7Chronic symptoms after subtotal or partial oesophagectomy: diagnosis and treatment
Section snippets
Anastomotic stenosis
Many factors, both local and systemic, influence the process of wound healing and thus the incidence of anastomotic complications.
When using the stomach as a substitute, the entire vascularization depends on the right gastroepiploic artery and vein. Approximately 60% of the gastric tube is supplied directly by this vessel, another 20% being more cranially supplied by the minute connections between the right and the left gastroepiploic vessels, whereas the most cranial 20% of the tube is
Reflux
Despite a significant reduction of acid output related to truncal vagotomy, persistent acid secretion has been reported. Hölscher et al10 found only a 30% reduction in peak acid output after pentagastric stimulation compared with controls. Gutschow et al11 noted that early after oesophagectomy and reconstruction with a denervated whole stomach, intraluminal acidity decreased in approximately two-thirds of the patients, although the stomach recovered its normal pH profile over time. Hashimoto et
Gastric emptying-related symptoms
Vagal denervation can result in chronic dysmotility of the gastric remnant and an outlet dysfunction of the pylorus, which may cause delayed emptying. This may induce a wide spectrum of symptoms: early satiety, postprandial fullness, heartburn, high dysphagia, aspiration and pneumonia.
The addition of a gastric drainage procedure has been advocated (in analogy with bilateral truncal vagotomy plus pyloroplasty in the treatment of duodenal ulcer disease). However, the need for such drainage
Gastric tube versus whole stomach
The individual variations in gastric tube activity may be related to different access routes, possible effects of torsion, the size and width of the gastric tube, elasticity and individual patterns of gastric dysmotility.
Finley et al20 studied the effect of different access routes, comparing right-sided, left-sided and transhiatal oesophagectomies. Oesophagectomy carried out through a right-sided posterolateral thoracotomy with cervical oesophagogastric anastomosis had a high incidence of
Treatment of gastric outlet obstruction
Irrespective whether or not a pyloric drainage procedure has been performed, a number of patients may suffer from gastric outlet obstruction. Balloon dilatation of the pylorus can be an effective procedure to solve this problem in some patients. Bemelman et al21 reported a successful outcome with balloon dilatation in 6 out of 18 patients.
An alternative is to administer erythromycin. Erythromycin is a motilin agonist and has been demonstrated to improve gastric emptying in normal subjects and
Intestinal metaplasia and gastric drainage procedures
The combination of biliary and acid reflux is commonly believed to play a central role in the pathogenesis of Barrett's metaplasia in patients suffering from gastro-oesophageal reflux disease. The ablation of the lower oesophageal sphincter mechanism at the time of oesophagectomy and the vagotomy-induced pyloric dysfunction with possible enterogastric biliary reflux are of increasing concern in relation to the risk of development of Barrett's metaplasia, especially in long-term survivors.
As
Dumping diarrhoea
After oesophagectomy followed by gastroplasty, many patients complain of diarrhoea and dumping (-like) symptoms, with a reported incidence of between 10 and 50%.14., 31., 32. These symptoms are early postprandial abdominal and vasomotor symptoms resulting from osmotic fluid shifts and the release of vasoactive neurotransmitters, and late symptoms secondary to reactive hypoglycaemia. Diarrhoea, abdominal cramps, nausea, dizziness, postprandial sweating and hypotension are the main complaints.
Vocal cord paralysis
Vocal cord paralysis is a well-known complication after subtotal oesophagectomy, causing hoarseness, dysphagia, weight loss, aspiration, dyspnoea and pneumonia. The dissection alongside both recurrent nerves, at the time of either thoracotomy or bilateral lymphadenectomy, may cause recurrent nerve damage followed by a temporary or definitive vocal cord paralysis. This paralysis can be unilateral or even bilateral. Precise data in relation to origin, incidence and associated morbidity are scarce.
Quality of life after oesophagectomy
Apart from substantial perioperative morbidity and even mortality, surgical therapy for oesophageal carcinoma can be accompanied by severe long-term functional disturbances, with a large impact on quality of life. The results of cancer treatment should be measured not only in terms of increased length of survival and therapy-induced morbidity: the broader effects on the patient's quality of life should also be taken into account. However, a review of the literature by Gelfand and Finley in 1994
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2019, Surgical OncologyCitation Excerpt :The addition of surgery is associated with a further physiological hit with morbidity and mortality risks [22–27], a long recovery time [28–30] and with a further significant QL impact [31,32]. Furthermore, division of the vagal nerve trunks, and resection of the lower oesophageal sphincter anti-reflux mechanism, increase the potential complications and quality of life risks [31–34]. The value of recording QL outcomes is well recognised.
Long term malnutrition and deficiencies after oesogastric surgery
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2015, Journal of Surgical ResearchCitation Excerpt :Reconstruction techniques after esophagectomy usually involve other digestive organs such as the stomach, jejunum, or colon [1,2]. Although outcomes have improved after esophagectomy in high-volume centers [3], this procedure is still associated with significant short- and long-term morbidities, including complications related to gastric reflux or redundancy of the gastric or colonic conduit [4–6]. In certain situations, having an esophageal substitute may allow for segmental replacement of the esophagus (SRE), which may reduce morbidity and preserve function.
Endoluminal Therapy for Esophageal Disease: An Introduction
2010, Gastrointestinal Endoscopy Clinics of North AmericaCitation Excerpt :A random sample of 20% of these cases showed that the overall in-hospital mortality rate was 11.3%, but it was lower in high-volume surgical centers, decreasing to 7.5%.18 Additionally, several large studies have found that 30% to 50% of patients experienced at least 1 serious postoperative complication, such as pneumonia, myocardial infarction, heart failure, or wound infection, and that the average length of hospital stay was at least 2 weeks.19 Late surgical complications, such as anastomotic strictures, are common, occurring in 10% to 56% of patients and require follow-up endoscopic dilation.20