title: Strategies to reduce pulmonary complications after transhiatal esophagectomy.
abstract: BACKGROUND
  By eliminating a thoracotomy, transhiatal esophagectomy (THE) is purported to reduce postoperative pulmonary complications. However, data from many early series do not support this contention, documenting pulmonary complications in up to 50% of patients and pneumonia in 5%-20%. Since 1990, we have implemented a management strategy designed to maximize airway protection in the postoperative period. The purpose of this study was to determine the current incidence of pulmonary complications after transhiatal esophagectomy without thoracotomy.
  
  
  METHODS
  From 1990 to 1995, 101 consecutive patients underwent THE. Surgical indications were esophageal carcinoma (90 patients) and Barrett mucosa with high-grade epithelial dysplasia (11 patients). Mean age was 60.2 +/- 1.2 years; 89 patients were male. Eighty-two patients were smokers and 26 had chronic obstructive pulmonary disease (COPD). Sixty-five patients were American Society of Anesthesiologists risk score 3 or 4. Postoperatively, all patients were managed according to a standardized clinical pathway that included overnight mechanical ventilation, chest physiotherapy, video pharyngo-esophagram postoperative day 6 or 7, and graduated post-esophagectomy therapeutic diet after acceptable esophagram.
  
  
  RESULTS
  Pulmonary complications were classified as major or minor depending upon whether or not a change in therapy was required. Ten patients (10%) had 11 major pulmonary complications. These included pneumonia (3), pleural effusion requiring drainage (4), exacerbation of COPD (2), and mucus plug requiring bronchoscopy or intubation (2). Minor pulmonary complications identified by chest film were atelectasis (97), pleural effusion (85), and pneumothorax (3). Patients with major pulmonary complications were older (69.3 +/- 9.8 vs. 59.2 +/- 12.1 years, p < .02) and more likely to have COPD (70% vs. 21%, p < .005) than those with only minor complications. There were 3 operative deaths; 2 caused by pneumonia and 1 by fungal sepsis in a patient who had exacerbation of COPD. Mean hospital length of stay was 13.1 +/- 1.4 days.
  
  
  CONCLUSIONS
  Minor pulmonary complications identified by chest film occur in nearly all patients undergoing THE. Strict adherence to a management protocol designed to maximize airway protection in the postoperative period results in a 10% incidence of major pulmonary complications. Older patient age and COPD are risk factors for major pulmonary complications after THE. Although pneumonia is uncommon, it remains the most frequent cause of death after THE.
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Gillinov
authors.forename: R F
authors.initials: RF
authors.lastname: Heitmiller
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000601:surgery*; D019091:Critical Pathways; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D006801:Humans; D008171:Lung Diseases / Q000209:etiology / Q000517:prevention & control*; D008173:Lung Diseases, Obstructive / Q000209:etiology / Q000517:prevention & control; D008297:Male; D008875:Middle Aged