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Chapter 6
https://t.me/med1917
Case on Recurrent Nerve Lesion (Double)
as a Consequence of Esophageal
Resection for Cancer
Ramon Gorter
Keywords Esophageal resection • RLN • Laryngoscopy • Cordotomy •
Arytenoidectomy
Diagnosis and Indication for Surgery
A 79-year-old male with complaints of dysphagia was evaluated at our outpatient
clinic. His medical history included a right-sided pneumonia and endoscopic treatment of a Zenker’s diverticulum. Endoscopy revealed an ulcerative adenocarcinoma of the esophagus at 28–34 cm from the incisors. Based on CT scans and
endosonograpy, the tumor was staged as T3N1M0.
Operation
Six weeks after neoadjuvant chemoradiation (CROSS-scheme: weekly administration of Carboplatin ® AUC = 2 en Paclitaxel ® 50 mg/m 2 with concurrent 5 days
weekly radiotherapy in fractions of 1.8 Gy, total 41,4 Gy [ 1 ]) the patient was admit-
ted for open transthoracic esophagectomy with two-fi eld lymphadenectomy followed by a right cervical gastric conduit anastomosis with the esophagus.
R. Gorter , M.D.
Pediatric Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: rr.gorter@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_6,
© Springer International Publishing Switzerland 2014
33
34
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R. Gorter
Pathology
Radically resected T3N1 adenocarcinoma of the esophagus.
Postoperative Course: Identifi cation and Treatment
of the Complication
Postoperatively, the patient was admitted to the intensive care unit. On the chest
radiograph a large pneumothorax was diagnosed on the right side and a second
chest tube was inserted (Fig. 6.1 ). The second postoperative day, the patient was
detubated, but during the following days, he became increasingly dyspnoic and
oxygenation was poor. Because of aphony and stridor, the ENT doctor evaluated the
vocal cords. Laryngoscopy showed bilateral vocal cord paralysis (Fig. 6.2 ). Because
Fig. 6.1 Postoperative
thorax X-ray
Fig. 6.2 Laryngoscopy
showing vocal bilateral cord
paralysis
6 Case on Recurrent Nerve Lesion (Double) as a Consequence of Esophageal Resection
https://t.me/med1917
Fig. 6.3 Laryngoscopy after
6 months showing recovery
of function of the right vocal
cord
of the respiratory insuffi ciency and stridor, it was decided to perform a tracheostomy. On the 17th postoperative day, a bronchopneumonia was diagnosed for which
intravenous antibiotics were started for 7 days. On the 19th postoperative day, it was
decided to start oral feeding with the assistance of a logopedist. Aspiration was then
noted clinically and the oral feeding was averted, whereas jejunostomy feeding was
continued. Aspiration pneumonia developed again several days later and intravenous antibiotics were restarted. Revaluation of the vocal cord paralysis showed no
signs of improvement. After discharge (1½ month after the initial surgery) the
patient had not initiated oral intake and continued breathing through the tracheostomy. Intensive training with a speech language logopedist and progressive oral
feeding started in an outpatient program. Six months after discharge, the patient was
eating normally, and before a vocal cord plasty was planned, a new laryngoscopy
showed recovery of the left vocal cord with normal spontaneous breathing (Fig. 6.3 ).
After 2 months tracheotomy was retired without respiratory problems. He is still
receiving speech therapy lessons to improve the quality of his voice.
35
Discussion
The recurrent laryngeal nerve (RLN) plays an essential role in the innervation of the
intrinsic muscles of the larynx especially those responsible for movement of the
vocal cords. Both uni- and bilateral lesions have been described with an incidence
ranging between 15 and 80 % depending on the cervical dissection and extensiveness
of the esophageal and lymph node dissection [ 1 – 3 ]. Most cases of unilateral RLN
paralysis are seen after cervical oesophagogastrostomy. This patient developed bilateral RLN lesions after transthoracic oesophagectomy with right cervical anastomosis
(Illustration 6.1 ). A cervical anastomosis is associated with a high incidence of RLN
damage either temporarily or defi nitive [ 1 – 5 ]. The fact that a cervical anastomosis
was performed on the right side may explain why the right RLN became damaged
36
A
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R. Gorter
Right vagal nerve
Right subclavian
Illustration 6.1 Anatomy of the recurrent laryngeal nerve (RLN)
artery
RL
Esophagus
Diaphragm
4
Left vagal nerve
3
Aorta
2
Places lesion of
recurrent nerves
1
Paratracheal dissection R
2
Paratracheal dissection L
3
Neck dissection L
4
Neck dissection R
1
and possibly also the left RLN, since no paratracheal or aortopulmonary window
lymphadenectomy was performed. Damage to the ipsilateral as well as the contralateral RLN is reported in 2 % of cases following transhiatal oesophageal resection [ 2 ].
Prevention of RLN lesion will include identifi cation and eventually monitoring during cervical and high mediastinal lymph node dissection. Any atraumatic dissection
and tractions will be avoided [ 4 ]. Symptoms associated with an unilateral lesion are
hoarseness and infrequently stridor, while a bilateral lesion leads to aphony, swallowing dysfunctions and stridor with breathing diffi culties causing signifi cant secondary respiratory morbidity, prolonged hospital stay, and decreased quality of life
[
1 – 3 ]. The risk of developing postoperative pneumonia, due to decreased respiratory
function, defi ciency of the coughing mechanism, and aspiration, is signifi cantly
greater in patients suffering from postoperative RLN injury. Treatment in the acute
phase depends on the severity of the symptoms. In most cases active physiotherapy
and logopedy can offer satisfactory results, although in bilateral injury with paralysis
in a median position, tracheostomy will be the only adequate treatment as described
in this case. In a later stage several vocal cord procedures can be carried out for bilateral injury, in order to lateralize one or both vocal cords to improve the patency of the
airways. Moreover, spontaneous recovery on one side is possible if only contusion of
the nerve during operation. Both cordotomy and arytenoidectomy have been reported
to have satisfactory results, although new techniques such as laryngeal pacing and
botulinum toxin injection may be considered as therapeutical options in the near
5 ].
future [
6 Case on Recurrent Nerve Lesion (Double) as a Consequence of Esophageal Resection
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37
References
1. Wright CD, Zeitels SM. Recurrent laryngeal nerve injuries after esophagectomy. Thorac Surg
Clin. 2006;16:23–33.
2. Hulscher JB, van Sandick JW, Devriese PP, et al. Vocal cord paralysis after subtotal oesopha-
gectomy. Br J Surg. 1999;86(12):1583–7.
3. Baba M, Natsugoe S, Shimada M, et al. Does hoarseness of voice from recurrent nerve paraly-
sis after esophagectomy for carcinoma infl uence patient quality of life? J Am Coll Surg.
1999;188:231–6.
4. Gelpke H, Grieder F, Decurtins M, Cadosch D. World J Surg 2010;34:2379–82.
5. Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Clin N Am.
2007;40:1109–31.
Chapter 7
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Case on Trachea-gastric Conduit Fistula
After Esophageal Resection
Koen Hartemink
Keywords Trachea fi stula • Esophageal resection • Esophageal cancer
Diagnosis and Indication for Surgery
A 62-year-old male patient was referred to our hospital after esophageal resection
performed in another hospital. His medical history revealed diabetes mellitus and
an appendectomy. A few months before, an adenocarcinoma of the mid-esophagus
had been found and the patient was treated by neoadjuvant chemo-radiotherapy
according to the CROSS scheme (Carboplatin/Paclitaxel with concurrent radiotherapy in 23 fractions of 1.8 Gy). Restaging showed a reduction in size of the
primary tumor without any signs of metastases and resection of the esophagus was
planned.
Operation
A thoracolaparoscopic esophageal resection was done and a gastric conduit with
an end-to-side cervical anastomosis was performed. The thoracoscopic phase was
done in prone position during which the esophagus was resected and an en bloc
carina lymphadenectomy was performed. Azygos vein was divided by means of
Haemaloc clips ® . Because the tumor was fi xed to the right lung, a local resection
of a pulmonary segment was done, after which a peroperative frozen section
K. Hartemink , M.D.
Intensive Care, Department of Surgery , VU University Medical Center ,
Amsterdam , The Netherlands
e-mail: k.hartemink@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_7,
© Springer International Publishing Switzerland 2014
39
40
https://t.me/med1917
showed no tumor in the resection margin. The patient was turned in supine position for the abdominal phase of the operation in which a celiac trunk lymphadenectomy was done and the gastric conduit was created. Cervical incision and
transection of the esophagus were done, followed by an end-to-side cervical anastomosis. A jejunostomy feeding tube was introduced for postoperative enteral
feeding.
K. Hartemink
Pathology
Histopathological examination showed an adenocarcinoma with growth through the
muscularis layer. One of nine lymph nodes showed a metastasis. Resection margins
were free of tumor (pT3N1, R0 resection).
Postoperative Course: Identifi cation and Treatment of the
Complication
Postoperative recovery was uneventful and the patient was discharged from the hospital on the seventh postoperative day. One week after discharge from the hospital,
the patient was readmitted because of pneumonia that was treated with antibiotics.
Because of progressive complaints of dyspnoe, coughing, and persistence of the
pneumonia, there was suspicion of a trachea-gastric conduit fi stula. A fl uoroscopic
swallow study showed an anastomotic leakage of contrast (Fig. 7.1 .a), and a CT-scan
showed an infi ltrate in the right lower lobe. An endoscopy showed partial dehiscence of the esophagogastric conduit anastomosis. Tracheobronchoscopy showed a
defect (1 cm diameter) on the dorsal side of the proximal right main bronchus
(Fig. 7.1b ). The patient was transferred to our hospital for operative correction of
the trachea-gastric conduit fi stula.
At admission to our hospital, the patient was already intubated and mechanically
ventilated, and after double intubation a right-sided thoracotomy was performed. A
fi stula was found between a semi-circular defect of the esophago-gastric conduit
anastomosis and a defect on the dorsal side of the proximal right main bronchus
(Fig. 7.2 ). Although the anastomosis was performed cervically, it had descended
into the thorax. The esophagogastric conduit anastomosis was disconnected from
the right bronchus, showing a t-shaped defect. The defect in the right main bronchus
was closed with interrupted sutures (Fig. 7.3 ), and an intercostal muscle fl ap was
used to reinforce the defect. After closure of the defect, the gastric conduit was reanastomosed with the cervical esophagus (Fig. 7.4 ).
The postoperative course was initially uneventful. However, 2 weeks after reoperation, the patient developed respiratory failure due to vomiting and aspiration in
both lungs, resulting in multiple organ failure and subsequent death.
7 Case on Trachea-gastric Conduit Fistula After Esophageal Resection
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41
a
b
Fig. 7.1 Contrast swallow study shows leakage ( arrow ) ( a ) and tracheoscopy showing the fi stula
opening ( b )
Fig. 7.2 Peroperative
macroscopic picture showing
a defect on the dorsal side of
the proximal right main
bronchus ( thin arrow ) and a
defect in the gastric conduit
( thick arrow )
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Fig. 7.3 Peroperative
macroscopic picture showing
the defect in the right main
bronchus which was closed
with interrupted sutures, and
an intercostal muscle fl ap
(not shown) was used to close
the defect. A gastric tube in
the cervical esophagus is seen
Fig. 7.4 Peroperative
macroscopic picture showing
the gastric conduit being
re-anastomosed with the
esophagus with interrupted
sutures
K. Hartemink
Discussion
The occurrence of a gastric conduit fi stula with trachea or bronchus following
esophagectomy for cancer is very low (0.3–0.5 %) but is mostly a lethal complication [ 1 , 2 ] The underlying pathophysiology consists of leakage of the anastomosis
with subsequent mediastinal abscess and rupture into the posterior wall of the tracheobronchial tree, tracheal ischemia after extensive dissection, traumatic injuries
to the trachea or bronchia during dissection, cuff-induced tracheal necrosis (during
prolonged endotracheal intubation), or tracheal erosion by the gastric conduit staple
line or clips [ 3 , 4 ]. Yasuda et al. classifi ed the fi stulas in three types: caused by anas-
tomotic leakage, by gastric necrosis, or/and by gastric ulcer [ 5 ]. Symptoms might be
mild (coughing) or more severe (recurrent pneumonia or mediastinitis). Diagnosis
is based on clinical suspicion and symptoms and confi rmed by radiological contrast
7 Case on Trachea-gastric Conduit Fistula After Esophageal Resection
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Trachea
Right
Fistula
Gastric conduit
bronchus
43
Right lung
Intercostal
muscle plasty
Illustration 7.1 Treatment of the tracheo-gastric conduit fi stula by closure and muscle plasty
Serratus
anterior plasty
study and CT scan, esophagogastroscopy, and bronchoscopy [ 1 ] There are different
possible management strategies (conservative, endoscopic, or surgical), and the
approach depends on the patient’s condition, site, and size of the fi stula, the underlying cause, and the clinical presentation and severity of symptoms [ 4 , 6 ] In patients
having a very bad condition—locally and general—temporary treatment by means
of stents may be an option to perform the defi nitive intervention at a better moment
[ 7 ]. When conservative measures fail or the patient’s condition worsens, a surgical
approach becomes necessary. Surgical treatment consists of identifi cation and dissection of the fi stula, closure of the tracheal- and gastric-conduit defects with use of
interposed vital tissue (pleural or pericardial tissue or a muscle-fl ap), and preservation if possible of the gastric conduit (Illustration 7.1 ) [ 1 – 6 ].
References
1. Nardella JE, Van Raemdonck D, Piessevaux H, et al. Gastro-tracheal fi stula - unusual and life
threatening complication after esophagectomy for cancer: a case report. J Cardiothorac Surg.
2009;4:69–71.
2. Kalmár K, Molnár TF, Morgan A, Horváth ÖP. Non-malignant tracheo-gastric fi stula following
esophagectomy for cancer. Eur J Cardiothoracic Surg. 2000;18:363–5.
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