Ivor Lewis Esophagectomy leak

Q) After Ivor Lewis esophagectomy, on POD 5 , bile is seen in chest tube. Patient's heart rate is 120,  temp is 101 degree F, BP is 100/70. What will be the next step?

a) Stenting

b) Colonic replacement of gastric conduit

c) IV antibiotics 

d) Conduit excision and  Esophageal diversion

Ans  d

Patients with a completely necrotic conduit are most often septic and brought to the operating room for emergent exploration.

If conduit necrosis is confirmed,   then the conduit must be resected and the patient
should be diverted with an end esophagostomy, venting gastrostomy, and feeding jejunostomy. Care should be
taken to maintain the longest possible length of remaining
esophagus to facilitate future reconstruction

Schakelford page 477



Q) Trans Hiatal Esophagectomy ( THE)  vs Trans Thoracic Esophagectomy ( TTE)   which is not true? ( Question asked in all AIIMS and INI exams since 2017) 

a) Leak rates are more with TTE 

b) Pulmonary complication is more with TTE

c) Side to side stapler anastomosis has less leaks than open two layer suturing

d) THE can be done through minimally invasive surgery

Esophagus Mock test  1

Esophagus Mock test 2 

Ans c

Pulmonary complications  are 57% with TTE 27% with  THE  ( SKF 409)

Anastomotic leak 16% TTE and 14% THE ( not significant) subclinical leak slightly more in THE

Option D is correct

Cardiac complications, Vocal cord paralysis , wound infection, chyle leak are all more with TTE

Blackmon et al. published a propensity-matched analysis comparing outcomes between side-to-side stapled anastomosis, end-to-end circular stapled anastomosis, and handsewn,
with no significant difference in leak rate noted.  ( SKF page 475)

SKF page 409

Caustic Injuries of Esophagus

Q . Caustic injury of esophagus. Which statement is not true  ( # All Questions of esophagus) 
a) Steroid is used as a treatment 
b) Carcinoma risk  is 30%
c) Contrast study has false negative of 25%
d Esophageal stent reduce leaks by 75%

Ans ) a

Points of esophagus caustic injuries

There is no proven benefit of starting steroids in early or intermediate phase of injury as there is no evidence to support prevention of stricture

  1. Endoscopy should be performed after initial stabilization
  2. Complete esophagus can be examined now with flexible endoscopes
  3. Available studies show no benefit of steroid use ( skf PAGE 521) 
  4. Cancer risk is 30% in injured and non injured portions


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