 Transhiatal Esophagectomy—Intraoperative Disasters
3. LeQuesne LP, Ranger R. Pharyngolaryngectomy
with immediate pharyngogastric anastomosis. Br J
Surg. 1966;53(2):105–09.
4. Hulscher JB, Tijssen JG, Obertop H, van Lanschot
5. Rentz J, Bull B, Harpole,
6. Chu KM, Law SY, Fok M,
7. Connors RC, Reuben BC, Neumayer LA, Bull DA.
8. Rindani R, Martin CJ, Cox MR.
9. Orringer MB, Marshall B, Chang AC, Lee
Transthoracic versus transhiatal resection for
JJ.
carcinoma of the esophagus: a meta-analysis. Ann
Thorac Surg. 2001;72(1):306–13.
Pappas T, Henderson W, Daley J, Khuri S. Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients. J Thorac Cardiovasc Surg.
2003;125:1114–20.
randomized comparison of transhiatal and transthoracic resection for lower-third esophageal carcinoma. Am J Surg. 1997;174(3):320–4.
Comparing outcomes after
atal esophagectomy: a 5-year prospective cohort of
17,395 patients. J Am Coll Surg. 2007;205(6):735–
40.
Ivor-Lewis oesophagectoy: is there a difference?
Aust N Z J Surg. 1999;69(3):187–94.
A, Lau CL. Two thousand transhiatal esophagecto-
Bailey S, Neumayer L,
Wong J. A prospective
transthoracic and transhi-
Transhiatal versus
J, Pickens
mies: changing trends, lessons learned. Ann Surg.
2007;246(3):363–74.
10.
Devaney EJ, Iannettoni
shall B. Esophagectomy for achalasia: patient selection and clinical experience. Ann Thorac Surg.
2001;72:854–8.
11.
Starling N, Rao S, Cunningham D, et al. Thrombo
embolism in patients with advanced gastroesophageal cancer treated with anthracycline, platinum,
and uoropyrimidine combination chemotherapy: a
report from the UK National Cancer Research Institute Upper Gastrointestinal Clinical Studies Group. J
Clin Oncol. 2009;27:3786–93.
12. Tetzlaff ED, Correa AM, Baker J, Ensor J, Ajani JA.
The impact on survival of thromboembolic phenomena occurring before and during protocol chemotherapy in patients with advanced gastroesophageal
adenocarcinoma. Cancer. 2007;109(10):1989–95.
13.
Teman NR, Silski
Orringer MB, Chang AC, Lin J, Reddy R. Thromboembolic events before esophagectomy for esophageal cancer do not result in worse outcomes. Ann
Thorac Surg. 2012;94(4):1118–25.
14.
Orringer MB. Transhiatal
thoracotomy. Oper Tech Thorac Cardiovasc Surg.
2005;10(1):63–83.
MD, Orringer MB, Mar-
L, Zhao L, Kober M, Urba SC,
esophagectomy without
-
Chyle Leak After Esophageal Surgery
Elena M. Ziarnik and Jonathan C. Nesbitt
5
Abbreviations
MIE Minimally invasive esophagectomy
NPO Nil per os
TPN Total parenteral nutrition
VATS Video-assisted thoracoscopic surgery
Introduction
A post-esophagectomy chylothorax is an uncommon complication with associated high morbidity and mortality if improperly managed. It occurs
in approximately 3 % of patients and is usually
noted by the occurrence of a pleural effusion or
the drainage of white fluid from the chest tubes
following the postoperative initiation of enteral
feeds. Immediate medical and interventional
measures are necessary to prevent significant nutritional and fluid losses. Selection of the most
appropriate method for management is based on
the severity of the chyle leak and the condition of
the patient.
J. C. Nesbitt ()
Department of Thoracic Surgery, Vanderbilt University,
609 Oxford House, 1313 21st St Avenue South,
Nashville, TN 37232-4682, USA
e-mail: Jon.nesbitt@vanderbilt.edu
E. M. Ziarnik
Department of Thoracic Surgery, Vanderbilt University
Medical Center, Nashville, TN, USA
e-mail: elena.m.ziarnik@vanderbilt.edu
Historical Review
Gasparo Aselli is credited with the discovery of
the lymphatic system, and Vesalius named the
thoracic duct vena alba thoracis because of the
milky white character of chyle in the 16th century [1]. Mascagni was the first to describe the
thoracic duct in detail in 1787 [2]. A report by
Bargebuhr described a series of 40 patients with
nontraumatic chylothorax, all related to neoplasms of the abdomen and thorax [3].
Though the first reference to a traumatic chylothorax was made by Langelot in 1663, Quinke
is credited with the first description of one in
1875 [4]. Zesas wrote a review in 1912 of 24
patients with traumatic chylothorax, of which 12
died [5]. In the 19th century, descriptions of repair of thoracic duct injuries began to appear. In
1922, Lee concluded that injuries should be repaired if possible and ligated otherwise, following his own experimental work with ligation and
review of the literature [6]. The significance of
this report lies in its challenge to the idea that thoracic duct drainage was essential to life. The turning point in the treatment of chylothorax came in
1948 when Lampson and associates successfully
treated a chylous fistula by ligating the thoracic
duct in the chest [7]. At the time of this report, the
mortality from nontraumatic and traumatic chylothorax was 100 and 50 %, respectively [8]. In
the subsequent decade, mortality dropped to less
than 10 % and currently is well below 5 % [9].
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_5,
© Springer Science+Business Media New York 2015
53
54 E. M. Ziarnik and J. C. Nesbitt
Fig. 5.1 Embryologic development of the lymphatic system. (Reprinted with permission from [48])
Basic Science
Embryology
The lymphatic system begins to develop in the
5th week of gestation. Lymphatic sacs were described by Sabin in 1916 as originating from the
endothelium of adjacent veins [10]. She noted six
lymphatic spaces; paired jugular sacs, paired iliac
sacs, a single retroperitoneal sac, and the cisterna
chyli (Fig. 5.1 ). The lymphatic sacs then become
buds that follow planes of least resistance and
progress toward the periphery.
The thoracic duct is formed from downward
growth of the jugular sacs and upward growth of
the cisterna chyli [11]. In the embryo, the thoracic duct exists as bilateral symmetrical plexus
of lymphatic vessels. The communicating vessels
enlarge and fuse, eventually leading to obliteration of the upper third of the right duct and the
lower two-third of the left duct leaving the adult
thoracic duct. The plexus of lymphatic drainage
results in multiple connections between the thoracic duct and adjacent veins, including the azygos and intercostals, and allows chyle to reach
the blood stream after duct ligation.
Fig. 5.2 Adult anatomy of the thoracic duct. (Reprinted
with permission from [48])
Anatomy
The anatomy of the thoracic duct is known for its
variability. The cisterna chyli originates in the abdomen from the union of two lumbar lymphatic
and one intestinal trunk (Fig. 5.2 ). The standard